Two different cancers wear the same name
Esophageal cancer starts in the tube that carries food from your throat to your stomach. It comes in two main types, and which one you get tracks closely with race in the United States.
Squamous cell carcinoma starts in the flat cells lining the esophagus and is driven by tobacco, alcohol, and very hot drinks. Adenocarcinoma starts in gland cells near the stomach and is driven by chronic acid reflux, Barrett's esophagus, and obesity. In a SEER analysis covering 1991 to 2000, squamous cell carcinoma was the more common type in Black patients, while adenocarcinoma was more common among white men. That split is the heart of this disparity: Black men carry the smoking-and-alcohol cancer, and they carry more of it.
That same SEER data put the age-adjusted incidence at 8.63 per 100,000 in Black Americans versus 4.39 in white Americans, with mortality at 7.79 versus 3.96. The numbers are close to double on both counts, and the gap is concentrated in the squamous cell type that hits Black men hardest. If you smoke, this is the article to finish.
Diagnosed later, treated less, surviving worse
The disparity does not stop at who gets the disease. A 2024 study in the American Journal of Gastroenterology of 23,768 esophageal squamous cell cancer patients found Black patients arrived with more advanced disease (26.7% had distant spread at diagnosis versus 23.8% of white patients) and had lower five-year survival at every stage: 19.3% versus 27.6% for localized disease, and 2.9% versus 6.5% once it had spread.
The treatment gap is starker than the diagnosis gap. In that same study, only 11.4% of Black patients had surgery versus 16.3% of white patients. Surgery is the treatment most tied to long-term survival in esophageal cancer, so being passed over for it matters. A 2021 study in the Journal of Surgical Oncology found Black patients had three times the odds of not being recommended for esophagectomy (the surgery to remove the cancer) compared with white patients, even after adjusting for demographics. This is not about patients refusing care. It is about who gets offered it.
What raises the risk
The squamous cell type that predominates in Black men has clear, mostly modifiable drivers:
- Tobacco. Smoking is the single largest driver of squamous cell esophageal cancer. If you smoke menthols, the path out is the same; our guide to quitting menthol cigarettes in the Black community walks through it.
- Alcohol. Heavy drinking raises risk on its own, and it multiplies the risk from smoking. A 2014 meta-analysis confirmed the two together do more damage than either alone.
- Very hot drinks. In 2016 the World Health Organization's cancer agency classified drinking beverages above 65 degrees Celsius (about 149 degrees Fahrenheit) as probably cancer-causing, with squamous cell esophageal cancer as the specific concern. Let the tea or coffee cool.
- Achalasia. This swallowing-muscle disorder leaves food sitting in the esophagus and sharply raises squamous cell risk over decades.
- Diet. Diets low in fruits and vegetables and high in processed meats are associated with higher risk.
The adenocarcinoma drivers are different: long-standing acid reflux, the precancerous lining change called Barrett's esophagus, and carrying excess weight. If reflux is a regular part of your life, treating it matters; here is what to know about GERD and acid reflux in Black adults.
The symptoms that get missed
Esophageal cancer is caught late partly because its first symptoms are easy to explain away. The most common early sign is trouble swallowing, a feeling that food is sticking or catching in your throat or chest, often starting with dry or coarse foods. People adapt by chewing more, eating slower, or switching to softer foods, which hides the problem for months.
Other signs to take seriously: pain when swallowing, unintentional weight loss, chest or back pain or pressure, hoarseness, persistent cough, vomiting, and black or tarry stools (a sign of bleeding). By the time swallowing is clearly difficult or weight is dropping, the cancer is often advanced. That is exactly why the early sticking sensation should never be waited out.
How it is diagnosed and treated
The key test is an upper endoscopy (also called an EGD), where a doctor passes a thin camera down your esophagus and takes a biopsy of anything suspicious. The biopsy confirms whether it is cancer and which type. If cancer is found, endoscopic ultrasound, CT, and PET scans stage how far it has gone. Staging drives the plan.
Treatment depends on stage. Very early cancers can sometimes be removed through the endoscope. Most others are treated with some combination of surgery to remove the esophagus (esophagectomy), chemotherapy, and radiation. Because Black patients are documented to be offered surgery less often, going to a high-volume cancer center and asking directly whether you are a surgical candidate is one of the most concrete things you can do for your own odds.
How to get care
If you have new or worsening trouble swallowing, do not wait for it to get worse. Ask your primary care doctor for a referral for an upper endoscopy, and if you smoke or drink heavily, say so, because that changes how seriously the symptom should be taken. The two prevention levers fully in your hands are quitting tobacco and cutting heavy alcohol; both lower squamous cell risk over time. To find a clinician who takes your concerns seriously, you can find a Black or Black-serving doctor in our directory.
Frequently asked questions
Why is esophageal cancer more common in Black men? ▼
Black men carry more of the squamous cell type of esophageal cancer, which is driven by smoking, alcohol, and very hot drinks. SEER data show roughly double the incidence and mortality compared with white Americans. Higher smoking and drinking exposure combined with later diagnosis and less surgery drive the gap.
What is the difference between squamous cell and adenocarcinoma esophageal cancer? ▼
Squamous cell carcinoma starts in the flat cells lining the esophagus and is tied to tobacco, alcohol, and hot beverages. It is the type more common in Black patients. Adenocarcinoma starts in gland cells near the stomach and is tied to acid reflux, Barrett's esophagus, and obesity, and is more common in white men.
What is the first sign of esophageal cancer? ▼
The most common early sign is trouble swallowing, a feeling that food is sticking or catching in your throat or chest, often with dry or coarse foods first. New or worsening difficulty swallowing warrants an upper endoscopy, not a wait-and-see approach.
Can esophageal cancer be prevented? ▼
There is no guaranteed prevention, but the squamous cell type is largely driven by modifiable factors. Quitting smoking, cutting heavy alcohol, letting hot drinks cool below 65 degrees Celsius, and treating chronic reflux all lower risk. Quitting tobacco and reducing alcohol are the two biggest levers.
How is esophageal cancer diagnosed? ▼
The main test is an upper endoscopy (EGD), in which a doctor passes a thin camera down the esophagus and biopsies anything suspicious. The biopsy confirms the cancer and its type. CT, PET, and endoscopic ultrasound then determine how far it has spread.
