Recent findings

Review of epidemiology of esophageal cancer and Barrett's

This Review by Dr. Thrift at Baylor updates the trends in the incidence of esophageal cancer (both histologic types) and summarizes current knowledge of its risk factors.

Importance of family history in Barrett's and esophageal adenocarcinoma

Family history of Barrett's and/or EAC was determined in 480 BE patients and 420 controls and validated using the Dutch nationwide histopathology database. A positive family history was found in 6.5% of BE patients, which is consistent with other studies, yielding a five-fold increased risk. The authors emphasize the importance of a detailed family history in patients with BE or EAC to identify individuals at increased risk who may benefit from early detection strategies to prevent EAC-related mortality

Website updates

Two new foundations added to "Additional Resources" page - Heartburn Cancer UK and Esophageal Cancer Education Foundation. Contact form also added.

Markov model indicates cost-effectiveness of Cytosponge-TFF3 screening

The Cytosponge-TFF3 tandem for non-endoscopic screening is one of several being developed or newly available to expand screening for Barrett's or early stage adenocarcinoma at lower cost and with less invasiveness and patient inconvenience. In this report from the BEST3 Consortium, Markov modeling was used to investigate cost effectiveness and quality-adjusted life-years in a randomized clinical trial. They found an ICER of £5,500 (a relatively low amount), which might be even lower in a younger population.

Modeling study suggests potential for risk-stratified screening in China

By combining individual risk factor data from over 26,000 persons in high-risk areas of China, the authors estimate that focusing endoscopic screening on only those at high-risk can have substantial benefits in efficiency.

Review of prevention strategies for esophageal cancer

A nice review of prevention approaches to both esophageal squamous cell carcinoma and adenocarcinoma. It includes a summary of surveillance methods and intervals recommended by four GI societies.

Blood type and ESCC risk

In the largest analysis of its kind, aggregating data from five studies in China, Dr. Chen and colleagues observed an approximately 30% higher risk of esophageal squamous cell carcinoma among those with blood type B and AB.

Esophageal cancer mortality trends in US

This report focuses on esophageal cancer mortality trends in the US from 1992-2016. Importantly, the dramatic decrease in esophageal squamous cell carcinoma among black males over the past several decades is highlighted and observed to be continuing. The authors attribute this decrease in part to reduced prevalence of heavy smoking. In addition, the recent leveling off of mortality for esophageal adenocarcinoma in white males was observed to continue.

Esophageal squamous cell risk predictor developed

Dr. Wang and colleagues developed and validated a risk prediction model and web-based calculator for ESCC, based on age, sex, smoking, alcohol and BMI. The AUC was 0.70 with a sensitivity and specificity of 56.8% and of 74.0%, respectively. Significantly Increased accuracy would likely be achieved by incorporating a more finely-grained assessment of age, smoking and alcohol.

When to stop Barrett's surveillance?

Gastroenterology societies recommend surveillance for non-dysplastic Barrett's but do not give guidance on when surveillance should stop. In this modeling study Dr. Omidvari and colleagues report that the optimal age for last surveillance of NDBE patients depends on the sex and the comorbidity level of patients. For men with NDBE without comorbidity, the optimal age for last surveillance is 81 years, while it may be up to 8 years earlier for those with comorbidity. For women, they found that without comorbidity, the optimal age for last surveillance of NDBE patients is 75 years, but can be up to 6 years earlier if patients have comorbidities.

ESCC risk may be affected by factors acting early in life

This highly technical analysis modeled incidence patterns of esophageal squamous cell carcinoma (ESCC) in the US, finding an important role of an esophageal field-defect that is predicted to occur predominantly in childhood and predisposes to ESCC in adult life. Age-specific ESCC incidence patterns are also known to differ considerably between Blacks and Whites, and between males and females in the US, but the model consistently predicts early-childhood field-defects in all four groups. The estimated historical field-defect trends appear consistent with possible early childhood nutritional deficiencies.

Indoor wood combustion and esophageal squamous dysplasia Kenya

In this cross-sectional study of non-smokers from a rural area of Kenya, where indoor cooking with wood is common, metabolites of carcinogenic PAHs were substantially elevated compared to non-smokers in other countries. Prevalence of esophageal squamous dysplasia in this high-risk areea was positively correlated with levels of various PAH metabolites in urine. The authors point out that: "High PAH exposure is a consistent finding in high-risk areas for ESCC, and we expected similar findings in this understudied high-risk population from East Africa. But the urinary PAH metabolite concentrations in the current study were dramatically higher than those reported in previous urine metabolite studies of other populations."

Prediction tools evaluated in large retrospective cohort study

Using a Northern California Kaiser Permanente cohort linked with local cancer registries to determine incidence of EAC, Dr. Rubenstein and colleagues evaluated the accuracy of four published prediction tools for EAC. The Kunzmann algorithm was found to be most effective (AUC = 0.73) and substantially better than using GERD symptoms alone to identify high-risk persons. Some of the limitations include the relatively small number of EAC outcomes (168), the need to impute multiple variables and records, and the lack of information on changes to participants' risk profiles (e.g., obesity, GERD symptoms, etc.) over the very long follow up time. Many of these limitations are conservative in nature, i.e., resulting in an underestimate of predictive ability. Also lacking, due to the source of the data, is information on other potential risk and preventive factors which have been shown to predict subsequent EAC. For example, a risk calculator (IC-RISC) that also includes race, family history and use of NSAIDs exhibits an AUC of 0.81 (although it has not been independently validated.) Nevertheless, the authors make the important point that any of the tested tools are vastly superior to using only GERD in defining "high-risk" persons for screening, and should be implemented in clinical practice.

Progress in methylated DNA markers for Barrett's detection

In order to be adopted widely, non-invasive technologies for detecting Barrett's esophagus (e.g., EsophaCap, Cytosponge) need a companion assay that is both accurate and inexpensive. Here Dr. Iyer at the Mayo Clinic and collaborators report promising results for a set of five methylated DNA markers.

Website updates

Additional information on ESCC (esophageal squamous cell carcinoma) has been added to the "Risk Factors" page. Several more potentially helpful websites have been added to the "Add'l Resources" page.

Visceral obesity and esophageal cancer

In this remarkably thorough review, Drs. Elliott and Reynolds summarize the evidence for and potential mechanisms underlying the association between visceral (abdominal or central) obesity and risk of esophageal adenocarcinoma, as well as potential roles for associated dietary, lifestyle, pharmacologic and surgical interventions on risk of EAC.

Clinical trial on RFA in low grade dysplasia

Results from this clinical trial on RFA vs. annual surveillance in persons with low grade dysplasia were modestly supportive of RFA in this population, with a 62% reduction in prevalence of Barrett's after three years which was of borderline statistically significance. One or more adverse events were experience by 19% of the RFA group, while spontaneous regression of LGD was observed in almost 1/3 of the surveillance patients. The small size of the study is an important limitation which limits interpretation.

Three-tiered screening program proposed

Drs. Yusuf and Fitzgerald review recent technological advancements in screening for Barrett's esophagus and propose a three-tier approach using risk prediction algorithms and minimally invasive approaches to improving detection rate for Barrett's and EAC

Review of Barrett's and Esophageal Adenocarcinoma

The authors review the incidence of BE and EAC and associated risk factors, evidence for improved outcomes among patients with a prior diagnosis of BE compared to those without, discuss the challenges of developing sufficiently accurate prediction models in the context of high population prevalence of risk factors (e.g., obesity, reflux, smoking), and emphasize the need for larger biomarker studies.

Good news in treatment of esophageal cancer

Dr. Ilson's editorial in the New England Journal of Medicine puts new findings regarding the monoclonal antibody, nivolumab, in treatment of esophagal cancer in perspective. [Figure from original research article by Kelly, et al in same issue]

Review of world-wide GI cancer epidemiology

The authors extensively review the epidemiology (incidence, risk factors, prevention) of cancers of the colon, stomach and esophagus across China, the US and Europe

Dutch study on RFA/EMR effectiveness

In an observational study of 1154 patients with BE or early EAC, 94% achieved complete eradication after treatment with RFA/EMR. A dysplasia recurrence rate of 1% per year was observed over a median 43 months.

Modeling suggests a role for Cytosponge in post-RFA surveillance

This is one of the first examinations of the Cytosponge as a non-endoscopic method of surveillance in persons who have been treated for dysplasia in Barrett's. Results suggest that it may be more cost-effective than endoscopy.

Young onset esophageal adenocarcinomas have poorer prognosis

Young-onset esophageal adenocarcinoma, while uncommon, is rising in incidence. Concerningly, the proportion of advanced disease continues to increase. Young-onset esophageal adenocarcinoma also presents at more advanced stages, resulting in poorer esophageal adenocarcinoma–free survival.
About
This website contains a curated and opinionated look at recent literature regarding the epidemiology and prevention of esophageal cancer, with an emphasis on esophageal adenocarcinoma. It is developed by Thomas L Vaughan MD, MPH ©2021
Disclaimer
This website should not be considered, or used as a substitute for, medical advice, diagnosis or treatment. This site does not constitute the practice of any medical or other professional health care advice, diagnosis or treatment. The information on this website represent the views solely of Dr. Vaughan.
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