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.
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]
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.
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.
Predictive model for progression in Barrett's
Using a Bayesian approach, these authors combine results from multiple studies to risk stratify persons with Barrett's. They also identify potential changes in risk associated with preventive measures such as statin use and weight loss.
Copy number instability key to risk prediction in Barrett's
British study lends strong support to use of genomic risk stratification (genomoe-wide copy number instability) to enable earlier intervention for high-risk Barrett's and at the same time reduce the intensity of monitoring and even reduce overtreatment in cases of stable disease.
Utility of Cytosponge demonstrated
This impressive randomized trial observed an approximately 10-fold increase in detection of Barrett's with use of the Cytosponge non-endoscopic test. Nine persons in the Cytosponge group were found to have treatable dysplasia or early stage cancer vs. none in the usual care group.
Barrett's in children
Barrett's in children does occur, but is rare. This cases series demonstrates a very strong preponderance in males. Among a very few children followed over time, several developed low grade dysplasia, but non were observed to progress to high grade dysplasia or cancer.
Obesity related markers and risk of Barrett's and EA
This article summarizes published reports on circulating biomarkers and risk of BE/EAC, finding that higher circulating levels of leptin, glucose, insulin, CRP, IL6, and sTNFR-2 may be associated with an increased risk of esophageal adenocarcinoma or Barrett esophagus.