What alarm symptoms should prompt urgent referral for gastroscopy?

Progressive dysphagia (difficulty swallowing that started with solids and has worsened) is the most important. Any adult with dysphagia should have urgent gastroscopy arranged, not a trial of proton pump inhibitor. Other alarm symptoms requiring urgent 2-week-pathway referral include: unexplained weight loss with any upper GI symptom; iron-deficiency anaemia without an obvious cause; haematemesis or melaena; persistent vomiting; odynophagia (painful swallowing); and a hoarse voice alongside swallowing symptoms (suggesting recurrent laryngeal involvement). Age over 40 with any of these symptoms increases the urgency. Do not attribute progressive dysphagia to reflux without endoscopic evaluation.

What is Barrett's oesophagus and who should be surveilled?

Barrett's oesophagus is a change in the lining of the lower oesophagus from normal squamous epithelium to intestinal-type columnar epithelium — a consequence of chronic acid and bile reflux. It progresses to adenocarcinoma in roughly 0.3–0.6% of patients per year. Surveillance gastroscopy is recommended for patients with confirmed Barrett's: every 3–5 years if no dysplasia is present per BSG 2022 guidelines. Low-grade dysplasia warrants referral for radiofrequency ablation (RFA) — the SURF trial showed a 75% reduction in progression to high-grade dysplasia or cancer. High-grade dysplasia or superficial cancer (T1a) is treated with RFA and endoscopic mucosal resection. Surveillance should not be offered to patients who would not be candidates for treatment.

What are the two main types of oesophageal cancer and how are they different?

Adenocarcinoma (AC, ~75% of AU cases) arises at the lower oesophagus or gastro-oesophageal junction, driven by GORD, Barrett's oesophagus, central obesity, smoking, and male sex. Squamous cell carcinoma (SCC, ~25%) arises in the mid or upper oesophagus from squamous epithelium, driven by tobacco, alcohol (synergistic), very hot beverages ≥65°C (IARC Group 2A, 2016), achalasia, and nutritional deficiency. SCC is disproportionately more common in Aboriginal and Torres Strait Islander Australians. The two types have different staging systems, biomarker profiles, and systemic therapy regimens — accurate histology from biopsy is essential before any treatment planning.

What does treatment look like for resectable oesophageal cancer?

Stage and histology determine approach. For superficial cancers (T1a, mucosal), endoscopic mucosal resection plus radiofrequency ablation of residual Barrett's is preferred over surgery. For locally advanced disease (T3–T4 or node-positive), the CROSS trial (van Hagen NEJM 2012, updated Eyck JCO 2021) established neoadjuvant chemoradiation — carboplatin plus paclitaxel with 41.4 Gy — followed by surgery as standard, with 5-year overall survival of 47% versus 33% with surgery alone. For junctional adenocarcinoma, perioperative FLOT chemotherapy is an alternative. For metastatic disease, immunotherapy combinations are now first-line: nivolumab plus ipilimumab or chemo for SCC (CheckMate 648); pembrolizumab plus chemo for adenocarcinoma if CPS ≥10 (KEYNOTE-590). HER2-positive adenocarcinoma receives trastuzumab-based therapy (ToGA trial).

What is the GP's role once oesophageal cancer is diagnosed?

After a diagnosis is made by a specialist, the GP's ongoing role covers several domains. Coordinating smoking cessation and alcohol reduction — the two modifiable risk factors for SCC. Managing comorbidities alongside oncology care, including iron-deficiency anaemia (IV iron may be needed pre-operatively) and GORD. Monitoring for and helping manage treatment side effects, including immune-related adverse events if immunotherapy is used. Psychosocial support — cancer-related distress is common and warrants a Mental Health Care Plan. Post-oesophagectomy: coordinating dietitian and speech pathology input for swallowing rehabilitation, dumping syndrome, and nutrition (weight loss is nearly universal post-oesophagectomy and requires active dietary management). Advance care planning for those with advanced disease.

Oesophageal cancer

Oesophageal cancer: alarm symptoms, referral, and Barrett's surveillance

By Dr HB Lo, FACRRM Reviewed 14 September 2026 7 min read

Oesophageal cancer affects approximately 1,600 Australians annually, with around 1,500 deaths per year and 5-year survival of roughly 22%. Late diagnosis is the primary driver of poor outcomes.

Adenocarcinoma (~75% of AU cases) arises from GORD, Barrett's oesophagus, and obesity. Squamous cell carcinoma (~25%) is driven by tobacco, alcohol, and very hot beverages, and is more common in Aboriginal and Torres Strait Islander Australians.

Dysphagia in any adult requires urgent gastroscopy, not a PPI trial. Patients with dysphagia, unexplained weight loss, iron-deficiency anaemia, or haematemesis should be referred on the urgent 2-week pathway.

Oesophageal cancer: why timing changes everything

Oesophageal cancer carries one of the poorest prognoses of any solid malignancy in Australia — a 5-year survival of roughly 22% across all stages. This is almost entirely explained by late diagnosis. Most patients present with symptoms only after the tumour has invaded the oesophageal wall or spread to regional lymph nodes, at which point curative-intent treatment is substantially harder to achieve.

The GP’s role in improving outcomes is not in managing the cancer itself but in recognising the symptoms that demand urgent investigation. Dysphagia in any adult is not a symptom to monitor and review — it is a symptom to investigate now.

A. Core clinical — the AU general-practice framework

The two types and their risk profiles

Adenocarcinoma (AC, ~75% of AU cases) arises from glandular epithelium at the lower oesophagus and gastro-oesophageal junction. It is driven by chronic acid and bile reflux, Barrett’s oesophagus, central obesity, smoking, male sex, and Caucasian ethnicity. The rising incidence of AC in Australia parallels obesity and GORD prevalence trends over the past four decades.

Squamous cell carcinoma (SCC, ~25%) arises from squamous epithelium in the mid or upper oesophagus. Key risk factors are tobacco and alcohol (synergistic carcinogenesis), drinking very hot beverages at temperatures ≥65°C (IARC Group 2A per WHO IARC Monograph 116, 2016), nutritional deficiency, achalasia, and prior caustic stricture. SCC is disproportionately prevalent in Aboriginal and Torres Strait Islander Australians.

Both histologies share an average age at diagnosis of around 70 years, and both present late in the majority of cases.

History and alarm symptoms

The symptom that demands investigation is progressive dysphagia — initially difficulty with solids, then semi-solids, then liquids. This symptom is present in approximately 75% of patients at the time of diagnosis, which indicates how late most presentations are.

Additional alarm symptoms requiring urgent referral include:

Unexplained weight loss (>5% in 6 months) with any upper GI symptom
Odynophagia (pain on swallowing)
Iron-deficiency anaemia without a clear alternative cause
Haematemesis or melaena
Hoarse voice alongside swallowing symptoms (recurrent laryngeal nerve involvement)
Persistent vomiting with weight loss
Regurgitation of undigested food

Any patient over 40 with dysphagia and at least one of the above should be referred as an urgent 2-week pathway case. Do not offer a PPI trial in the presence of dysphagia — this delays diagnosis and does not investigate the cause.

Risk factors to document: GORD duration and severity; Barrett’s oesophagus (known); smoking pack-years; alcohol use (standard drink estimation); BMI and weight trajectory; family history of upper GI cancer; Aboriginal or Torres Strait Islander identity (for SCC risk context).

Examination

Cachexia and performance status — prognostic and treatment-relevant
Virchow’s node (left supraclavicular) — suggests lower oesophageal or junctional metastasis
Cervical lymphadenopathy — upper-third SCC
Chest: signs of aspiration pneumonia or effusion
Abdomen: hepatomegaly (distant metastasis), ascites (peritoneal disease)

Initial investigations in general practice

Before referral:

FBC — microcytic anaemia from chronic bleeding
Iron studies — confirm iron-deficiency anaemia, guide replacement
LFTs, U&E, weight — baseline and for staging context
CXR — mediastinal widening, aspiration changes

The GP does not investigate oesophageal cancer; the GP identifies alarm symptoms and refers. Endoscopy, staging CT, EUS, PET-CT, and biomarker testing (HER2, PD-L1, CLDN18.2 IHC) are all specialist-arranged.

Barrett’s oesophagus surveillance

Patients with established Barrett’s oesophagus — whether diagnosed incidentally or during a GORD workup — require ongoing surveillance:

No dysplasia: gastroscopy every 3–5 years per BSG 2022
Indefinite for dysplasia: repeat after PPI optimisation at 6 months
Low-grade dysplasia: refer for radiofrequency ablation (RFA) — the SURF trial (Phoa JAMA 2014) demonstrated a 75% reduction in progression to high-grade dysplasia or adenocarcinoma
High-grade dysplasia or T1a (mucosal) cancer: RFA plus endoscopic mucosal resection (EMR) — curative in selected patients without surgery

Barrett’s surveillance should not be started for patients who would not accept endoscopic or surgical treatment if dysplasia were found.

B. Evidence and controversies

Neoadjuvant chemoradiation for locally advanced disease

The CROSS trial (van Hagen NEJM 2012) established neoadjuvant carboplatin/paclitaxel with 41.4 Gy radiotherapy followed by surgery as the standard for resectable locally advanced oesophageal and junctional cancer. Five-year overall survival was 47% versus 33% for surgery alone. The 10-year update (Eyck JCO 2021) confirmed sustained benefit. Perioperative FLOT chemotherapy is an alternative for junctional and gastric adenocarcinoma (FLOT4 trial).

Immunotherapy in metastatic disease

Immunotherapy has transformed the first-line treatment of metastatic oesophageal cancer. For SCC, CheckMate 648 (Doki NEJM 2022) showed overall survival benefit with nivolumab plus ipilimumab, and nivolumab plus chemotherapy, versus chemotherapy alone.

For adenocarcinoma, KEYNOTE-590 (Sun Lancet 2021) showed pembrolizumab plus chemotherapy improved overall survival in PD-L1 CPS ≥10 tumours (HR 0.73). For HER2-positive AC, trastuzumab added to chemotherapy improved overall survival in the ToGA trial (Bang Lancet 2010), with trastuzumab deruxtecan now a 2nd-line option. For CLDN18.2-positive junctional and gastric AC, zolbetuximab added to FOLFOX (SPOTLIGHT trial) or CAPOX (GLOW trial) improved overall survival — PBS listing is pending.

Radiofrequency ablation for Barrett’s with low-grade dysplasia

The SURF trial (Phoa JAMA 2014) randomised 136 patients with confirmed low-grade dysplasia Barrett’s to RFA or surveillance. RFA reduced progression to high-grade dysplasia or adenocarcinoma by 75% at 3 years. Diagnostic reproducibility of low-grade dysplasia is poor (pathologist agreement is moderate at best), so referral to a high-volume centre for expert Barrett’s pathology is important before RFA.

C. Oesophageal cancer in Australian practice

MBS items

Gastroscopy (item 30473) — specialist, diagnostic
CT chest and abdomen (items 56407/56412) — Authority Required
EUS-FNA (item 30562) — T/N staging
PET-CT (item 61628) — Authority Required, MSAC
Chronic Disease Management Plan (items 965/967) — oesophageal cancer qualifies as a chronic condition
Mental Health Care Plan (items 2715/2717) — cancer-related distress
Iron infusion (item 13950) — for preoperative iron-deficiency anaemia
Advance care planning (item 731)

PBS items

Chemotherapy agents (5-fluorouracil, leucovorin, capecitabine, oxaliplatin, paclitaxel, carboplatin) are available through Section 100 Efficient Funding of Chemotherapy. Nivolumab, pembrolizumab, and trastuzumab for applicable indications are Authority Required Section 100. Zolbetuximab PBS listing is pending. Oral PPIs (esomeprazole, pantoprazole) are PBS general schedule for co-management of GORD.

Cancer Council and multidisciplinary team

Cancer Council Australia 13 11 20 provides free information and peer support. The Gut Foundation Australia has patient-facing Barrett’s and oesophageal cancer resources. Oesophageal cancer management requires a multidisciplinary team — upper GI surgery, radiation oncology, medical oncology, dietitian, speech pathology, and GP.

Aboriginal and Torres Strait Islander considerations

Over-representation of SCC in Aboriginal and Torres Strait Islander Australians requires proactive engagement through ACCHOs and Aboriginal Liaison services. Access barriers to endoscopy and tertiary oncology are real — document and actively assist with transport, cultural safety requirements, and interpreter needs.

D. Special populations

Post-oesophagectomy nutrition. Weight loss and dietary restriction are nearly universal after oesophagectomy. Dumping syndrome (early satiety, diarrhoea after meals), reflux, and vitamin B12 malabsorption require dietitian input and GP coordination. Oral B12, vitamin D, and iron supplementation are often needed long-term; parenteral B12 may be required.

Patients with ADPKD or immunosuppression. No specific oesophageal cancer interaction, but standard GORD and Barrett’s surveillance principles apply.

Older adults (median age ~70 at diagnosis). Functional status and comorbidity, not age alone, determine treatment intensity. Many older Australians with good performance status benefit from curative-intent treatment. Advance care planning conversations are appropriate early.

Patients on long-term PPI therapy. Long-term PPI does not prevent oesophageal adenocarcinoma in Barrett’s but does reduce acid-driven progression. Monitor for B12 and magnesium deficiency with long-term use.

When to escalate

Refer urgently (2-week pathway) for any:

Dysphagia at any age
Age ≥40 with weight loss plus any upper GI symptom
Iron-deficiency anaemia unexplained in any adult
Haematemesis or melaena

Refer to the emergency department immediately for:

Complete aphagia (inability to swallow solids or liquids)
Acute haemorrhage
Suspected oesophageal perforation (severe chest pain, subcutaneous emphysema)
Aspiration pneumonia with systemic sepsis
Neutropenic sepsis during chemotherapy

What this article is and is not

This is general health information drawn from Cancer Australia, AIHW, Therapeutic Guidelines (eTG), NCCN, and published trials. It is not personal medical advice and does not replace assessment and management by your GP and specialist team.

For AU consumer resources: Cancer Council Australia 13 11 20, Gut Foundation Australia, HealthDirect.

Sources cited

Frequently asked questions

What alarm symptoms should prompt urgent referral for gastroscopy?

Progressive dysphagia (difficulty swallowing that started with solids and has worsened) is the most important. Any adult with dysphagia should have urgent gastroscopy arranged, not a trial of proton pump inhibitor. Other alarm symptoms requiring urgent 2-week-pathway referral include: unexplained weight loss with any upper GI symptom; iron-deficiency anaemia without an obvious cause; haematemesis or melaena; persistent vomiting; odynophagia (painful swallowing); and a hoarse voice alongside swallowing symptoms (suggesting recurrent laryngeal involvement). Age over 40 with any of these symptoms increases the urgency. Do not attribute progressive dysphagia to reflux without endoscopic evaluation.
What is Barrett's oesophagus and who should be surveilled?

Barrett's oesophagus is a change in the lining of the lower oesophagus from normal squamous epithelium to intestinal-type columnar epithelium — a consequence of chronic acid and bile reflux. It progresses to adenocarcinoma in roughly 0.3–0.6% of patients per year. Surveillance gastroscopy is recommended for patients with confirmed Barrett's: every 3–5 years if no dysplasia is present per BSG 2022 guidelines. Low-grade dysplasia warrants referral for radiofrequency ablation (RFA) — the SURF trial showed a 75% reduction in progression to high-grade dysplasia or cancer. High-grade dysplasia or superficial cancer (T1a) is treated with RFA and endoscopic mucosal resection. Surveillance should not be offered to patients who would not be candidates for treatment.
What are the two main types of oesophageal cancer and how are they different?

Adenocarcinoma (AC, ~75% of AU cases) arises at the lower oesophagus or gastro-oesophageal junction, driven by GORD, Barrett's oesophagus, central obesity, smoking, and male sex. Squamous cell carcinoma (SCC, ~25%) arises in the mid or upper oesophagus from squamous epithelium, driven by tobacco, alcohol (synergistic), very hot beverages ≥65°C (IARC Group 2A, 2016), achalasia, and nutritional deficiency. SCC is disproportionately more common in Aboriginal and Torres Strait Islander Australians. The two types have different staging systems, biomarker profiles, and systemic therapy regimens — accurate histology from biopsy is essential before any treatment planning.
What does treatment look like for resectable oesophageal cancer?

Stage and histology determine approach. For superficial cancers (T1a, mucosal), endoscopic mucosal resection plus radiofrequency ablation of residual Barrett's is preferred over surgery. For locally advanced disease (T3–T4 or node-positive), the CROSS trial (van Hagen NEJM 2012, updated Eyck JCO 2021) established neoadjuvant chemoradiation — carboplatin plus paclitaxel with 41.4 Gy — followed by surgery as standard, with 5-year overall survival of 47% versus 33% with surgery alone. For junctional adenocarcinoma, perioperative FLOT chemotherapy is an alternative. For metastatic disease, immunotherapy combinations are now first-line: nivolumab plus ipilimumab or chemo for SCC (CheckMate 648); pembrolizumab plus chemo for adenocarcinoma if CPS ≥10 (KEYNOTE-590). HER2-positive adenocarcinoma receives trastuzumab-based therapy (ToGA trial).
What is the GP's role once oesophageal cancer is diagnosed?

After a diagnosis is made by a specialist, the GP's ongoing role covers several domains. Coordinating smoking cessation and alcohol reduction — the two modifiable risk factors for SCC. Managing comorbidities alongside oncology care, including iron-deficiency anaemia (IV iron may be needed pre-operatively) and GORD. Monitoring for and helping manage treatment side effects, including immune-related adverse events if immunotherapy is used. Psychosocial support — cancer-related distress is common and warrants a Mental Health Care Plan. Post-oesophagectomy: coordinating dietitian and speech pathology input for swallowing rehabilitation, dumping syndrome, and nutrition (weight loss is nearly universal post-oesophagectomy and requires active dietary management). Advance care planning for those with advanced disease.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.