Oesophageal Cancer: Recognising the Warning Signs and Referring Appropriately
How to identify the red flag symptoms of oesophageal cancer at the pharmacy counter and refer using NICE NG12 criteria.
Why this matters
Oesophageal cancer causes around 9,500 deaths in the UK each year and is the seventh most common cause of cancer death.1,2 Fewer than one in five patients survives five years from diagnosis, largely because symptoms are often attributed to benign heartburn or indigestion until the disease is well advanced.3 Stage 1 carries a five-year survival of around 65%, yet most patients are diagnosed at stage 3 or beyond.3 Community pharmacists are one of the most accessible points of contact in the healthcare system. A patient who has been buying antacids or proton pump inhibitors for months without relief, or who mentions that food seems to be sticking when they swallow, may be describing the early warning signs of a cancer that is highly treatable when caught early. Recognising those signs and acting on them can directly influence outcomes.
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Difficulty swallowing | Occasional, associated with eating too quickly or dry food | Progressive dysphagia starting with solids, worsening to soft food and then liquids |
| Heartburn or reflux | Intermittent, triggered by meals or lying flat, responds to antacids | Persistent heartburn lasting weeks, not responding to antacids or a prescribed proton pump inhibitor |
| Weight | Stable weight or intentional loss with diet change | Unintentional weight loss of 3 kg or more over weeks to months |
| Swallowing pain | Absent or transient, related to a sore throat or cold | Persistent painful swallowing (odynophagia) not explained by infection |
| Regurgitation | Occasional, shortly after overeating | Frequent regurgitation of undigested food, or a sensation of food returning from the chest |
| Voice and cough | Normal voice, cough explained by known cause such as a cold | Unexplained persistent hoarseness or chronic cough without obvious cause |
| Bleeding | None | Vomiting blood, or black tarry stools (melaena), suggesting upper gastrointestinal bleeding |
| Fatigue and pallor | Tiredness explained by lifestyle, sleep, or workload | Unexplained tiredness, pallor, or breathlessness suggesting iron deficiency anaemia from occult bleeding |
Risk Factor Assessment
Oesophageal cancer is not one disease. Adenocarcinoma of the lower oesophagus is strongly linked to chronic gastro-oesophageal reflux disease and Barrett's oesophagus, while squamous cell carcinoma of the upper and mid oesophagus is more closely associated with smoking and heavy alcohol use. Understanding a patient's background helps you judge the significance of their symptoms.
- Age over 55: incidence rises steeply after this threshold, and NICE NG12 referral criteria use age 55 as a key decision point.4
- Male sex: oesophageal cancer is approximately three times more common in men than in women.1
- Chronic heartburn or known gastro-oesophageal reflux disease: longstanding, poorly controlled reflux is the primary driver of adenocarcinoma.
- Known Barrett's oesophagus: a pre-malignant condition in which the normal oesophageal lining is replaced by columnar epithelium; patients should already be under surveillance but may not mention it.
- Smoking: increases risk of both squamous cell carcinoma and adenocarcinoma.
- Heavy or longstanding alcohol use: particularly associated with squamous cell carcinoma.
- Obesity or high body mass index: increases intra-abdominal pressure, promotes reflux, and is an independent risk factor for adenocarcinoma.
- Deprivation: incidence rates in the most deprived communities are up to 50% higher in men and 43% higher in women compared with the least deprived quintile.1
No risk factor is required for referral. Dysphagia at any age meets the NICE 2-week wait threshold regardless of other risk factors.
Questions to Ask at the Counter
Patients with oesophageal cancer often present asking for antacids, asking why their heartburn tablets are not working, or mentioning swallowing difficulties in passing. Use these questions to identify those who need urgent review.
- "Have you had any difficulty swallowing? Does food seem to stick in your throat or chest when you eat?"
- "How long have you had these symptoms? Have they been getting worse, better, or staying the same?"
- "Have you lost any weight recently without trying to?"
- "Has your heartburn or indigestion been getting worse despite taking the tablets? Has it stopped responding to medicines that used to work?"
- "Have you noticed any blood when you are sick, or dark or tarry stools?"
- "Have you felt unusually tired or short of breath lately?"
A patient who answers yes to progressive swallowing difficulty, unexplained weight loss, or any bleeding should be directed to their GP the same day, not given further OTC product.
What to do in pharmacy
Key takeaways
- Progressive difficulty swallowing at any age is a NICE NG12 2-week wait criterion: do not supply further antacids without directing the patient to their GP the same day.
- In a patient aged 55 or over, unexplained weight loss combined with persistent heartburn, reflux, or upper abdominal pain meets the 2-week wait threshold even without dysphagia.
- Patients buying repeated antacids or proton pump inhibitors without improvement are a key safety-netting opportunity: always ask how long symptoms have lasted and whether swallowing is affected.
📚 References
- Cancer Research UK. Oesophageal cancer incidence statistics [Internet]. London: Cancer Research UK; 2022 [cited 2026 Jun]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oesophageal-cancer/incidence
- Cancer Research UK. Oesophageal cancer mortality statistics [Internet]. London: Cancer Research UK; 2024 [cited 2026 Jun]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oesophageal-cancer/mortality
- Cancer Research UK. Oesophageal cancer survival statistics [Internet]. London: Cancer Research UK; 2024 [cited 2026 Jun]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oesophageal-cancer/survival
- National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline NG12. London: NICE; 2015 (updated May 2025). Available from: https://www.nice.org.uk/guidance/ng12
- Cancer Research UK. Oesophageal cancer symptoms [Internet]. London: Cancer Research UK; 2024 [cited 2026 Jun]. Available from: https://www.cancerresearchuk.org/about-cancer/oesophageal-cancer/symptoms