Esophageal cancer is probably not the first type of cancer that comes to mind when trying to list the most common types. However, according to statistics by the world health organization, it is listed as number eight in the most common types of cancer around the globe. The outcome of this disease is not always good because most cases are diagnosed very late when other medical conditions worsen the prognosis. That’s why it is important to be attentive at the signs and symptoms of esophageal cancer and ask your doctor if you ever have a reason to suspect this ailment in yourself or any other member of your family.
In this article, you will understand the most important signs and symptoms of esophageal cancer, why they appear and how to detect them. However, keep in mind that most of these symptoms are shared with other pathologies and only a skilled doctor with a series of imaging and lab studies will be able to reach to a definite conclusion.
The most common symptoms are as follows:
1) Difficulty to swallow
Among all of the listed signs and symptoms, problems to swallow is probably the most characteristic because it is not caused by many other diseases. The esophagus is the first portion of the gastrointestinal tube. It is located in the chest and connects the mouth with the stomach. Thus, dysfunction in this organ would cause a sensation of choking as if there was food or something else stuck on the way to the chest. Such difficulty, which sometimes is accompanied by pain to swallow, is named dysphagia by doctors.
At first, dysphagia in patients with esophageal cancer is not especially prevalent. It starts as mild discomfort and aggravates over time. The lumen of the esophagus gets progressively smaller as more cancer cells invade the tissue and the tumor becomes bigger. In the process, esophageal cancer interferes with the regular movements of the esophagus when there’s food to swallow. Thus, swallowing becomes harder, and people start avoiding certain types of food and need to take small bites and chew carefully before swallowing. In the end, patients may even require to eat soft foods only, because they are the only ones that can move through their esophagus.
2) Increased salivation
As the swallowing problem gets worse, patients also describe an increase in salivation. Saliva is the body’s lubricant that helps to pass food to the stomach, and chewing activates salivation. The organism would likely start producing more saliva to improve transit through the esophagus or triggered by careful and slow chewing adopted by the patient to avoid choking on big pieces of food.
3) Chest pain
Patients with esophageal cancer would likely experience chest pain while swallowing, and even without passing food through the esophagus. During swallowing, and especially when symptoms become serious, the unpleasant feeling while passing food through the esophagus turns into chest pain and choking sensation, especially on solid foods with insufficient chewing.
When the tumor becomes large enough that food starts having trouble to get past it, patients may feel a surge of pain a few seconds after swallowing. This pain is triggered by the abnormal tissue in the esophagus struggling to force food into the small opening that is left. In some cases, patients may even report feeling stuck food for a very long time, and come to the emergency room with such uncomfortable symptoms.
On the other hand, patients may also report symptoms of acid reflux, especially a burning sensation all over the chest with an acid taste to their mouth. Sustained gastroesophageal reflux is often one of the leading conditions that trigger something called Barret’s esophagus, which may become the first step towards esophageal cancer. Not fixing this acid reflux problem would lead the patient to have this problem combined with esophagus cancer symptoms throughout the disease.
4) Heartburn
Chest pain may also appear as heartburn, which is felt either as pressure or as a burning sensation to the middle part of the chest. This type of pain is independent of chewing or passing food through the esophagus and may become a continuous symptom caused by stomach acid alterations instead of esophageal cancer itself. Thus, heartburn is considered to be an ailment closely related to esophageal cancer, sometimes deeply associated with its appearance in the first place.
5) Vomiting
Both vomiting and regurgitating food becomes more common as the esophageal disease gets worse. The esophageal opening becomes compromised, and so it happens with the normal function and movements that push food to the stomach. Having food stuck in the esophagus would trigger vomiting as one of the defensive reflexes of the gastrointestinal system. Thus, it is common to see esophageal cancer patients arching and vomiting closely after having their meal. In advanced cases of cancer, patients may also experience frequent blood vomits, not necessarily related to eating. When vomiting becomes repetitive and sustained over time, it may also lead to dehydration, electrolyte imbalances, and other diseases.
6) Chronic Coughing
Another important reflex of the gastrointestinal tract that deserves special consideration in esophageal cancer is coughing. This is a crucial defence to prevent infants and people in general from inhaling food or liquids to the lungs. When food or liquids are stuck in the esophagus, and they happen to be close to the airways, the coughing reflex would immediately activate to expel them out and prevent choking with food. Since the whole esophagus tissue becomes affected with cancer, these patients may also trigger coughing independent from having or not food stuck in the gastrointestinal tract.
The esophagus sends an aberrant signal to the nervous system that activates the coughing reflex and causes repeated coughing while eating and at rest. Thus, chronic coughing without a known cause is another symptom you should pay attention to and ask your doctor about your condition. Plenty of ailments may cause chronic coughing, and you would need a professional approach to rule out esophageal cancer and many other possibilities, including asthma, gastroesophageal reflux, lung infections, and certain drugs.
7) Hoarseness
This is not an early sign of esophageal cancer. Instead, it usually appears when the tumor has grown big enough and already caused alterations to the normal transit of food through the esophagus and the nerve reflexes in this part of the gastrointestinal tract. Hoarseness has to do with an alteration to the vocal cords or the structures directly in contact with them. Acid reflux is one of the possible explanations, which triggers both esophageal cancer in the long term and hoarseness as well. However, in more advanced cases of cancer, hoarseness is not caused by acid reflux but a spread of cancer cells to the nearby tissue.
When the tumor becomes large enough and starts spreading all over the area, they may also take the recurrent laryngeal nerve, a particular structure that is responsible for maintaining the muscular tone of the larynx. With an alteration to this nerve structure, the vocal cords would behave differently and patients would start having a hoarse voice.
8) Hiccups
We have already discussed several reflex systems associated with the esophagus, and hiccups are also one of them. Patients with advanced esophageal cancer would have frequent hiccups combined with the symptoms described above. Hiccups are commonly seen in healthy patients, and there are even diseases featuring chronic hiccups without involving any type of tumor growth. Thus, this symptom is not thought to be the primary warning sign to detect esophageal cancer, and your doctor might need to perform certain imaging diagnostic tests and lab tests to fully understand the root cause of your hiccups in combination with the symptoms we have already described.
9) Black stools
We have already mentioned vomiting and how such reflex would sometimes turn into blood vomiting. Cancer cells grow new blood vessels, and they need to do that in order to grow bigger and prevent cancer cell death due to lack of nutrients or insufficient oxygen. In the process, tumors start growing aberrant blood vessels with a thin lining that’s very susceptible to bleeding. As the tumor grows bigger, there’s more contact and wear down of the structures, and these aberrant blood vessels become easily damaged, resulting in gastrointestinal bleeding.
One of the manifestations of gastrointestinal bleeding is vomiting blood, and the other is black stools. When the blood goes through all of the digestive tube it becomes rotten and changes color to a dark red or black. It may also start smelling as the gastrointestinal microbiota does its part. In the end, patients start passing black stools frequently, and this is a sign of gastrointestinal bleeding that doctors should trace all over the digestive tube.
Studying black stools would require to perform a stool test, a blood test, imaging techniques, and even more invasive procedures such as endoscopy. This is often the only way to determine what is wrong and may become the diagnostic procedure to detect esophageal cancer and even perform biopsies to know what type of cancer is it.
10) Anemia
Frequent gastrointestinal bleeding may also lead to anemia, which is a reduction to the normal levels of hemoglobin in the blood. Frequent blood loss that overcomes the capacity of the organism to produce new hemoglobin results in this condition, which is often felt as weakness and lightheadedness, but may also be asymptomatic.
Another common cause of anemia is the resulting dietary alteration when patients have sustained difficulty swallowing and pain while eating. Patients may start adopting a soft diet with insufficient nutrients to maintain healthy levels of hemoglobin. For example, they may stop having meat and other important sources of vitamin B, which leads to B vitamin deficiency and anemia as one of many manifestations.
Patients with anemia may have severe signs and symptoms leading them to the emergency room while others would go undetected, but all of them will have low levels of hemoglobin that only a blood test would detect. Thus, it is important not to trust on signs and symptoms alone, and ask your doctor about your symptoms to get the most appropriate management of your condition.
11) Weight loss
Similar to anemia, weight loss is also associated with the dietary restrictions patients have during esophageal cancer. It becomes harder to pass food through the esophagus, and such difficulty leads patients to eat only the strictly necessary and even less than that. When there are dietary restrictions, nutrient deficiencies become more common if we are not careful to pick the correct foods to get complete nutrition out of the food we are eating. Thus, uncontrolled esophageal cancer usually results in malnutrition, which worsens the prognosis and makes the individual more susceptible to the underlying disease.
Another reason why esophageal cancer patients experience weight loss is related to cancer cells, which steal excess nutrients and oxygen from the blood to grow without restraint. Thus, dietary restrictions and cancer itself are responsible for the unplanned weight loss, which also has a prognostic value in the event of esophageal cancer.
12) Bone pain
In advanced esophageal cancer, the last stage is metastasis or cancer spread to other tissues, and one of the most common is bone tissue. Metastasis to the bones would result in bone pain that is initially mild and becomes more common and severe over time.
Other common sites of metastasis are the liver, the lung, and the brain. Liver metastases are likely to cause jaundice, healing problems and abdominal pain. Lung metastasis may cause coughing, chest pain, and various respiratory symptoms. Brain metastasis would cause various symptoms depending on the exact location of the cancer spread.
References
Enzinger, P. C., & Mayer, R. J. (2003). Esophageal cancer. New England Journal of Medicine, 349(23), 2241-2252.
Zhang, Y. (2013). Epidemiology of esophageal cancer. World journal of gastroenterology: WJG, 19(34), 5598.
Holmes, R. S., & Vaughan, T. L. (2007, January). Epidemiology and pathogenesis of esophageal cancer. In Seminars in radiation oncology (Vol. 17, No. 1, pp. 2-9). WB Saunders.
Wu, S. G., Zhang, W. W., He, Z. Y., Sun, J. Y., Chen, Y. X., & Guo, L. (2017). Sites of metastasis and overall survival in esophageal cancer: a population-based study. Cancer management and research, 9, 781.