Risk factors for esophageal cancer

A risk factor is something that increases the risk of developing cancer. It could be a behaviour, substance or condition. Most cancers are the result of many risk factors. But sometimes esophageal cancer develops in people who don’t have any of the risk factors described below.

The most common types of esophageal cancer are adenocarcinoma and squamous cell carcinoma (SCC). Some risk factors are common to both types of esophageal cancer, but other risk factors are linked with only adenocarcinoma or SCC.

Men are more likely to be diagnosed with cancer of the esophagus than women. Most people diagnosed with esophageal cancer are men over the age of 60. The highest rates of SCC of the esophagus occur in parts of China, Iran, South America, France and Africa, and the incidence is decreasing worldwide. In contrast the incidence of adenocarcinoma of the esophagus is increasing, especially in high- and middle-income countries. Low socioeconomic status increases the risk of esophageal cancer, especially SCC.

Barrett’s esophagus is the most common precancerous condition of the esophagus. It isn’t cancer, but it can sometimes become esophageal cancer if it isn’t treated. Some of the risk factors for esophageal cancer may also cause Barrett’s esophagus. Find out more about Barrett’s esophagus.

Risk factors are generally listed in order from most to least important. But in most cases, it is impossible to rank them with absolute certainty.

Tobacco

Alcohol

Betel quid

Gastroesophageal reflux disease (GERD)

Having obesity or overweight

Drinking very hot beverages

Tylosis

Achalasia

Plummer-Vinson syndrome

Chemical injury to the esophagus

History of cancer in the upper airway

Exposure to ionizing radiation

There is convincing evidence that the following factors increase your risk for esophageal cancer.

Using any kind of tobacco has been linked to the development of esophageal cancer. Tobacco use combined with drinking alcohol increases the risk of developing esophageal cancer more than either risk factor alone.

Smoking cigarettes causes both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus, but people who smoke are more likely to develop SCC.

The more you smoke, the greater your risk of developing SCC of the esophagus. Research shows that the risk of developing SCC of the esophagus decreases after you stop smoking.

For adenocarcinoma of the esophagus, the risk is lower in people who have quit smoking than in people who still smoke. But it is not clear how much a person's risk decreases after they stop smoking.

People who smoke pipes and cigars have a higher risk of developing SCC of the esophagus.

Researchers have shown that smokeless tobacco increases the risk for both SCC and adenocarcinoma of the esophagus.

Drinking alcohol increases your risk for SCC of the esophagus. Drinking alcohol combined with using tobacco increases the risk of esophageal cancer more than either risk alone. It is not known for sure if alcohol is a risk for adenocarcinoma of the esophagus. The less alcohol you drink, the lower your cancer risk.

Find out more about how to limit alcohol.

Betel quid, or paan, is areca nut (the seed from the fruit of the oriental palm) and lime wrapped in a betel leaf. Some people chew areca nut by itself. Chewing betel quid is common in China, India and some other countries in Asia and among some Asian immigrants in Canada.

Betel quid contains cancer-causing substances that increase the risk of developing SCC of the esophagus. Betel quid and tobacco are often chewed together, but there is a risk of developing SCC of the esophagus whether or not tobacco is also chewed.

Gastroesophageal reflux disease (GERD) is a disorder in which the contents of the stomach (including stomach acid) back up, or reflux, into the esophagus. This causes heartburn and discomfort in the upper abdomen or chest. The stomach acid can damage the tissue at the lower end of the esophagus.

GERD increases the risk of Barrett’s esophagus, which increases the risk of developing adenocarcinoma of the esophagus.

Having overweight or obesity increases the risk of adenocarcinoma of the esophagus. These factors also increase the risk of GERD.

People who drink very hot coffee, tea, maté and other beverages (hotter than 65°C) have a higher risk of developing esophageal cancer, particularly squamous cell carcinoma. Hot maté is made by pouring boiling water over leaves of the yerba maté plant and is drunk through a metal straw. Drinking very hot maté is common in South American countries. Drinking very hot tea or coffee is common in China, Japan, Iran and Turkey.

Tylosis is a rare inherited disease that increases the risk of developing esophageal cancer. Researchers have identified the tylosis esophageal cancer (TOC) gene. People with this abnormal gene develop scaly patches (hyperkeratosis) on the palms of the hands or soles of the feet. They also have growths with finger-like projections, called papillomas, in the esophagus.

Achalasia is an uncommon condition in which the nerves that control the normal rhythmic contractions in the esophagus and the lower esophageal sphincter do not work properly. The part of the esophagus above the sphincter becomes enlarged, and a person has a hard time swallowing food and liquid.

Researchers think that achalasia increases the risk for SCC of the esophagus because the food trapped in the esophagus can cause chronic irritation. After symptoms start, it can take many years for cancer to develop.

Plummer-Vinson syndrome is also called Paterson-Kelly syndrome. In this rare syndrome, the mucous membranes of the mouth, throat (pharynx) and esophagus waste away. A thin membrane of tissue (known as an esophageal web) can also grow anywhere along the esophagus, which causes problems swallowing. Doctors think Plummer-Vinson syndrome is caused by a lack of vitamins and iron. People with this syndrome often have iron-deficient anemia.

About 10% of people with Plummer-Vinson syndrome will develop SCC of the esophagus. Researchers think that this syndrome increases the risk for SCC of the esophagus because it causes nutritional problems, and the food trapped in the webs can cause chronic irritation.

The esophagus can be damaged by exposure to chemicals. Drinking a caustic chemical such as lye can lead to narrowed areas called strictures in the esophagus. SCC of the esophagus can occur in these strictures many years after the chemical injury.

People who had cancer that started in the upper airway, such as oral, pharyngeal or laryngeal (voice box) cancer, are at risk for SCC of the esophagus. These cancers have some of the same risk factors as esophageal cancer, such as tobacco and alcohol use.

People who were exposed to ionizing radiation have a higher risk of developing esophageal cancer, mainly SCC of the esophagus. Studies have shown that the risk of developing adenocarcinoma of the esophagus after exposure to ionizing radiation is much lower.

People who were given radiation therapy to treat breast cancer or Hodgkin lymphoma have a higher risk of developing SCC of the esophagus. However, the benefit of treating cancer often greatly outweighs the risk of developing esophageal cancer later in life.

Ankylosing spondylitis is a type of arthritis that affects the spine. People who were given x-ray therapy to treat this disease have a higher risk of developing SCC of the esophagus.

The following factors have been linked with esophageal cancer, but there is not enough evidence to show for sure that they are risk factors. More research is needed to clarify the role of these factors for esophageal cancer.

• family history
• human papillomavirus (HPV) infection
• eating processed meat
• a diet low in vegetables and fruit
• physical inactivity

Significant evidence shows that you do not have a higher risk of esophageal cancer if you drink carbonated beverages or have a Helicobacter pylori (H. pylori) infection.

To make the decisions that are right for you, ask your healthcare team questions about risks.