Remembering Christopher Hitchens — and Understanding Esophageal Cancer

What Hitchens wrote about it himself

Christopher Hitchens was diagnosed with stage 4 esophageal cancer in 2010, and he wrote about it until he could not. NPR's review of his posthumous book "Mortality" records the sequence.

He described the morning it started, on a publicity tour for his memoir: "I have more than once in my time woken up feeling like death. But nothing prepared me for the early morning in June when I came to consciousness feeling as if I were actually shackled to my own corpse. The whole cave of my chest and thorax seemed to have been hollowed out and then refilled with slow-drying cement."

A biopsy gave the diagnosis. NPR notes it was the same disease that had killed his father at 79. Hitchens died 18 months later, on December 15, 2011, at 62. He wrote plainly about his own habits, saying he had spent years "knowingly burning the candle at both ends and finding that it often gives a lovely light."

He also documented what treatment did: neuropathy, chemo-brain, and pneumonias.

That is his account, in his words. Nothing here adds to it or judges it. What follows is the disease.

Two cancers wearing one name

The National Cancer Institute states that two histological types account for most esophageal cancers, and that their epidemiology varies markedly.

Squamous cell carcinoma starts in the flat cells lining the esophagus and can develop anywhere along it. Worldwide it is the predominant type, and it used to be the more common one in the United States.

Adenocarcinoma starts in gland cells and typically appears in the lower esophagus. NCI reports that its incidence has risen dramatically in recent decades, and that it is now more prevalent than squamous cell carcinoma in the United States and western Europe. The rise has been most notable among White men. NCI states the cause of that shift is unknown.

Anatomy explains part of the difference. The esophagus is a muscular tube running from the throat to the stomach. NCI describes it as extending roughly 30 to 40 cm when measured by endoscopy from the front teeth, divided into cervical, upper thoracic, middle thoracic, and lower thoracic segments. Most adenocarcinomas sit in that last, lowest stretch, where stomach acid reaches.

Reflux, Barrett esophagus, and risk

NCI lists tobacco use and alcohol use as risk factors for squamous cell carcinoma of the esophagus.

For adenocarcinoma, NCI says the risk factors are less clear, with one exception: Barrett esophagus. In Barrett esophagus, the lining of the lower esophagus changes into a type of tissue that more closely resembles intestinal lining. NCI calls chronic reflux the predominant cause of that change, and notes that a population-based study strongly suggested symptomatic gastroesophageal reflux is a risk factor for esophageal adenocarcinoma. The frequency, severity, and duration of reflux symptoms were positively correlated with increased risk.

Risk factors describe populations. They do not explain any single person's cancer, and they are not a verdict on anyone.

When to get checked

Esophageal cancer has one cardinal symptom, and most people meet it late. NCI says to check with a doctor about:

• Painful or difficult swallowing.
• Weight loss.
• Pain behind the breastbone.
• Hoarseness and cough.
• Indigestion and heartburn.
• A lump under the skin.

Difficulty swallowing deserves a longer look. It usually starts with solid food, especially dry bread or meat, feeling as though it has stopped partway down. Over weeks it can progress to softer food, then liquids. That pattern, solids first and worsening, is the one to act on.

Practical thresholds:

• New trouble swallowing at any age is a reason for an endoscopy, not a longer trial of antacids.
• Heartburn several times a week for years is worth a conversation about whether Barrett esophagus should be looked for.
• Unintended weight loss alongside any swallowing difficulty should not wait.
• Vomiting blood is an emergency. Go to an emergency department.

How it is found and treated

Diagnosis rests on endoscopy with biopsy. A thin lighted tube goes down the esophagus, the abnormal area is seen directly, and tissue is taken.

NCI describes the treatments. Surgery is the most common. An esophagectomy removes part of the esophagus, and the surgeon connects the remaining healthy esophagus to the stomach so the patient can still swallow, sometimes using a plastic tube or a segment of intestine to bridge the gap. Nearby lymph nodes are removed and examined.

Small early-stage cancers and high-grade dysplasia can sometimes be removed through the endoscope, without open surgery. When a tumor partly blocks the esophagus, an expandable metal stent can be placed to hold it open.

Nutrition is not a side issue here. NCI notes that many people with esophageal cancer find it hard to eat, because the tumor or the treatment narrows the esophagus. Some receive nutrients directly into a vein. Others need a feeding tube passed through the nose or mouth into the stomach until they can eat again.

What the numbers show

These are group figures. They summarize thousands of people and describe no individual.

NCI is direct about the overall picture: in most cases esophageal cancer is a treatable disease, but it is rarely curable. NCI gives a five-year relative survival rate of 21.6%, and notes that 18.2% of patients are diagnosed at the local stage, where five-year relative survival is 48.1%. Favorable prognostic factors are early-stage disease and complete surgical removal.

The American Cancer Society projects 22,530 new esophageal cancers in the United States for 2026, about 1.1% of all new cancers, and 16,290 deaths; SEER carries that projection. Five-year relative survival across all stages is 22.2% for people diagnosed from 2016 to 2022.

The stage distribution is the heart of the problem. SEER records that only 19% of cases are found while localized, where five-year relative survival is 48.6%. Another 32% are regional, at 29.1%. And 39% are already distant at diagnosis, where five-year relative survival is 5.3%. Esophageal cancer is most often diagnosed between ages 65 and 74, and NCI puts the median age at diagnosis at 69.

Read those two lines together. Nearly four in ten esophageal cancers are found after they have spread, and the survival gap between localized and distant disease is roughly nine-fold.

That is the argument for taking a swallowing problem seriously the first month rather than the sixth. It is not a promise to anyone, and it does not describe what happened to any one person. It is what the numbers, taken across a whole country, are saying.

Sources

• NCI: Esophageal Cancer Treatment (PDQ) — Health Professional Version
• NCI: Esophageal Cancer Treatment (patient version)
• NCI: Symptoms of Esophageal Cancer
• SEER Cancer Stat Facts: Esophageal Cancer
• NPR: How Christopher Hitchens Faced His Own 'Mortality'