Predicting the Future Burden of Esophageal Cancer by Histological Subtype: International Trends in Incidence up to 2030

Burden of esophageal cancer between 2010 and 2019 in Asian countries by geographical region and sociodemographic index: A comparison with global data

BACKGROUND

The aim of this study was to describe the trends in incidence, mortality, and burden of esophageal cancer (EC) in Asia from 2010 through 2019 and compare with other global continental data.

METHODS

We collected EC data from the 2019 Global Burden of Disease study from 2010 to 2019 in 49 countries and territories in Asia based on the sociodemographic index (SDI). For all locations, annual case data and age-standardized rates (ASRs) were extracted to investigate the EC incidence, prevalence, mortality, and disability-adjusted life-years (DALYs). The ASR relative difference (%) between years and the male/female (M/F) ratio were calculated. Data are reported in values and 95% uncertainty interval (UI).

RESULTS

In 2019, more than 70% of EC new cases, deaths, prevalence, and DALYs occurred in Asian countries. From 2010 to 2019, incidences, deaths, prevalence cases, and DALY number of EC increased over 1.10-, 1.07-, 1.14-, and 1.03-fold, in Asia. During this period, the age-standardized incidence rate (ASIR), age-standardized death rate (ASDR), age-standardized prevalence rate (ASPR), and age-standardized DALYs rate (DALYs ASR) of EC decreased by 18, 21, 14, and 22%, respectively. The rate of decline in Asia is higher than in the world and other continents. In 2019, age-specific incidence, death, prevalence, and DALY cases of EC cancer peaked at 65-74, 70-74, 65-69, and 65-69 years, respectively. In 2019, the highest ASIR, ASDR, ASPR, and DALYs ASR of EC were observed in East Asian countries, while having the highest decreasing trend. In 2019, among high SDI Asian countries, Taiwan had the highest ASIR, ASPR, and DALYs ASR, and the United Arab Emirates had the highest ASDR. Among high-middle SDIs, Kazakhstan had the highest ASIR, ASPR, ASDR, and DALYs ASR; among middle SDIs, China had the highest ASIR, ASDR, and ASPR, and Viet Nam had the highest DALYs ASR; among low-middle SDIs, Mongolia had the highest ASIR, ASDR, ASPR, and DALY ASR of EC cancer. Among low SDI Asian countries, Pakistan had the highest ASIR and ASPR, and DALY ASR for EC cancer. For four indicators, in most countries, the ratio of men was higher than women, and in some countries, this ratio reached more than 10 times.

CONCLUSION

Although the rate of decline in incidence, death, prevalence and burden of EC in Asia was higher than in other areas in the last 10 years, more than 70% of these amounts occur in Asia. Therefore, it appears that adopting appropriate strategies in the field of identifying and controlling modifiable risk factors for EC, implementing screening programs, and timely diagnosis and treatment will help in reducing the burden of this disease in Asian countries.

Dissecting the inflammatory tumor microenvironment of esophageal adenocarcinoma: mast cells and natural killer cells are favorable prognostic factors and associated with less extensive disease

PURPOSE

Esophageal adenocarcinoma (EAC) remains a challenging and lethal cancer entity. A promising target for new therapeutic approaches, as demonstrated by the success of immune checkpoint inhibitors, are tumor-associated immune cells and the tumor microenvironment (TME). However, the understanding of the TME in esophageal cancer remains limited and requires further investigation.

METHODS

Over 900 EAC samples were included, including patients treated with primary surgery and neoadjuvant (radio-)chemotherapy. The immune cell infiltrates of mast cells (MC), natural killer cells (NK cells), plasma cells (PC), and eosinophilic cells (EC) were assessed semi-quantitatively and correlated with histopathological parameters and overall survival (OS).

RESULTS

A high presence of all four immune cell types significantly correlated with a less extensive tumor stage and a lower frequency of lymph node metastasis, and, in case of NK cells, with less distant metastasis. The presence of MC and NK cells was favorably associated with a prolonged OS in the total cohort (MC: p < 0.001; NK cells: p = 0.004) and patients without neoadjuvant treatment (MC: p < 0.001; NK cells: p = 0.01). NK cells were a favorable prognostic factor in the total cohort (p = 0.007) and in the treatment-naïve subgroup (p = 0.04). Additionally, MC were a favorable prognostic factor in patients with lymph node metastasis (p = 0.009).

CONCLUSION

Our results indicate a complex and important role of mast cells, NK cells, and the other assessed immune cells in the tumor microenvironment of EAC. Therefore, they are one further step to a better understanding of the immune cell environment and the potential therapeutic implications in this cancer entity.

Public Preference Heterogeneity and Predicted Uptake Rate of Upper Gastrointestinal Cancer Screening Programs in Rural China: Discrete Choice Experiments and Latent Class Analysis

BACKGROUND

Rapid increases in the morbidity and mortality of patients with upper gastrointestinal cancer (UGC) in high-incidence countries in Asia have raised public health concerns. Screening can effectively reduce the incidence and mortality of patients with UGC, but the low population uptake rate seriously affects the screening effect.

OBJECTIVE

We aimed to determine the characteristics that influence residents' preference heterogeneity for a UGC-screening program and the extent to which these characteristics predict residents' uptake rates.

METHODS

A discrete choice experiment was conducted in 1000 residents aged 40-69 years who were randomly selected from 3 counties (Feicheng, Linqu, and Dongchangfu) in Shandong Province, China. Each respondent was repeatedly asked to choose from 9 discrete choice questions of 2 hypothetical screening programs comprising 5 attributes: screening interval, screening technique, regular follow-up for precancerous lesions, mortality reduction, and out-of-pocket costs. The latent class logit model was used to estimate residents' preference heterogeneity for each attribute level, their willingness to pay, and the expected uptake rates.

RESULTS

Of the 1000 residents invited, 926 (92.6%) were included in the final analyses. The mean age was 57.32 (SD 7.22) years. The best model contained 4 classes of respondents (Akaike information criterion=7140.989, Bayesian information criterion=7485.373) defined by different preferences for the 5 attributes. In the 4-class model, out of 926 residents, 88 (9.5%) were assigned to class 1, named as the negative latent type; 216 (3.3%) were assigned to class 2, named as the positive integrated type; 434 (46.9%) were assigned to class 3, named as the positive comfortable type; and 188 (20.3%) were assigned to class 4, named as the neutral quality type. For these 4 latent classes, "out-of-pocket cost" is the most preferred attribute in negative latent type and positive integrated type residents (45.04% vs 66.04% importance weights), whereas "screening technique" is the most preferred factor in positive comfortable type residents (62.56% importance weight) and "screening interval" is the most valued attribute in neutral quality type residents (47.05% importance weight). Besides, residents in different classes had common preference for painless endoscopy, and their willingness to pay were CNY ¥385.369 (US $59.747), CNY ¥93.44 (US $14.486), CNY ¥1946.48 (US $301.810), and CNY ¥3566.60 (US $552.961), respectively. Residents' participation rate could increase by more than 89% (except for the 60.98% in class 2) if the optimal UGC screening option with free, follow-up for precancerous lesions, 45% mortality reduction, screening every year, and painless endoscopy was implemented.

CONCLUSIONS

Public preference heterogeneity for UGC screening does exist. Most residents have a positive attitude toward UGC screening, but their preferences vary in selected attributes and levels, except for painless endoscopy. Policy makers should consider these heterogeneities to formulate UGC-screening programs that incorporate the public's needs and preferences to improve participation rates.

Recent Mortality Patterns and Time Trends for the Major Cancers in 47 Countries Worldwide

BACKGROUND

Most prior studies have reported cancer mortality trends across countries for specific cancer types. Herein, we examine recent patterns and trends in cancer mortality rates for the eight common forms of cancer in 47 countries across five continents (except Africa) based on the World Health Organization mortality database.

METHODS

Rates were age-standardized to the 1966 Segi-Doll world population, and trends in the age-standardized rates for the most recent 10 years of data were examined using Joinpoint regression.

RESULTS

Cancer-specific mortality rates vary substantially across countries, with rates of infection-related (cervix and stomach) and tobacco-related cancers (lung and esophagus) varying by 10-fold. Recent mortality rates for all major cancers decreased in most of the studied countries except lung cancer in females and liver cancer in males, where increasing rates were observed in most countries. Rates decreased or stabilized in all countries for lung cancer in men and stomach cancer in both sexes.

CONCLUSIONS

The findings reinforce the importance of implementing and strengthening resource-stratified and targeted cancer prevention and control programs in all parts of the world to further reduce or halt the rising cancer burden.

IMPACT

The results may inform cancer prevention and treatment strategies and in so doing, reduce the marked global cancer disparities observed today.

Current status and future perspectives for the treatment of resectable locally advanced esophagogastric junction cancer: A narrative review

Incidence rates for esophagogastric junction cancer are rising rapidly worldwide possibly due to the economic development and demographic changes. Therefore, increased attention has been paid to the prevention, diagnosis, and the treatment of esophagogastric junction cancer. Although there are discrepancies in the treatment strategy between Asian and Western countries, surgery remains the mainstay of treatment for esophagogastric junction cancer. Recent developments of perioperative multidisciplinary treatment may lead to better therapeutic effect, higher complete resection rate, and better control of the residual diseases, thus result in prolonged prognosis. In this review, we will focus on the treatment of locally advanced resectable esophagogastric junction cancer, and discuss the current status and future perspectives of the perioperative treatment including chemotherapy, radiation therapy, and immunotherapy, as well as the surgical strategy. Better understanding of the latest treatment strategy and future overlook may enable to standardize and individualize the treatment for esophagogastric junction cancer, thus leading to better prognosis for those patients.

S-1 maintenance therapy in Caucasian patients with metastatic esophagogastric adenocarcinoma-final results of the randomized AIO MATEO phase II trial

PURPOSE

Platinum-fluoropyrimidine combinations are standard of care for treatment of metastatic esophagogastric adenocarcinoma. The optimal duration of first-line chemotherapy is unknown, however, and maintenance strategies have not yet been established.

DESIGN

MATEO is an international randomized phase II trial exploring efficacy and safety of S-1 maintenance therapy in human epidermal growth factor receptor 2 (HER2)-negative advanced esophagogastric adenocarcinoma. After 3 months of first-line platinum-fluoropyrimidine-based induction therapy, patients without progression were randomized in a 2 : 1 allocation to receive S-1 monotherapy (arm A) or to continue combination chemotherapy (arm B). The primary objective was to show non-inferiority of overall survival in the S-1 maintenance group. Progression-free survival, adverse events, and quality of life were secondary endpoints.

RESULTS

From 2014 to 2019, 110 and 55 patients were randomized in arm A and arm B, respectively (recruitment closed prematurely). Median overall survival from randomization was 13.4 months for arm A and 11.4 months for arm B [hazard ratio 0.97 (80% confidence interval 0.76-1.23), P = 0.86]. Median progression-free survival from randomization was 4.3 and 6.1 months for arm A versus arm B, respectively [hazard ratio 1.10 (80% confidence interval 0.86-1.39), P = 0.62]. Patients in arm A had numerically fewer treatment-related adverse events (84.9% versus 93.9%) and significantly less peripheral sensory polyneuropathy ≥grade 2 (9.4% versus 36.7%).

CONCLUSIONS

S-1 maintenance following platinum-based induction therapy leads to non-inferior survival outcomes compared with the continuation of platinum-based combination. Toxicity patterns favor a fluoropyrimidine maintenance strategy. These data challenge the continued use of platinum combination chemotherapy after response to 3 months induction therapy in patients with advanced human epidermal growth factor receptor 2-negative esophagogastric adenocarcinoma.

The global burden and trends of four major types of heart disease, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

OBJECTIVES

The global burden of heart disease is severe and increasing in the coming years. This study aims to analyze the global burden of heart disease.

STUDY DESIGN

Rheumatic heart disease (RHD), ischemic heart disease (IHD), hypertensive heart disease (HHD), and non-rheumatic valvular heart disease (NRVHD) were selected and analyzed from the Global Burden of Disease Study 2019.

METHODS

The prevalence, deaths, disability-adjusted life years and their corresponding age-standardized rates were obtained from the Global Burden of Disease Study 2019. In addition, estimated annual percentage change was calculated to better assess epidemiological trends. In addition, we performed an age-period-cohort analysis using the Nordpred package in R program to predict death trends over the next 20 years.

RESULTS

Globally, the prevalence of four heart diseases (RHD, IHD, HHD, and NRVHD) increased by 70.5%, 103.5%, 137.9%, and 110.0% compared with 1990, respectively. The deaths cases of RHD decreased by 15.6%, whereas IHD, HHD, and NRVHD increased by 60.4%, 76.6%, and 110.6%. Compared with absolute values, their corresponding age-standardized rates only showed a slight increase trend or even decreased in some areas with high sociodemographic index. In the next 20 years, the absolute values of deaths will continue to increase, whereas their age-standardized rates of deaths will flatten out.

CONCLUSIONS

Globally, the absolute values of heart disease have increased over the past 30 years and will continue to increase over the next 20 years. Targeted prevention and control strategies and measures need to be developed and improved to reduce this burden.

A novel staging system based on deep learning for overall survival in patients with esophageal squamous cell carcinoma

PURPOSE

We developed DeepSurv, a deep learning approach for predicting overall survival (OS) in patients with esophageal squamous cell carcinoma (ESCC). We validated and visualized the novel staging system based on DeepSurv using data from multiple cohorts.

METHODS

Totally 6020 ESCC patients diagnosed from January 2010 to December 2018 were included in the present study from the Surveillance, Epidemiology, and End Results database (SEER), randomly assigned to the training and test cohorts. We developed, validated and visualized a deep learning model that included 16 prognostic factors; then a novel staging system was further constructed based on the total risk score derived from the deep learning model. The classification performance at 3-year and 5-year OS was assessed by the receiver-operating characteristic (ROC) curve. Calibration curve and the Harrell's concordance index (C-index) were also used to comprehensively assess the predictive performance of the deep learning model. Decision curve analysis (DCA) was utilized to assess the clinical utility of the novel staging system.

RESULTS

A more applicable and accurate deep learning model was established, which outperformed the traditional nomogram in predicting OS in the test cohort (C-index: 0.732 [95% CI 0.714-0.750] versus 0.671 [95% CI 0.647-0.695]). The ROC curves at 3-year and 5-year OS for the model also showed good discrimination ability in the test cohort (Area Under the Curve [AUC] at 3-/5-year OS = 0.805/0.825). Moreover, using our novel staging system, we observed a clear survival difference among different risk groups (P < 0.001) and a significant positive net benefit in the DCA.

CONCLUSIONS

A novel deep learning-based staging system was constructed for patients with ESCC, which performed a significant discriminability for survival probability. Moreover, an easy-to-use web-based tool based on the deep learning model was also implemented, offering convenience for personalized survival prediction. We developed a deep learning-based system that stages patients with ESCC according to their survival probability. We also created a web-based tool that uses this system to predict individual survival outcomes.

Population-based investigation of common and deviating patterns of gastric cancer and oesophageal cancer incidence across populations and time

BACKGROUND

The subtypes of gastric cancer (GC) and oesophageal cancer (EC) manifest distinct epidemiological profiles. Here, we aim to examine correlations in their incidence rates and to compare their temporal changes globally, both overall and by subtype.

METHODS

Long-term incidence data were obtained from population-based registries available from the Cancer Incidence in Five Continents series. Variation in the occurrence of EC and GC (overall and by subtype) was assessed using the GC:EC ratio of sex-specific age-standardised rates (ASR) in 2008-2012. Average annual per cent changes were estimated to assess temporal trends during 1998-2012.

RESULTS

ASRs for GC and EC varied remarkably across and within world regions. In the countries evaluated, the GC:EC ratio in men exceeded 10 in several South American countries, Algeria and Republic of Korea, while EC dominated in most sub-Saharan African countries. High rates of both cardia gastric cancer and oesophageal squamous cell carcinoma (ESCC) were observed in several Asian populations. Non-cardia gastric cancer rates correlated positively with ESCC rates (r=0.60) and negatively with EAC (r=-0.79). For the time trends, while GC incidence has been uniformly decreasing by on average 2%-3% annually over 1998-2012 in most countries, trends for EC depend strongly on histology, with several but not all countries experiencing increases in EAC and decreases in ESCC.

CONCLUSIONS

Correlations between GC and EC incidence rates across populations are positive or inverse depending on the GC subsite and EC subtype. Multisite studies that include a combination of populations whose incidence rates follow and deviate from these patterns may be aetiologically informative.

Clinical and prognostic significance of perioperative change in red cell distribution width in patients with esophageal squamous cell carcinoma

BACKGROUND

Numerous studies have reported the prognostic significance of the red cell distribution width (RDW) in patients with esophageal squamous cell carcinoma (ESCC), but the relationship between the perioperative change in RDW (delta RDW) and survival in patients with ESCC after surgery has not been evaluated.

METHODS

A total of 594 patients with newly diagnosed ESCC after surgery were enrolled in the study. Delta RDW (delta RDW = Postoperative RDW-Preoperative RDW) was counted based on data within one week before surgery and two weeks after surgery. To investigate the relationship between delta RDW and overall survival (OS), the median delta RDW was chosen as the cut-off value.

RESULTS

99 (16.7%) patients had pathological stage 1a-1b, 202 (34.0%) patients had pathological stage 2a-2b, and 293 (49.3%) patients had pathological stage 3a-3c.There were 179 (30.1%) patients who had vessel invasive, and 415 (69.9%) patients without vessel invasive. There were 216 (36.4%) patients with nerve infiltration, and 378 (63.6%) without nerve infiltration. In univariate analysis, five parameters including delta RDW(≥ 0.44 vs.<0.44) (P = 0.039, HR = 1.337, 95% CI = 1.014-1.762) significantly correlated with worse OS. Multivariate analysis revealed that delta RDW(≥ 0.44 vs.<0.44) was an independent prognostic marker for OS (P = 0.033, HR = 1.356, 95% CI = 1.025-1.793). Kaplan-Meier curves showed that delta RDW ≥ 0.44 was significantly associated with worse OS (P = 0.039). Subgroup analysis suggested that delta RDW ≥ 0.44 indicated worse survival in patients with ESCC exclusively in these subtypes such as female patients, age > 60 patients, patients with lymph node metastasis, and patients with vessel invasive.

CONCLUSIONS

Perioperative change in red cell distribution width predicts worse survival in patients with ESCC after surgery.

Ethanolic extract of Ocimum sanctum leaf modulates oxidative stress, cell cycle and apoptosis in head and neck cancer cell lines

Ocimum sanctum Linn. is a medicinal herb that has cytotoxic effects by inducing oxidative stress in some carcinomas. This study aimed to examine the impact of O. sanctum leaf extract on oxidative stress, cell cycle progression, and apoptosis in cell lines of head and neck squamous cell carcinoma (HNSCC). Isogenic primary (HN18/HN30) and metastatic (HN17/HN31) HNSCC cell lines were used. Preparation of the ethanolic extract of O. sanctum leaf (EEOS) was carried out. HNSCC cell lines were exposed to varying concentrations (0.1-0.8 mg/ml) of EEOS for a duration of 72 h, and the MTT assay was utilized to determine the cytotoxic doses. To assess the impact of EEOS on HNSCC cells, the levels of reactive oxygen species (ROS) and malondialdehyde were measured using a fluorometric method. Flow cytometry was utilized to evaluate effects of EEOS on the cell cycle, DNA damage, and apoptosis in HNSCC cells. Caspase-3 and -9 levels in the EEOS-treated HNSCC cells were measured by ELISA. The chemical components in EEOS were detected using high-performance liquid chromatography-electrospray ionization-time of flight-mass spectrometry. EEOS exhibited cytotoxicity against the HN18, HN17, HN30 and HN31 cells at minimum concentrations of 0.1, 0.3, 0.2 and 0.2 mg/ml, respectively. Treatment with EEOS resulted in a significant increase in ROS levels in HN18 and HN17 cells. Additionally, EEOS significantly induced the levels of malondialdehyde in HN18 and HN31 cells. Moreover, EEOS arrested the cell cycle in HN30 and HN31 cells, and significantly induced DNA damage and apoptosis in the HN18, HN30, and HN31 cells. EEOS selectively increased caspase-9 in the HN18 cells. However, caspase-3 was activated without apoptosis in the EEOS-treated HN17 cells. The constituents of EEOS were identified as rosmarinic acid, caffeic acid, and apigenin. In conclusion, EEOS exhibits various prooxidative and apoptotic effects between HNSCC cells.

Short-term outcomes of reduced-port laparoscopic surgery versus conventional laparoscopic surgery for total gastrectomy: a single-institute experience

BACKGROUND

The efficacy of reduced-port laparoscopic surgery (RLS) for total gastrectomy remains unclear. This study focused on evaluating the short-term outcomes of RLS compared with conventional laparoscopic surgery (CLS) for total gastrectomy.

METHODS

One hundred and ten patients who underwent completed laparoscopic total gastrectomy for gastric cancer between September 2018 and June 2022 were retrospectively collected and classified into two groups (65 CLS and 45 RLS) according to different operation approach. Twenty-four RLS cases underwent single-incision plus two ports laparoscopic surgery (SILS + 2) and twenty-one underwent single-incision plus one port laparoscopic surgery (SILS + 1). Surgical outcomes, pain intensity, cosmetic and postoperative morbidity, and mortality were compared between groups.

RESULTS

The overall incidence of postoperative complications was similar between the CLS group and the RLS group (16.9% vs. 8.9%, P = 0.270). It was also comparable in the Clavien-Dindo classification (P = 0.774). However, compared with the CLS group, the RLS group had a significantly shorter total length of incision (5.6 ± 1.0 cm vs. 7.1 ± 0.7 cm, P = 0.000); shorter time to first ambulation (24.9 ± 5.9 h vs. 27.6 ± 5.0 h, P = 0.009), flatus (3.0 ± 0.8 d vs. 3.5 ± 1.0 d, P = 0.022) and oral intake (4.0 ± 1.6 d vs. 6.1 ± 5.1 d, P = 0.011); lower white blood cell count on the third day after the operation (9.8 ± 4.0*10⁹/L vs. 11.6 ± 4.7*10⁹/L, P = 0.037); and lower visual analogue scale score on postoperative days 1 and 3(3.0 ± 0.7 vs. 3.3 ± 0.7, P = 0.044 and 0.6 ± 0.7 vs. 1.6 ± 0.6, P = 0.000 respectively). On the other hand, it didn't find any difference in short-term outcomes between the SILS + 2 group and the SILS + 1 group (P > 0.05). But the proximal resection margin was longer in the SILS + 2 group than in the SILS + 1 group (2.6 ± 0.7 cm vs. 1.5 ± 0.9 cm, P = 0.046) in patients with adenocarcinoma of the esophagogastric junction (AEG).

CONCLUSIONS

RLS for total gastrectomy is a feasible and safe technique when performed by an experienced laparoscopic surgeon. Moreover, compared with SILS + 1, SILS + 2 might have some advantages in AEG patients.

Cancer Risk in Barrett's Esophagus: A Clinical Review

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence and is associated with a poor prognosis. Barrett's esophagus (BE) is a known precursor of esophageal adenocarcinoma. This review aims to explore Barrett's esophagus, esophageal adenocarcinoma, and the progression from the former to the latter. An overview of the definition, diagnosis, epidemiology, and risk factors for both entities are presented, with special attention being given to the areas of debate in the literature. The progression from Barrett's esophagus to esophageal adenocarcinoma is reviewed and the relevant molecular pathways are discussed. The definition of Barrett's esophagus remains debated and without international consensus. This, alongside other factors, has made establishing the true prevalence of Barrett's esophagus challenging. The degree of dysplasia can be a histological challenge, but is necessary to guide clinical management. The progression of BE to EAC is likely driven by inflammatory pathways, pepsin exposure, upregulation of growth factor pathways, and mitochondrial changes. Surveillance is maintained through serial endoscopic evaluation, with shorter intervals recommended for high-risk features.

Epidemiological landscape of esophageal cancer in Asia: Results from GLOBOCAN 2020

BACKGROUND

Esophageal cancer (EC) is a global health problem. Asia represents a huge burden of EC globally, and incidence and mortality vary considerably across different Asian regions.

METHODS

Data on incidence, mortality, and preference were extracted from GLOBOCAN 2020. Age-standardized incidence and mortality rates were calculated overall by sex, age, country, region, and continent. The predicted burden of incidence and mortality in 2040 was calculated based on global demographic projections.

RESULTS

It was estimated there were 481 552 new cases of and 434 363 deaths from EC in Asia in 2020, accounting for 79.7% and 79.8% of world EC cases and deaths, respectively. EC incidence and mortality in Asia ranked the highest among all continents. Eastern Asia represents the highest age-standardized world incidence rate (ASWIR) of 12.3 per 100 000 for all Asian regions. Western Asia represents the lowest ASWIR of 1.7 per 100 000, accounting for 0.7% of the globe. There exist obvious differences in epidemiological features in Asian countries, including incidence, mortality, prevalence, and mortality incidence ratio. There is forecast to be up to 781 000 new cases of EC in Asia by 2040, with increasing rates of 63% for incidence and 72% for mortality from 2020.

CONCLUSIONS

Asia has an increasing number of EC cases and deaths. Strategies for targeting in high-incidence areas, the elderly, and survival should be prioritized to reduce the global EC burden, especially in low- and middle-income countries in Asia.

Relationship between pathogenic microorganisms and the occurrence of esophageal carcinoma based on pathological type: a narrative review

INTRODUCTION

Esophageal cancer (EC) is one of the most common malignant tumors of the upper gastrointestinal tract. The etiology of EC is complicated and increasing evidence has shown that microbial infection is closely related to the occurrence of various malignant tumors. Though many studies have been focused on this subject in recent years, the exact relationship between microbial infection and the occurrence of EC remains unclear.

AREAS COVERED

In this review, we searched all eligible literature reports, summarized the most recent studies in this research field, and analyzed the pathogenic microorganisms associated with EC, providing the latest evidence and references for the prevention of pathogenic microorganism-related EC.

EXPERT OPINION

In recent years, increasing evidence has shown that pathogenic microbial infections are closely associated with the development of EC. Therefore, it is necessary to describe in detail the relationship between microbial infection and EC and clarify its possible pathogenic mechanism, which will shed a light on clinical prevention and treatment of cancer caused by pathogenic microbial infection.

Clinical-Pathological Characteristics of Adenosquamous Esophageal Carcinoma: A Propensity-Score-Matching Study

There are few studies on esophageal adenosquamous carcinoma (ADSC). Our study intended to investigate the clinical and survival features of ADSC. We included esophageal cancer (EC) data from the Surveillance, Epidemiology, and End Results program database to explore clinical and survival traits. Propensity score matching (PSM), the multivariate Cox regression model, and survival curves were used in this study. A total of 137 patients with ADSC were included in our analysis. The proportion of ADSC within the EC cohort declined from 2004 to 2018. Besides, results indicated no significant difference in survival between ADSC and SCC groups (PSM-adjusted HR = 1.249, P = 0.127). However, the survival rate of the ADSC group was significantly worse than that of the ADC group (PSM-adjusted HR = 1.497, P = 0.007). For the ADSC group, combined treatment with surgery had a higher survival rate than other treatment methods (all P < 0.001). Surgical resection, radiotherapy, and chemotherapy were independent protective prognostic factors (all P < 0.05). The proportion of ADSC has been declining from 2004 to 2018. The prognosis of ADSC is not significantly different from that of SCC but is worse than that of ADC. Surgery, radiotherapy, and chemotherapy could improve the prognosis of patients. Comprehensive treatment with surgery as the main treatment is more beneficial for some patients.

Role of PD-1 Inhibitors in the Treatment of Esophagogastric Adenocarcinoma: Patient Selection and Reported Outcomes

Esophagogastric cancers are aggressive malignancies, with poor prognosis despite current standard-of-care therapies. PD-1 inhibitors are a newer class of antitumor agents with the potential to improve outcomes among appropriately selected patients. This review provides an overview of the key trials that have guided the use of PD-1 and PD-L1 inhibitors in the refractory and first-line settings. We highlight recent studies investigating the role of genomic classification in predicting therapeutic activity of PD-1 inhibitors. In addition, there is a discussion of the use of different scoring systems and criteria to determine PD-L1 positivity, the impact on the therapeutic use of immune checkpoint inhibition with anti-PD-1 agents, and the controversies in current methods of PD-L1 testing and their implications in patient selection for anti-PD-1 therapy.

Disease Burden of Total and Early-Onset Colorectal Cancer in China from 1990 to 2019 and Predictions of Cancer Incidence and Mortality

Background

Understanding the temporal trends in the epidemiology of colorectal cancer (CRC) and early-onset CRC (EOCRC) in China is essential for policymakers to develop appropriate strategies to reduce the CRC burden.

Methods

The prevalence, incidence, mortality, years of life lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life years (DALYs) of CRC were obtained from the Global Burden of Disease (GBD) Study 2019. The incidence and mortality of CRC over the next 25 years were predicted.

Results

From 1990 to 2019, the prevalence, incidence, and mortality of total CRC and EOCRC significantly increased in males, with milder trends in females. In 2019, the number of people living with CRC (or EOCRC) in China was approximately 3.4 (0.59) million, which was over seven (five) times higher than that in 1990. The DALYs, YLDs, and YLLs moderately increased from 1990 to 2019 in both sexes. The age-standardized mortality rate (ASMR) for females has shown a stable trend in total CRC, and a downward trend in EOCRC since 2000. While the ASMR for males showed increasing trends in total CRC and EOCRC. In 2019, the highest incidence, prevalence, YLDs, YLLs, and DALYs were all observed in the 65 to 69 age group, while the highest mortality was in the 70 to 74. By 2044, the incidence and deaths of CRC are expected to reach 1310 thousand and 484 thousand, respectively. For EOCRC, the incidence will peak at about 101 thousand around 2034, and the mortality will continuously decrease to a nadir at about 18 thousand around 2044.

Conclusion

Although the age-standardized incidence and mortality of total CRC and EOCRC in China will reach a plateau, the number of incident cases and deaths of CRC have been increasing in the last three decades and will continue to increase in the next 25 years.

Current Status and Future Prospects for Esophageal Cancer

Esophageal cancer (EC) is the ninth most common cancer and the sixth leading cause of cancer deaths worldwide. Esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) are the two main histological subtypes with distinct epidemiological and clinical features. While the global incidence of ESCC is declining, the incidence of EAC is increasing in many countries. Decades of epidemiologic research have identified distinct environmental exposures for ESCC and EAC subtypes. Recent advances in understanding the genomic aspects of EC have advanced our understanding of EC causes and led to using specific genomic alterations in EC tumors as biomarkers for early diagnosis, treatment, and prognosis of this cancer. Nevertheless, the prognosis of EC is still poor, with a five-year survival rate of less than 20%. Currently, there are significant challenges for early detection and secondary prevention for both ESCC and EAC subtypes, but Cytosponge™ is shifting this position for EAC. Primary prevention remains the preferred strategy for reducing the global burden of EC. In this review, we will summarize recent advances, current status, and future prospects of the studies related to epidemiology, time trends, environmental risk factors, prevention, early diagnosis, and treatment for both EC subtypes.

Updated epidemiology of gastrointestinal cancers in East Asia

Globally, gastrointestinal cancers represent more than one-fourth of all cancer incidence and one-third of cancer-related mortality. Although there has been much progress in screening colorectal cancer, the prognosis of other gastrointestinal cancers tends to be poor. The highest burden of gastrointestinal cancers, including stomach, liver, oesophageal and gallbladder cancers, was observed in regions in East Asia. The increasing burden of gastrointestinal cancers in East Asian regions is related to population growth, ageing and the westernization of lifestyle habits in this region. Furthermore, the rising incidence of young-onset colorectal cancer is an emerging trend in East Asia. This Review provides a comprehensive and updated summary of the epidemiology of gastrointestinal cancers in East Asia, with emphasis on comparing their epidemiology in East Asia with that in Western regions, and highlights the major risk factors and implications for prevention. Overall, to optimally reduce the disease burden incurred by gastrointestinal cancers in East Asian regions, a concerted effort will be needed to modify unhealthy lifestyles, promote vaccination against the hepatitis virus, control Helicobacter pylori, liver fluke and hepatitis virus infections, increase the uptake rate of colorectal cancer screening, enhance detection of early cancers and their precursors, and improve cancer survivorship through an organized rehabilitation programme.

Circ_0001686 knockdown suppresses tumorigenesis and enhances radiosensitivity in esophagus cancer through regulating miR-876-5p/SPIN1 axis

BACKGROUND

Abnormal expression of circular RNAs (circRNAs) plays an important role in tumorigenesis and radiosensitivity of many cancers. Nevertheless, it is not clear whether circ_0001686 is associated with the development and radiosensitivity of esophagus cancer.

METHODS

Quantitative real-time polymerase chain reaction (qRT-PCR) was used to detect the expression levels of circ_0001686, microRNA-876-5p (miR-876-5p) and spindlin 1 (SPIN1). Counting Kit-8 (CCK-8) assay, EdU assay, flow cytometry and transwell assay were applied to evaluate cell viability, cell proliferation, cell apoptosis and cell invasion capacities. Radiosensitivity was monitored by colony formation assay. The target relationship between miR-876-5p and circ_0001686 or SPIN1 was identified by dual-luciferase reporter assay. The protein level of SPIN1 was measured by western blot assay. Xenograft tumor models were used to analyze the influence of circ_0001686 on radiosensitivity and tumor growth in vivo.

RESULTS

The expression levels of circ_0001686 and SPIN1 were increased, while miR-876-5p was decreased in esophagus cancer tissues and cells. Interference of circ_0001686 constrained cell proliferation and invasion, but promoted cell apoptosis and radiosensitivity. Additionally, miR-876-5p was the target of circ_0001686 and miR-876-5p inhibition effectively ameliorated the impacts of circ_0001686 deficiency on tumorigenesis and radiosensitivity. Moreover, SPIN1 was a direct target of miR-876-5p and SPIN1 overexpression partially overturned the effects of miR-876-5p transfection on tumor progression and radiosensitivity. Importantly, circ_0001686 could sponge miR-876-5p to regulate SPIN1 expression. In addition, circ_0001686 silencing also constrained tumor growth and increased radiosensitivity in vivo.

CONCLUSION

Circ_0001686 contributed to the progression and radioresistance of esophagus cancer cells via regulating SPIN1 expression by targeting miR-876-5p, providing a new therapeutic target for improving the prognosis of esophagus cancer patients.

Epidemiology of esophageal cancer in 2020 and projections to 2030 and 2040

Esophageal cancer is a familiar malignancy with high incidence and mortality, and the overall prognosis is poor. The numbers of cases of and deaths from esophageal cancer have risen rapidly in recent decades. It is one of the most malignant cancers, with more than 0.6 million new cases and 0.54 million deaths worldwide in 2020. Here, we present the global epidemiology of esophageal cancer in 2020 and projections to 2030 and 2040 at different geographical levels of continents, regions and countries, and analyze them by gender, race, geographic region and human development index. We summarize the prospects for the esophageal cancer burden and risk factors in different areas, which will be useful for global esophageal cancer clinical therapy and cancer control planning.

Cost-effectiveness analysis of sintilimab vs. placebo in combination with chemotherapy as first-line therapy for local advanced or metastatic oesophageal squamous cell carcinoma

Objective

Results of Orient 15 indicated the health benefits to patients with local advanced or metastatic oesophageal squamous cell carcinoma (OSCC). This study aimed to evaluate the cost-effectiveness of sintilimab plus chemotherapy in treating OSCC from the perspective of Chinese healthcare system.

Methods

A partitioned survival model was constructed to evaluate the cost-effectiveness of sintilimab plus chemotherapy vs. chemotherapy in treating OSCC. Baseline characteristics of patients and key clinical data were extracted from Orient 15. Costs and utilities were collected from published studies and open-access databases. Costs, quality-adjusted life-years (QALYs), life-years gained, and incremental cost-effectiveness ratios (ICER) were chosen as economic outcome indicators. We also performed sensitivity analyses and subgroup analyses to verify the stability of results.

Results

Combination therapy provided additional 0.84 QALYs and 1.46 life-years with an incremental cost of $25,565.48 than chemotherapy, which had an ICER of $30,409.44 per QALY. The probabilistic sensitivity analysis indicated that combination therapy had a 98.8% probability of cost-effectiveness at the willingness-to-pay threshold (WTP) of $38,184 per QALY. Deterministic sensitivity analysis showed that model outcomes were sensitive to the utilities of progression-free survival and progression disease. The subgroup analysis revealed that combination therapy was cost-effective in patients with high expression of PD-L1 and several specific subgroups.

Conclusion

In this economic evaluation, sintilimab plus chemotherapy was likely to be cost-effective compared with chemotherapy in the first-line therapy of advanced OSCC from the perspective of Chinese healthcare system. Our findings may provide evidence for clinicians to make optimal decisions in clinical practice and for decision-makers to evaluate the cost-effectiveness of sintilimab.

Integrin beta1 (ITGB1) as a prognostic marker in esophageal adenocarcinoma

Today, individual prognosis in patients with adenocarcinoma of the esophagus (EAC) is based on post-surgical TNM staging and valid biomarkers are still not implemented. Integrin beta1 (ITGB1) is widely expressed in epithelial cells and promotes cell adhesion and growth. Its impact on tumor progression was described for different tumor entities before, data on its function as a potential biomarker in EAC is not available. Aim of the study is to evaluate the expression level of ITGB1 in a large collective of EAC and its impact on patients´ prognosis. 640 patients with esophageal adenocarcinoma were analyzed immunohistochemically for ITGB1. The data was correlated with long term outcome, clinical, pathological and molecular data (TP53, HER2/neu, c-myc, GATA6, PIK3CA and KRAS). Of 640 patients to be analyzed, 127 (19.8%) showed expression of ITGB1. ITGB1 expression was associated with lymph node metastasis, expression of integrin alphaV and KRAS mutation status. Patients with high ITGB1 expression showed impaired overall survival (22.5 months (95% CI 15.3-29.7 months), vs. 34.1 months (95% CI 25.3-42.4 months), P = 0.024). This effect was particularly evident in the group of patients undergoing primary surgery without prior neoadjuvant therapy (10.2 months (95% CI 1.9-41.7 months) vs. 31.4 months (95% CI 21.1-144.2 months, P = 0.008). ITGB1 was also an independent prognostic marker in multivariable analysis (HR 1.696 (95% CI 1.084-2.653, P = 0.021) in patients that underwent primary surgery. We demonstrate for the first time the prognostic significance of ITGB1 expression in a large EAC patient population.

Development and Validation of a Prognostic Model for Esophageal Adenocarcinoma Based on Necroptosis-Related Genes

Necroptosis is a newly developed cell death pathway that differs from necrosis and apoptosis; however, the potential mechanism of necroptosis-related genes in EAC and whether they are associated with the prognosis of EAC patients remain unclear. We obtained 159 NRGs from the Kyoto Encyclopedia of Genes and Genomes (KEGG) and performed differential expression analysis of the NRGs in 9 normal samples and 78 EAC tumor samples derived from The Cancer Genome Atlas (TCGA). Finally, we screened 38 differentially expressed NRGs (DE-NRGs). The results of the GO and KEGG analyses indicated that the DE-NRGs were mainly enriched in the functions and pathways associated with necroptosis. Protein interaction network (PPI) analysis revealed that TNF, CASP1, and IL-1B were the core genes of the network. A risk score model based on four DE-NRGs was constructed by Least Absolute Shrinkage and Selection Operator (LASSO) regression, and the results showed that the higher the risk score, the worse the survival. The model achieved more efficient diagnosis compared with the clinicopathological variables, with an area under the receiver operating characteristic (ROC) curve of 0.885. The prognostic value of this model was further validated using Gene Expression Omnibus (GEO) datasets. Gene set enrichment analyses (GSEA) demonstrated that several metabolism-related pathways were activated in the high-risk population. Single-sample GSEA (ssGSEA) provided further confirmation that this prognostic model was remarkably associated with the immune status of EAC patients. Finally, the nomogram map exhibited a certain prognostic prediction efficiency, with a C-index of 0.792 and good consistency. Thus, the prognostic model based on four NRGs could better predict the prognosis of EAC and help to elucidate the mechanism of necroptosis-related genes in EAC, which can provide guidance for the target prediction and clinical treatment of EAC patients.

Patterns of care amongst older adults diagnosed with locally advanced esophageal cancer: A cohort study

INTRODUCTION

Since the early 2010s, neoadjuvant chemoradiation followed by esophagectomy (trimodal therapy) has been a recommended treatment for patients diagnosed with locally advanced esophageal cancer. However, it may also add treatment-related toxicity, particularly for older adults with significant comorbidity and frailty burdens. We examined contemporary patterns of care in older adults, which have not been well characterized.

MATERIALS AND METHODS

We used the Surveillance Epidemiology and End Results-Medicare database to identify a cohort of US adults aged 66 years and older diagnosed with incident locally advanced esophageal cancer between 2004 and 2017. Calendar year age-standardized percentages of treatment receipt were calculated. Joinpoint regression was used to detect temporal trends in treatment receipt. Descriptive associations between patient factors and treatment were assessed. Trend analyses quantified how the percentage of trimodal and definitive chemoradiation (no surgery) patients receiving cisplatin-based, carboplatin-based, and other chemotherapy regimens evolved over time.

RESULTS

In total, 4332 adults aged ≥66 years with locally advanced esophageal cancer were included. The age-standardized percentage of patients receiving trimodal therapy increased from 16.7% in 2004 to 26.1% in 2017 (annual percent change = 3.5%; 95% confidence interval [CI], 0.7%-6.4%) in adenocarcinomas and from 7.3% in 2004 to 9.1% in 2017 (annual percent change = 0.4%; 95% CI, -4.1%-5.1%) in squamous cell carcinomas. By 2017, definitive chemoradiation became the most frequently used treatment modality for adenocarcinomas (49.8%; 95% CI, 43.5-56.0) and squamous cell carcinomas (59.5%; 95% CI, 50.8-68.2). Patients with higher comorbidity and frailty burdens were less likely to be treated with trimodal therapy. Amongst patients receiving chemoradiation as part of their treatment, a large and swift channeling away from cisplatin and towards carboplatin-based regimens was observed.

DISCUSSION

In practice, definitive chemoradiation is the most commonly received treatment by older adults with locally advanced esophageal cancer. Four out of five older adults do not receive trimodal therapy, some of whom are potentially undertreated.

Global and national trends in the age-specific sex ratio of esophageal cancer and gastric cancer by subtype

A male predominance was observed in esophageal and gastric cancers, though present limited data has revealed variations by age. We aim to investigate the global age-specific sex differences in esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cardia cancer (GCC) and gastric noncardia cancer (GNCC). Data on esophageal and gastric cancers incidence by diagnosis year, sex, histology, subsite and age group were extracted from 171 registries in 54 countries included in the last two volumes (X and XI, 2003-2012) of Cancer Incidence in Five Continents, which contributing to over 80% of the global burdens of these cancers. Age-standardized incidence rates (ASIRs) and male-to-female ASIRs ratios were estimated for esophageal and gastric cancers, by histological subtype and subsite, globally and by country. We consistently observed a male predominance in esophageal and gastric cancers across the world from 2003 to 2012, with male-to-female ASIRs ratios of 6.7:1 for EAC, 3.3:1 for ESCC, 4.0:1 for GCC and 2.1:1 for GNCC. The sex differences were consistent across time periods but varied significantly by age across the life span. Across the four cancer types, the male-to-female incidence rate ratios increased from young ages, approaching a peak at ages 60-64, but sharply declined thereafter. Similar "low-high-low" trends of age-specific sex ratio were observed in other digestive cancers including liver, pancreas, colon and rectum with peak ages ranging from 50 to 65. Age-dependent risk factors warrant further investigation to aid our understanding of the underlying etiologies of esophageal and gastric cancers by histological subtype and subsite.

Trimodality Therapy vs Definitive Chemoradiation in Older Adults With Locally Advanced Esophageal Cancer

BACKGROUND

The comparative effectiveness of trimodality therapy vs definitive chemoradiation for treating locally advanced esophageal cancer in older adults is uncertain. Existing trials lack generalizability to older adults, a population with heightened frailty. We sought to emulate a hypothetical trial comparing these treatments using real-world data.

METHODS

A cohort of adults aged 66-79 years diagnosed with locally advanced esophageal cancer between 2004 and 2017 was identified in the Surveillance Epidemiology and End Results-Medicare database. The clone-censor-weight method was leveraged to eliminate time-related biases when comparing outcomes between treatments. Outcomes included overall mortality, esophageal cancer-specific mortality, functional adverse events, and healthy days at home.

RESULTS

A total of 1240 individuals with adenocarcinomas and 661 with squamous cell carcinomas were identified. For adenocarcinomas, the standardized 5-year risk of mortality was 73.4% for trimodality therapy and 83.8% for definitive chemoradiation (relative risk [RR] = 0.88, 95% confidence interval [CI] = 0.82 to 0.95). Trimodality therapy was associated with mortality risk reduction for squamous cell carcinomas (RR = 0.87, 95% CI = 0.70 to 1.01). The 1-year incidence of functional adverse events was higher in the trimodality group (adenocarcinomas RR = 1.40, 95% CI = 1.22 to 1.65; squamous cell carcinomas RR = 1.21, 95% CI = 1.00 to 1.49). Over 5 years, trimodality therapy was associated with 160 (95% CI = 67 to 229) and 177 (95% CI = 51 to 313) additional home days in individuals with adenocarcinomas and squamous cell carcinomas, respectively.

CONCLUSIONS

Compared with definitive chemoradiation, trimodality therapy was associated with reduced mortality but increased risk of function-related adverse events. Discussing these tradeoffs may help optimize care plans.

Targeting the complexity of ERBB2 biology in gastroesophageal carcinoma

ERBB2 is the most prominent therapeutic target in gastroesophageal adenocarcinoma (GEA). For two decades, trastuzumab was the only treatment available for GEA overexpressing ERBB2. Several drugs showing evidence of efficacy over or in complement to trastuzumab in breast cancer failed to show clinical benefit in GEA. This resistance to anti-ERBB2 therapy is peculiarly recurrent in GEA and is mostly due to tumor heterogeneity with the existence of low expressing ERBB2 tumor clones and loss of ERBB2 over time. The development of new ERBB2 testing strategies and the use of antibody-drug conjugates having a bystander effect are providing new tools to fight heterogeneity in ERBB2-positive GEA. Co-amplifications of tyrosine kinase receptors, alterations in mitogen-activated protein kinase (MAPK) and phosphatidylinositol-3-kinase (PI3K) signaling pathways and in proteins controlling cell cycle are well known to contribute resistance to anti-ERBB2 therapy, and they can be targeted by dual therapy. Recently described, NF1 mutations are responsible for Ras phosphorylation and activation and can also be targeted by MEK/ERK inhibition along with anti-ERBB2 therapy. Multiple lines of evidence suggest that immune mechanisms involving antibody-dependent cell-mediated cytotoxicity are preponderant over intracellular signaling in anti-ERBB2 therapy action. A better comprehension of these mechanisms could leverage immune action of anti-ERBB2 therapy and elucidate efficacy of combinations associating immunotherapy and anti-ERBB2 therapy, as suggested by the recent intermediate positive results of the KEYNOTE-811 trial.

Investigating the predictive value of vascular endothelial growth factor in the evaluation of treatment efficacy and prognosis for patients with non-surgical esophageal squamous cell carcinoma

In this study, we aim to investigate the predictive value of serum vascular endothelial growth factor (VEGF) in evaluating treatment efficacy and long-term prognosis for patients with non-surgical esophageal squamous cell carcinoma (ESCC). The patients diagnosed with ESCC by histopathology who didn’t receive surgical treatment were retrospectively analyzed. Through follow-up and prognostic analysis, we explored the value of serum VEGF changes before, during, and after radiotherapy for predicting treatment efficacy, and identified important indicators to construct the predictive model. Eighty-four patients were enrolled in this study, and the objective response rate (ORR) after treatment was 75.0%. The serum VEGF before, during and after radiotherapy were 108.2 ± 38.4, 98.6 ± 20.3 and 96.9 ± 20.0pg/ml, respectively. Staging and serum VEGF during radiotherapy were the independent factors affecting the treatment efficacy of non-surgical ESCC patients (OR=0.182 and 0.959, P<0.05). The median overall survival (OS) and progression-free survival (PFS) were 24.4 and 15.8 months. The 3-year, 5-year, 10-year OS rates and PFS rates were 35.7%, 26.2%, 14.4%, and 26.2%, 22.6%, 12.3%, respectively. By performing COX regression analysis, we found that the TNM stage, changes of VEGF after radiotherapy (∆VEGF2), and endoscopic histopathological response were the independent prognostic factors for OS and PFS (P<0.05). The R² of the constructed prediction model was 0.328 and 0.362, and the C-index was 0.697 and 0.708, respectively. The follow-up time-dependent AUC showed that the predicted AUC was stable and greater than 0.7 as the follow-up time increased. For patients with non-surgical ESCC, those with low VEGF levels during radiotherapy had better treatment efficacy, and those with significant VEGF reduction after radiotherapy had a better prognosis. In summary, our results demonstrate that it is feasible to construct a model to evaluate and predict the efficacy and prognosis of patients with non-surgical ESCC based on serum VEGF measurement.

Landscape and predictions of inflammatory bowel disease in China: China will enter the Compounding Prevalence stage around 2030

Background

This study aims to explore the epidemiological trends of inflammatory bowel disease (IBD) over the past three decades in China and further predict the trends of IBD in the next 25 years.

Methods

The prevalence, incidence, mortality, years of life lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life years (DALYs), and annual percentage changes of the above metrics of IBD in China from 1990 to 2019 were extracted from the Global Burden of Disease Study 2019. The corresponding trends in the next 25 years were predicted.

Results

From 1990 to 2019, the cases of IBD in China raised to 484 thousand [95% uncertainty interval (UI) 411-571] and 427 thousand (366-498) among males and females, respectively. The age-standardized incidence rate of IBD increased from 1.72 per 100,000 population (1.44-2.05) to 3.35 per 100,000 population (2.88-3.88) among males and from 1.20 per 100,000 population (1.02-1.42) to 2.65 per 100,000 population (2.29-3.08) among females. The highest incidence rate occurred in people aged 35-39 years. The total YLDs attributed to IBD significantly increased, but the YLLs showed a decreasing trend, resulting in minor alterations of the DALYs. In the next 25 years, the incidence of IBD would continue to increase until a plateau by 2030, and IBD-related deaths would also increase to about 7.57 thousand by 2044 despite the decreasing age-standardized mortality rate. Similar trends were observed for both sexes, with a slight male predominance.

Conclusions

Although China is still a low-endemic area of IBD, the prevalence and incidence of IBD dramatically increased in the past three decades. The burden of IBD in China is expected to grow continuously in the next 25 years due to the large population base and severe aging problem. China is estimated to enter the Compounding Prevalence stage around 2030.

Systems biology and OMIC data integration to understand gastrointestinal cancers

Gastrointestinal (GI) cancers are a set of diverse diseases affecting many parts/ organs. The five most frequent GI cancer types are esophageal, gastric cancer (GC), liver cancer, pancreatic cancer, and colorectal cancer (CRC); together, they give rise to 5 million new cases and cause the death of 3.5 million people annually. We provide information about molecular changes crucial to tumorigenesis and the behavior and prognosis. During the formation of cancer cells, the genomic changes are microsatellite instability with multiple chromosomal arrangements in GC and CRC. The genomically stable subtype is observed in GC and pancreatic cancer. Besides these genomic subtypes, CRC has epigenetic modification (hypermethylation) associated with a poor prognosis. The pathway information highlights the functions shared by GI cancers such as apoptosis; focal adhesion; and the p21-activated kinase, phosphoinositide 3-kinase/Akt, transforming growth factor beta, and Toll-like receptor signaling pathways. These pathways show survival, cell proliferation, and cell motility. In addition, the immune response and inflammation are also essential elements in the shared functions. We also retrieved information on protein-protein interaction from the STRING database, and found that proteins Akt1, catenin beta 1 (CTNNB1), E1A binding protein P300, tumor protein p53 (TP53), and TP53 binding protein 1 (TP53BP1) are central nodes in the network. The protein expression of these genes is associated with overall survival in some GI cancers. The low TP53BP1 expression in CRC, high EP300 expression in esophageal cancer, and increased expression of Akt1/TP53 or low CTNNB1 expression in GC are associated with a poor prognosis. The Kaplan Meier plotter database also confirmed the association between expression of the five central genes and GC survival rates. In conclusion, GI cancers are very diverse at the molecular level. However, the shared mutations and protein pathways might be used to understand better and reveal diagnostic/prognostic or drug targets.

Mapping the adult human esophagus in vivo and in vitro

Many esophageal diseases can arise during development or throughout life. Therefore, well-characterized in vitro models and detailed methods are essential for studying human esophageal development, homeostasis and disease. Here, we (1) create an atlas of the cell types observed in the normal adult human esophagus; (2) establish an ancestrally diverse biobank of in vitro esophagus tissue to interrogate homeostasis and injury; and (3) benchmark in vitro models using the adult human esophagus atlas. We created a single-cell RNA sequencing reference atlas using fresh adult esophagus biopsies and a continuously expanding biobank of patient-derived in vitro cultures (n=55 lines). We identify and validate several transcriptionally distinct cell classes in the native human adult esophagus, with four populations belonging to the epithelial layer, including basal, epibasal, early differentiating and terminally differentiated luminal cells. Benchmarking in vitro esophagus cultures to the in vivo reference using single-cell RNA sequencing shows that the basal stem cells are robustly maintained in vitro, and the diversity of epithelial cell types in culture is dependent on cell density. We also demonstrate that cultures can be grown in 2D or as 3D organoids, and these methods can be employed for modeling the complete epithelial layers, thereby enabling in vitro modeling of the human adult esophagus.

Bombyx mori Cecropin D could trigger cancer cell apoptosis by interacting with mitochondrial cardiolipin

Cecropin D is an antimicrobial peptide from Bombyx mori displaying anticancer and pro-apoptotic activities and, together with Cecropin XJ and Cecropin A, one of the very few peptides targeting esophageal cancer. Cecropin D displays poor similarity to other cecropins but a remarkable similarity in the structure and activity spectrum with Cecropin A and Cecropin XJ, offering the possibility to highlight key motifs at the base of the biological activity. In this work we show by NMR and MD simulations that Cecropin D is partially structured in solution and stabilizes its two-helix folding upon interaction with biomimetic membranes. Simulations show that Cecropin D strongly interacts with the surface of cancer cell biomimetic bilayers where it recognises the phosphatidylserine headgroup often exposed in the outer leaflet of cancerous cells by means of specific salt bridges. Cecropin D is also able to penetrate deeply in bilayers containing cardiolipin, a phospholipid found in mitochondria, causing significant destabilization in the lipid packing which might account for its pro-apoptotic activity. In bacterial membranes, phosphatidylglycerol and phosphatidylethanolamine act synergically by electrostatically attracting cecropin D and providing access to the membrane core, respectively.

International trends in esophageal cancer incidence rates by histological subtype (1990-2012) and prediction of the rates to 2030

BACKGROUND

We provide an up-to-date overview of recent international trends (1990-2012) and predicted trends (2013-2030) in the incidence rates of esophageal cancer.

METHODS

We used data from the Cancer Incidence in Five Continents (CI5plus) database that contains annual incidence data by cancer site, age, and sex as well as corresponding populations. The age-standardized esophageal cancer incidence rates of each country were calculated and plotted from 1990 through 2012 and were predicted to 2030 using a Bayesian age-period-cohort model.

RESULTS

Globally, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) showed opposing trends between 1990 and 2012; ESCC showed a decreasing trend, with an AAPC of - 1.5 (95% CI - 2.4, - 0.7), yet EAC showed an increasing trend, with an AAPC of 5.2 (95% CI 4.2, 6.2). The increasing trend in EAC was commonly observed in high-income countries. The predicted trend to 2030 indicated that most countries will continue to experience a decreasing trend or a stable trend in esophageal cancer incidence, except Denmark, the Netherlands, and the UK, where the overall esophageal cancer incidence rates, mainly driven by EAC, are predicted to increase.

CONCLUSIONS

Decreasing trends in ESCC have been observed worldwide in both low- and middle-income countries and high-income countries, which may have been offset by increasing trends in EAC in high-income countries. The changing patterns of these two main subtypes of esophageal cancer may call for interventions, especially innovative interventions, to address obesity, GERD, and Barrett's esophagus.

Global burden and temporal trends in incidence and mortality of oesophageal cancer

INTRODUCTION

Oesophageal cancer is a prevalent and deadly cancer around the world.

OBJECTIVES

We aimed to present a comprehensive analysis of the global geographic patterns and temporal trends in the mortality and incidence of oesophageal cancer.

METHODS

The mortality and incidence data of oesophageal cancer in 2020 were obtained from the GLOBOCAN database. Based on World Health Organization (WHO) mortality database and the Cancer Incidence in Five Continents (CI5), we also retrieved the mortality and incidence age-standardized rates (ASRs) of oesophageal cancer. The average annual percentage changes (AAPCs) of mortality and incidence were calculated using the joinpoint regression analysis.

RESULTS

Globally, 0.54 million deaths and 0.6 million new cases were identified in 2020. In the majority of countries of South America and Asia, the mortality and incidence trends have substantially decreased, but trends in European countries have varied. The prevalence in European nations varied, but the incidence in most other continents decreased dramatically. In terms of mortality, the global average rate was 5.6 per 100000, ranging from 16.7 (Malawi) to 0.28 (Belize). European countries varied in mortality, such as Norway (AAPC, male: 0.68; female: 0.89) and Ireland (AAPC, male: -0.96; female: -1.52). Most non-European countries saw large decreases in mortality, such as Singapore (AAPC, male: -4.78; female: -6.89). The elderly had more noticeable trends in mortality and incidence in most countries.

CONCLUSIONS

We have identified different trends in mortality and incidence among European countries, whereas declining trends were identified in most non-European countries. However, increasing trends were identified in specific subgroups of some countries, such as men in Thailand. For populations with rising mortality and incidence trends, more preventative efforts are required.

Integrating microarray-based spatial transcriptomics and single-cell RNA-sequencing reveals tissue architecture in esophageal squamous cell carcinoma

Background

The tumor microenvironment (TME) serves as an important factor in tumorigenesis and metastasis. Although distinct cell subsets can be identified via single-cell RNA sequencing (scRNA-seq), the spatial composition of cells within the TME is difficult to characterise.

Methods

Tissue samples were collected from three patients with esophageal squamous cell carcinoma (ESCC), and scRNA-seq was performed to identify distinct cell subsets. In addition, a microarray-based spatial transcriptomics (ST) method was used to characterise the spatial landscape of expression data via an array of spots. Using multimodal intersection analysis (MIA) to integrate scRNA-seq and ST, the exact cellular components of the tumor and stromal regions were annotated.

Findings

The subpopulations of seven stromal cells were identified within the TME of ESCC, and the architecture of scRNA-seq-determined subsets was mapped in cancer and stromal regions. The distribution of various stromal cells and their subpopulations was heterogeneous. Compared with immune cells, non-immune stromal cells were significantly enriched in the TME. Most subsets of epithelial cells were enriched in the cancer regions, whereas inflammatory cancer-associated fibroblasts were correlated with the stromal regions. Furthermore, TME features were different between metastatic and non-metastatic samples and between the primary and metastatic sites of the metastatic sample.

Interpretation

This study revealed the spatial landscape of various cell subsets within the TME and the potential cross-talk among diverse cells, which provides novel insights into cancer intervention.

Funding

A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.

The Global Landscape of Esophageal Squamous Cell Carcinoma and Esophageal Adenocarcinoma Incidence and Mortality in 2020 and Projections to 2040: New Estimates From GLOBOCAN 2020

BACKGROUND & AIMS

The aim of this study was to provide an overview of the burden of esophageal cancer in 185 countries in 2020 and projections for the year 2040.

METHODS

Estimates of esophageal cancer cases and deaths were extracted from the GLOBOCAN database for 2020. Age-standardized incidence and mortality rates were calculated overall, by sex, histologic subtype (adenocarcinoma [AC] and squamous cell carcinoma [SCC]), country, and level of human development for 185 countries. The predicted burden of incidence and mortality in 2040 was calculated based on global demographic projections.

RESULTS

Globally, there were an estimated 604,100 new cases of, and 544,100 deaths from, esophageal cancer in 2020, corresponding to age-standardized incidence and mortality rates of 6.3 and 5.6 per 100,000, respectively. Most cases were SCCs (85% [512,500 cases]) and 14% (85,700 cases) were ACs. Incidence and mortality rates were 2- to 3-fold higher in male (9.3 and 8.2, respectively) compared with female (3.6 and 3.2, respectively) individuals. Global variations in incidence and mortality were observed across countries and world regions; the highest rates occurred in Eastern Asia and Southern and Eastern Africa and the lowest occurred in Western Africa and Central America regions. If rates remain stable, 957,000 new cases (141,300 AC cases and 806,000 SCC cases) and 880,000 deaths from esophageal cancer are expected in 2040.

CONCLUSIONS

These updated estimates of the global burden of esophageal cancer represent an important baseline for setting priorities in policy making and developing and accelerating cancer control initiatives to reduce the current and projected burden. Although primary prevention remains key, screening and early detection represent important components of esophageal cancer control in high-risk populations.

Proton Beam Therapy for Esophageal Cancer

Simple Summary

Early-stage esophageal cancer is managed surgically, with the addition of radiotherapy for locally advanced disease. Current photon-based radiotherapy results in a high treatment-related complications, due to proximal organ involvement. The anatomic location of the esophagus raises challenges due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. In this review, we present the role of PBT for esophageal cancer, including treatment planning, early clinical comparisons with photon-based techniques, ongoing trials, current challenges, toxicities, and issues of equity and health services.

Abstract

Early-stage esophageal cancer is often primarily managed surgically, with the addition of radiotherapy for locally advanced disease. However, current photon-based radiotherapy regimens and surgery results in a high incidence of treatment-related cardiac and pulmonary complications due to the involvement of proximal organs at risk. In addition, the anatomic location of the esophagus raises challenges for radiotherapy due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These challenges propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. Several dosimetric studies support the potential advantages of PBT for esophageal cancer treatment however, translation of these results to improved clinical outcomes remains unclear with limited clinical data, especially in large populations. Studies on the effect on quality of life are likewise lacking. Here, we review the existing and emerging role of PBT for esophageal cancer, including treatment planning, early clinical comparisons of PBT with photon-based techniques, recently concluded and ongoing clinical trials, challenges and toxicities, effects on quality of life, and global inequities in the treatment of esophageal cancer.

Recent advances in multidisciplinary therapy for adenocarcinoma of the esophagus and esophagogastric junction

Esophageal adenocarcinoma (EAC) and adenocarcinoma of the esophagogastric junction (EGJA) have long been associated with poor prognosis. With changes in the spectrum of the disease caused by economic development and demographic changes, the incidence of EAC and EGJA continues to increase, making them worthy of more attention from clinicians. For a long time, surgery has been the mainstay treatment for EAC and EGJA. With advanced techniques, endoscopic therapy, radiotherapy, chemotherapy, and other treatment methods have been developed, providing additional treatment options for patients with EAC and EGJA. In recent decades, the emergence of multidisciplinary therapy (MDT) has enabled the comprehensive treatment of tumors and made the treatment more flexible and diversified, which is conducive to achieving standardized and individualized treatment of EAC and EGJA to obtain a better prognosis. This review discusses recent advances in EAC and EGJA treatment in the surgical-centered MDT mode in recent years.

The survival of esophageal cancer by subtype in China with comparison to the United States

Adenocarcinoma (AC) and squamous cell carcinoma (SCC) are the main subtypes of esophageal cancer (EC), but nationwide survival of both EC subtypes has never been reported in China. This study aimed to estimate the survival trends of EC by subtype in China and compare them with those in the USA for the same period. We used data from 64 Chinese cancer registries, which included EC patients diagnosed during 2008 and 2015 and followed up until 31st December 2017. The 5-year age-standardized relative survival by subtype, sex, age group, and urban or rural area between 2008 and 2017 were analyzed. We stratified survival estimates by calendar period (2008-09, 2010-11, 2012-14, and 2015-17). Data from the SEER 18 programme were calculated to estimate the survival of EC in the USA. A further comparison between the survivals in areas covered and not covered by population-based endoscopic screening programmes in China was conducted. A total of 129 962 records were included in the survival analyses. Results revealed that age-standardised 5-year relative survivals for AC and SCC increased in both China and USA from 2008 to 2017. In 2015-17, 5-year survival from both subtypes in China was better than the USA (SCC: 36.9% vs 18.5%, AC: 34.8% vs 22.3%). The survival for both subtypes was significantly higher in screening areas than in non-screening areas in China (SCC: 40.6% vs 32.8%; AC: 43.0% vs 31.3%). A survival gap in EC by subtype exists between China and USA. Our results may support the beneficial effect of population-based endoscopic screening for survival, and may be poised to inform national policy-making in both countries. This article is protected by copyright. All rights reserved.

Identification of Early Esophageal Cancer by Semantic Segmentation

Early detection of esophageal cancer has always been difficult, thereby reducing the overall five-year survival rate of patients. In this study, semantic segmentation was used to predict and label esophageal cancer in its early stages. U-Net was used as the basic artificial neural network along with Resnet to extract feature maps that will classify and predict the location of esophageal cancer. A total of 75 white-light images (WLI) and 90 narrow-band images (NBI) were used. These images were classified into three categories: normal, dysplasia, and squamous cell carcinoma. After labeling, the data were divided into a training set, verification set, and test set. The training set was approved by the encoder–decoder model to train the prediction model. Research results show that the average time of 111 ms is used to predict each image in the test set, and the evaluation method is calculated in pixel units. Sensitivity is measured based on the severity of the cancer. In addition, NBI has higher accuracy of 84.724% when compared with the 82.377% accuracy rate of WLI, thereby making it a suitable method to detect esophageal cancer using the algorithm developed in this study.

Identification of plasma proteins associated with oesophageal cancer chemotherapeutic treatment outcomes using SWATH-MS

Oesophageal adenocarcinoma (OAC) is an aggressive cancer with a five-year survival of <15%. Current chemotherapeutic strategies only benefit a minority (20-30%) of patients and there are no methods available to differentiate between responders and non-responders. We performed quantitative proteomics using Sequential Window Acquisition of all THeoretical fragment-ion spectra-Mass Spectrometry (SWATH-MS) on albumin/IgG-depleted and non-depleted plasma samples from 23 patients with locally advanced OAC prior to treatment. Individuals were grouped based on tumour regression (TRG) score (TRG1/2/3 vs TRG4/5) after chemotherapy, and differentially abundant proteins were compared. Protein depletion of highly abundant proteins led to the identification of around twice as many proteins. SWATH-MS revealed significant quantitative differences in the abundance of several proteins between the two groups. These included complement c1q subunit proteins, C1QA, C1QB and C1QC, which were of higher abundance in the low TRG group. Of those that were found to be of higher abundance in the high TRG group, glutathione S-transferase pi (GSTP1) exhibited the lowest p-value and highest classification accuracy and Cohen's kappa value. Concentrations of these proteins were further examined using ELISA-based assays. This study provides quantitative information relating to differences in the plasma proteome that underpin response to chemotherapeutic treatment in oesophageal cancers. SIGNIFICANCE: Oesophageal cancers, including oesophageal adenocarcinoma (OAC) and oesophageal gastric junction cancer (OGJ), are one of the leading causes of cancer mortality worldwide. Curative therapy consists of surgery, either alone or in combination with adjuvant or neoadjuvant chemotherapy or radiation, or combination chemoradiotherapy regimens. There are currently no clinico-pathological means of predicting which patients will benefit from chemotherapeutic treatments. There is therefore an urgent need to improve oesophageal cancer disease management and treatment strategies. This work compared proteomic differences in OAC patients who responded well to chemotherapy as compared to those who did not, using quantitative proteomics prior to treatment commencement. SWATH-MS analysis of plasma (with and without albumin/IgG-depletion) from OAC patients prior to chemotherapy was performed. This approach was adopted to determine whether depletion offered a significant improvement in peptide coverage. Resultant datasets demonstrated that depletion increased peptide coverage significantly. Additionally, there was good quantitative agreement between commonly observed peptides. Data analysis was performed by adopting both univariate as well as multivariate analysis strategies. Differentially abundant proteins were identified between treatment response groups based on tumour regression grade. Such proteins included complement C1q sub-components and GSTP1. This study provides a platform for further work, utilising larger sample sets across different treatment regimens for oesophageal cancer, that will aid the development of 'treatment response prediction assays' for stratification of OAC patients prior to chemotherapy.

Chinese and Global Burdens of Gastrointestinal Cancers From 1990 to 2019

Background

Gastrointestinal (GI) cancers are an important component of the tumor. This study aimed to investigate the burden of six major GI cancers in China and globally from 1990 to 2019.

Methods

We conducted a cross-sectional study based on the Global Burden of Disease Study (GBD) 2019. Indicators on incidence, deaths, disability-adjusted life-years (DALYs), and risk factors for esophageal, stomach, liver, pancreatic, colon and rectum, and gallbladder and biliary tract cancers were collected and analyzed for time trends. The contribution of each cancer and the proportion of cases in China among global cases were further reported.

Results

Global incidence cases, death cases, and DALYs of GI cancers showed an overall ascending trend over the past 30 years, but there was temporal and geographical variation across cancer types. By 2019, colon and rectum cancer had overtaken stomach cancer as the most burdensome GI cancer globally. However, stomach cancer narrowly continued to be the most burdensome GI in China. In addition, the proportion of incidence and death cases of stomach, pancreatic, colon and rectum, and gallbladder and biliary tract cancers among global cases had further increased. It was noteworthy that the burden of liver cancer in China has been alleviated significantly.

Conclusion

GI cancers remain a major public health problem in China and globally. Despite the temporal and geographic diversity of different cancers, targeted primary and secondary prevention are still necessary for the future to face these unknown challenges.

The Association Between Family History of Upper Gastrointestinal Cancer and the Risk of Death from Upper Gastrointestinal Cancer-based on Linxian Dysplasia Nutrition Intervention Trial (NIT) Cohort

Objective

Explore the influence of family history of upper gastrointestinal (UGI) cancer on UGI cancer death, based on the Linxian Dysplasia Nutrition Intervention Trial (NIT) cohort.

Methods

Family history of UGI cancer was defined as at least one first-degree relative (parent, child, or sibling) had a history of esophageal or gastric cancer. Cancer death was carried out by ICD-10 code. Family history information was collected at baseline and cancer deaths were assessed at each annual follow-up. The COX proportional risk model was used to estimate the hazard ratio (HR) and 95% confidence interval (95% CI). We compared the positive family history group with the negative to determine the risk of family history on UGI cancer death. The effect of category of relatives, number of relatives with UGI cancer, and diagnosis age of relatives on the UGI death risk were further analyzed. Interaction and stratification analyses were done to see the subgroup effects. Sensitivity analyses were also conducted by exclusion of individuals who were followed up less than three years. We considered controlling of covariates including: gender, age (continuity), community, education level, number of siblings (continuity), BMI (continuity), smoking, alcohol use, fresh fruit intake, fresh vegetable intake, hot beverage intake, edible oil intake, meat intake, and moldy staple food intake. All food intake variables were converted into categorical variables.

Results

From1985 to2015, we followed up total 3,318 individuals with 898 UGI cancer deaths (537 from ESCC, 77 from GNCC, and 284 from GCC). In a single factor analysis, family history of UGI cancer increased the risk of death of esophageal squamous cell carcinoma (ESCC) by 27% (HR=1.270, 95%CI1.072-1.504). No associations were observed in gastric cardia carcinoma (GCC) and gastric non-cardia carcinoma (GNCC). After adjusting for multi-factor, a family history of UGI cancer risk of death increased by 31.9% from ESCC (HR=1.319,95%CI:1.110-1.567). Subgroup analysis of different types of relatives with UGI cancers, UGI cancers in the mother (HR=1.457,95%CI:1.200-1.768), brother (HR=1.522,95%CI:1.117-2.073), and sister (HR=1.999,95%CI:1.419-2.817) were independent risk factors for ESCC death, while the father was not. In addition, 2 relatives with UGI cancer (HR=1.495, 95%, CI:1.110-2.013) and ≥3 relatives with UGI cancer (HR=2.836, 95%CI:1.842-4.367) significantly increased the risk of ESCC death, and the trend test was statistically significant (P<0.001). Relatives’ diagnostic age of 51-60 years (HR=1.322, 95%CI:1.046-1.672) and 41-50 years (HR=1.442, 95%CI:1.078-1.930) were the risk factors for ESCC death, with statistical significance in the trend test (P=0.010). No statistically significant result of the family history effect on the risk of death from GCC or GNCC was found. Sensitivity analysis of 80% of subjects, randomly selected, did not change the results.

Conclusion

A family history of UGI cancer may predict the risk of death from ESCC but not from GCC or GNCC. UGI cancer in the mother may predict the risk of death from ESCC, but not father, which indicates gender differences. Gender and smoking are the interaction items with family history in a similar extent. In the subgroup, the risk of ESCC death is more distinct by family history in younger, female, and better-lifestyle individuals, which indicates the unique role of genetic factors.

Efficacy and tolerability of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) in unselected patients with advanced gastric and gastroesophageal cancer: does age really matter?

PURPOSE

Fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) regimen has shown strong efficacy as perioperative therapy for patients with locally advanced gastric (GC) and gastroesophageal (AEG) carcinoma. In the palliative situation, FLOT is recommended only for young fit patients. Data of efficacy and tolerability of FLOT in elderly patients are scarce and controversial. Thus, this study aimed to provide real-life experience of elderly patients with GC and AEG treated with FLOT as first-line palliative chemotherapy.

METHODS

Patients with advanced or metastatic GC or AEG and treated with FLOT as first-line palliative therapy between 2010 and 2021 were analyzed. Patients were grouped into < 65 years old (n = 35) and ≥ 65 years old (n = 22) groups. Overall survival (OS), progression-free survival (PFS), feasibility and toxicity were analyzed.

RESULTS

The median OS was 10.4 months with no significant difference between both groups (HR 0.86; 95% CI 0.48, 1.57; p = 0.632). The ECOG performance status showed powerful influence on OS in the subgroup analysis with median OS of 12.3 months for ECOG = 0 compared to 5.0 months for ECOG ≥ 1 (p = 0.015) as well as in multivariate analysis (HR 2.62; 95% CI 1.36, 5.04; p = 0.004).

CONCLUSION

In the present study the ECOG performance status showed a stronger prognostic value than patient age in FLOT as first- line therapy in a real-life cohort with advanced and metastatic GC and AEG. The performance status should therefore be considered in the therapeutic decision making of elderly patients with GC and AEG.