Causes and Risk Factors for Esophageal Cancer

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Since the disease is often diagnosed in the later, less treatable stages, having an awareness of the risk factors, as well as being familiar with the symptoms of esophageal cancer, is important to detect the disease as early as possible. For reasons unknown, the incidence of adenocarcinoma of the esophagus has recently shown a dramatic increase in developed countries.


Like many cancers, genetics likely factor into the development of esophageal cancer, and clusters of cancer within families have been noted in some regions of the world. Genetics probably play a greater role in squamous cell carcinoma than adenocarcinoma, especially with regard to certain gene abnormalities that have been tied to the disease. One genetic syndrome, tylosis, is associated with a very high risk of esophageal squamous cell carcinoma. The syndrome is characterized by thickening of the skin on the palms and soles due to defective vitamin A metabolism.


Understanding Risk


Some of the risk factors for esophageal cancer are things that cause irritation and damage to the lining of the esophagus, and we are learning that chronic inflammation can lead to changes in tissue that eventually lead to cancer. Some risk factors, such as tobacco, contain carcinogens (cancer-causing substances) that can directly damage DNA. 

Squamous Cell Carcinoma

Squamous cell cancers begin in the surface cells (squamous cells) that line the esophagus. These cancers are more common in the upper part of the esophagus and are the most common type worldwide.

Risk factors for this type of esophageal cancer include:






In the United States, squamous cell carcinomas are much more common in blacks than in whites, while the opposite is true for adenocarcinomas.


The incidence of both types of esophageal cancer varies significantly around the world. The highest incidence of squamous cell carcinoma of the esophagus is in what's been coined the "Asian Esophageal Cancer Belt." This region includes areas such as Turkey, Iran, Kazakhstan, and central and northern China. The incidence is also very high in southeastern Africa.


Squamous cell carcinomas of the esophagus are roughly five times more common in people who smoke. Smoking is not, however, a risk factor for esophageal cancer in all parts of the world. For example, in China, it appears that smoking plays only a small role; dietary factors appear more important.

Heavy Alcohol Use

Like smoking, alcohol intake is a significant risk factor for squamous cell carcinoma of the esophagus in some parts of the world but not others. Heavy alcohol intake is associated with a 1.8- to 7.4-fold increase in risk. Low to moderate alcohol intake, according to a 2018 study, is actually associated with a lower risk of developing the disease than for those who abstain.

Smoking Plus Heavy Alcohol Use


Environmental Exposures

Exposure to some chemicals—tetrachloroethylene used in dry cleaning, for example—may increase the risk of esophageal cancer.

Drinking Lye (Drain Cleaner)



Achalasia is a condition in which the muscular band around the lower part of the esophagus (the lower esophageal sphincter) doesn't relax properly to allow food to leave the esophagus and enter the stomach. This results in food remaining in and stretching the lower esophagus. Achalasia is associated with a high risk of esophageal cancer, with cancer often occurring 15 to 20 years after the diagnosis.

Radiation Therapy to the Chest and Upper Abdomen

Radiation therapy to the chest for conditions such as breast cancer or Hodgkin's disease may increase risk. While women who have had radiation after a mastectomy have an elevated risk, this does not appear to be the case for women who have radiation to remaining breast tissue after a lumpectomy.

History of Head and Neck or Lung Cancer


Drinking Hot Beverages





In China, foods high in nitrates may double the risk. The risk is also higher for those who have vitamin and mineral deficiencies (especially folate, vitamin C, and molybdenum) in developing countries.

Human Papillomavirus Infection (HPV)




Risk factors for this type of esophageal cancer include:


Like squamous cell cancers, adenocarcinomas are most common in people between ages 50 and 70.


In the United States, adenocarcinomas are eight times more common in men than in women.





Gastroesophageal Reflux Disease (GERD)

Acid reflux, or gastroesophageal reflux disease (GERD), is a significant risk factor for esophageal adenocarcinoma, with roughly 30 percent of these cancers thought to be linked to the condition. It's thought that between 0.5 percent and 1 percent of people with GERD will develop esophageal cancer.

Barrett's Esophagus

Barrett's esophagus is a condition in which the normal cells of the lower esophagus (squamous cells) are replaced with glandular cells like those present in the stomach and intestines. It is usually found in people who have longstanding chronic acid reflux and occurs in 6 percent to 14 percent of people with chronic GERD. Though estimates vary, roughly 1 in 100 to 1 in 200 people with Barrett's esophagus will develop esophageal cancer each year. Like adenocarcinoma, Barrett's esophagus is increasing in the United States.


Hiatal Hernia



Being overweight or obese increases the risk of adenocarcinoma of the esophagus. According to a  2015 review, people who are overweight (body mass index of 25 to 29) are about 50 percent more likely to develop cancer, while those who are obese (body mass index of 30 or higher) are roughly twice as likely to develop esophageal cancer. Having type 2 diabetes may also increase risk, but it's uncertain whether this is related to diabetes itself or co-occurring obesity.




Some medications are associated with either an increased or decreased risk of adenocarcinoma of the esophagus. The use of bisphosphonates (used for osteoporosis) may increase risk, as may the use of estrogen-only hormone replacement therapy. In contrast, the use of aspirin is associated with a decreased risk. 

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