Esophageal cancer comes in two main types. Adenocarcinoma usually starts in the lower esophagus, is linked to long-term acid reflux, a condition called Barrett’s esophagus, and excess weight, and is the more common type in Western countries. Squamous cell carcinoma usually starts higher up, is linked to smoking, alcohol and very hot drinks, and makes up more than 90 percent of cases in China. The first signs are often difficulty swallowing and weight loss. This article explains prevention, the tests, treatment for each type, and nutrition.
Prevention
Barrett’s esophagus. People with Barrett’s esophagus are monitored with regular endoscopy so that early changes can be treated before they become cancer. In the British AspECT trial of 2,557 people with Barrett’s esophagus, a high dose of the acid-reducing drug esomeprazole, especially combined with aspirin, improved long-term outcomes.1
Very hot drinks. The International Agency for Research on Cancer classifies drinking very hot beverages, above about 65°C (149°F), as probably causing esophageal cancer.2 Letting tea and coffee cool for a few minutes lowers the risk.
Vitamins in Linxian, China. In Linxian County, one of the areas with the highest rates of esophageal cancer in the world, a large trial found that a combination of selenium, vitamin E and beta-carotene reduced cancer deaths by 13 percent, mainly from stomach cancer.3 See our article on stomach cancer.
The Tests Every Patient Needs
An endoscopy with biopsy confirms the diagnosis and the type. An endoscopic ultrasound shows how deeply the cancer has grown, and a PET-CT scan checks for spread. Tumor testing for HER2, PD-L1, MSI and Claudin 18.2 guides treatment, especially in advanced disease. See our article on tumor sequencing.
Adenocarcinoma: A German Trial Changes Treatment
For adenocarcinoma that can be removed, the two standard approaches have been FLOT chemotherapy before and after surgery, developed in Germany, or chemotherapy with radiation before surgery, called CROSS, developed in the Netherlands. The German ESOPEC trial, led by Jens Hoeppner of the University of Bielefeld, compared them directly in 438 patients. With FLOT, median overall survival was 66 months, compared with 37 months with CROSS, and at five years, 50.6 percent were alive, compared with 38.7 percent.4 FLOT is now the preferred approach.
When cancer remains in the tissue removed at surgery after chemoradiation, a year of nivolumab doubled the time free of cancer, 22.4 months compared with 11.0 months, in the CheckMate 577 trial.5
Squamous Cell Cancer: Advances From China
Before surgery. In the Chinese NEOCRTEC5010 trial led from Sun Yat-sen University, chemotherapy with radiation before surgery extended median overall survival to 100.1 months, compared with 66.5 months with surgery alone.6
Advanced disease. Three Chinese trials of Chinese immunotherapy drugs added to chemotherapy extended survival. Camrelizumab extended median overall survival to 15.3 months, compared with 12.0 months, in the ESCORT-1st trial.7 Toripalimab extended it to 17.0 months, compared with 11.0 months, in the JUPITER-06 trial.8 Tislelizumab extended it to 17.2 months, compared with 10.6 months, in the RATIONALE-306 trial.9 See our article on how immunotherapy works.
Keeping the esophagus. For some patients, especially with squamous cell cancer, chemotherapy and radiation without surgery can control the cancer and preserve the esophagus.
Nutrition
Because swallowing is difficult, weight loss is common and weakens people before treatment. Soft, high-protein, high-calorie foods, nutritional drinks, and sometimes a temporary feeding tube help maintain strength. After surgery to remove the esophagus, small, frequent meals and sitting upright after eating help prevent reflux and dumping syndrome. Fasting is not appropriate for people who are losing weight.
How Cancer Expert MD Helps
Cancer Expert MD provides education and consultation for people with every type and stage of cancer, and specializes in Stage IV and metastatic cancer. Our guide to what to do when chemotherapy stops working explains re-testing and the next steps, and our book, The New Reality of Cancer, covers testing and treatment across all cancers.
Frequently Asked Questions
What is the best treatment before surgery for esophageal adenocarcinoma?
In the German ESOPEC trial, FLOT chemotherapy before and after surgery extended median survival to 66 months, compared with 37 months with chemoradiation, and is now preferred.
Does immunotherapy work for esophageal cancer?
Yes. Three Chinese trials of camrelizumab, toripalimab and tislelizumab with chemotherapy extended survival in advanced squamous cell cancer.
Can esophageal cancer be prevented?
Monitoring Barrett’s esophagus, treating reflux, not smoking, limiting alcohol, and letting very hot drinks cool all lower the risk.
What should I eat if swallowing is hard?
Soft, high-protein, high-calorie foods and nutritional drinks. A temporary feeding tube is sometimes needed to maintain strength.
About the author. Dr. Silver, MD, graduated from Temple University School of Medicine, trained as an interventional cardiologist, and has practiced medicine for nearly fifty years. A lymphoma survivor of about twenty-five years, he is co-author, with Dr. Lindmeier, DHSc, of The New Reality of Cancer: The Science of Recovery. Read more about Dr. Silver, MD.
Research by Dr. Lindmeier, DHSc, cancer educator and co-author of The New Reality of Cancer.
This article is for general education only and is not individual medical advice. Always consult your own doctor before making any changes to your care.
© 2026 Cancer Expert MD, Dr. Silver, MD, and Dr. Lindmeier, DHSc. All rights reserved. This article draws on the research in The New Reality of Cancer and may not be copied, republished or distributed without written permission.
For more in-depth information on this topic and many others, get our book, The New Reality of Cancer: The Science of Recovery.
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References
- Jankowski JAZ, de Caestecker J, Love SB, et al. Esomeprazole and aspirin in Barrett’s oesophagus (AspECT): a randomised factorial trial. The Lancet. 2018;392(10145):400–408.
- International Agency for Research on Cancer. Drinking coffee, mate, and very hot beverages. IARC Monographs, Volume 116. 2018.
- Blot WJ, Li JY, Taylor PR, et al. Nutrition intervention trials in Linxian, China: supplementation with specific vitamin/mineral combinations, cancer incidence, and disease-specific mortality in the general population. Journal of the National Cancer Institute. 1993;85(18):1483–1492.
- Hoeppner J, Brunner T, Schmoor C, et al. Perioperative chemotherapy or preoperative chemoradiotherapy in esophageal cancer (ESOPEC). New England Journal of Medicine. 2025;392(4):323–335.
- Kelly RJ, Ajani JA, Kuzdzal J, et al. Adjuvant nivolumab in resected esophageal or gastroesophageal junction cancer (CheckMate 577). New England Journal of Medicine. 2021;384(13):1191–1203.
- Yang H, Liu H, Chen Y, et al. Neoadjuvant chemoradiotherapy followed by surgery versus surgery alone for locally advanced squamous cell carcinoma of the esophagus (NEOCRTEC5010). Journal of Clinical Oncology. 2018;36(27):2796–2803.
- Luo H, Lu J, Bai Y, et al. Effect of camrelizumab vs placebo added to chemotherapy on survival and progression-free survival in patients with advanced or metastatic esophageal squamous cell carcinoma (ESCORT-1st). JAMA. 2021;326(10):916–925.
- Wang ZX, Cui C, Yao J, et al. Toripalimab plus chemotherapy in treatment-naïve, advanced esophageal squamous cell carcinoma (JUPITER-06). Cancer Cell. 2022;40(3):277–288.
- Xu J, Kato K, Raymond E, et al. Tislelizumab plus chemotherapy versus placebo plus chemotherapy as first-line treatment for advanced or metastatic oesophageal squamous cell carcinoma (RATIONALE-306). The Lancet Oncology. 2023;24(5):483–495.
This article is for education only. It is not medical advice and does not diagnose or treat any condition. Cancer Expert MD has no financial relationship with any laboratory, drug maker, supplement company, clinic or hospital.
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