About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Two types: adenocarcinoma (lower third — now more common in UK, linked to Barrett's/GORD/obesity) and SCC (upper/mid — linked to smoking/alcohol)
- Cardinal symptom: progressive dysphagia (solids → liquids) + weight loss — always requires urgent OGD
- Dysphagia at ANY age = urgent 2WW OGD referral (NICE NG12)
- Staging: CT + EUS + PET-CT. Curative treatment: neoadjuvant chemo(radio)therapy + oesophagectomy
- Poor overall prognosis (~15% 5-year survival) — most present with advanced disease
Overview
Oesophageal cancer is the fourteenth most common cancer in the UK but carries a poor prognosis due to late presentation. The two main histological types are adenocarcinoma (now the predominant type in the UK, arising in the lower third of the oesophagus, typically from Barrett's oesophagus) and squamous cell carcinoma (arising in the upper or middle third, associated with smoking and alcohol). Adenocarcinoma incidence has risen dramatically in Western countries, paralleling the obesity epidemic and increased GORD prevalence.
Epidemiology
Approximately 9,000 new cases per year in the UK. More common in males (3:1 for adenocarcinoma, 1.5:1 for SCC). Adenocarcinoma: risk factors include Barrett's oesophagus, chronic GORD, obesity, male sex, white ethnicity. SCC: risk factors include smoking, alcohol (synergistic), achalasia, Plummer-Vinson syndrome (iron deficiency + oesophageal web), caustic stricture, hot beverages, coeliac disease. Five-year survival is approximately 15% overall.
Clinical Features
Symptoms
Progressive dysphagia: initially solids, then soft food, then liquids (mechanical obstruction)
Unintentional weight loss (often significant)
Odynophagia (painful swallowing)
Regurgitation of undigested food
Chest pain or back pain (local invasion)
Hoarseness (recurrent laryngeal nerve invasion)
Cough after swallowing (tracheo-oesophageal fistula)
Signs
Cachexia and significant weight loss
Left supraclavicular lymphadenopathy (Virchow node)
Hepatomegaly (metastases)
Cervical lymphadenopathy
Hoarse voice (RLN palsy)
Investigations
First-line
Urgent OGD with biopsyFirst-line for any dysphagia — visualises tumour, obtains histology. 2WW referral pathway for all new dysphagia (NICE NG12)
FBCIron deficiency anaemia (chronic blood loss from ulcerated tumour)
Second-line
CT chest/abdomen/pelvisStaging: local extent, lymph node involvement, distant metastases (liver, lung)
Endoscopic ultrasound (EUS)T-staging (depth of wall invasion) and regional lymph node assessment
PET-CTIdentifies occult metastatic disease and guides curative treatment decisions
Specialist
Staging laparoscopyFor GOJ tumours — exclude peritoneal disease before curative surgery
BronchoscopyIf upper/mid-oesophageal tumour — assess tracheal/bronchial invasion
HER2 and PD-L1 testingOn biopsy — guides targeted and immunotherapy in advanced disease
1
Curative treatment
- Neoadjuvant chemotherapy (FLOT for adenocarcinoma) or chemoradiotherapy (CROSS regimen — SCC) followed by oesophagectomy
- Ivor Lewis oesophagectomy: two-stage (abdominal + right thoracotomy) — for lower/mid tumours
- Three-stage (McKeown) oesophagectomy: for upper tumours
- Endoscopic resection: early T1a tumours arising in Barrett's (endoscopic mucosal resection or endoscopic submucosal dissection)
- Radiofrequency ablation (RFA): for flat dysplastic Barrett's segments
2
Palliative treatment
- Endoscopic stenting (self-expanding metallic stent): for dysphagia palliation
- Palliative chemotherapy for metastatic disease
- Radiotherapy for SCC (more radiosensitive than adenocarcinoma)
- Nutritional support: NG tube, PEG/RIG, or parenteral nutrition
- Best supportive care and palliative input
Complications
- Malnutrition and cachexia: From dysphagia and metabolic effects of cancer
- Aspiration pneumonia: From regurgitation or tracheo-oesophageal fistula
- Tracheo-oesophageal fistula: Direct invasion into trachea/bronchus — cough after swallowing, recurrent pneumonia
- Recurrent laryngeal nerve palsy: Hoarseness from nerve involvement
- Post-oesophagectomy: Anastomotic leak (~5–10%), conduit necrosis, chyle leak, pneumonia, dumping syndrome
UKMLA Exam Tips
- 1Progressive dysphagia (solids → liquids) + weight loss = oesophageal cancer until proven otherwise
- 2Adenocarcinoma = LOWER third, Barrett's/GORD. SCC = UPPER/MID third, smoking/alcohol
- 3Dysphagia at ANY age = urgent 2WW OGD — there is no age threshold for this symptom
- 4Plummer-Vinson syndrome: iron deficiency anaemia + dysphagia (oesophageal web) + glossitis → risk factor for SCC
- 5Barrett's → low-grade dysplasia → high-grade dysplasia → adenocarcinoma — this sequence is commonly examined
- 6Tracheo-oesophageal fistula: coughing immediately after swallowing liquids — a late and ominous sign
practicetest your knowledge on oesophageal cancerApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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