Modifiable factors and esophageal cancer: a systematic review of published meta-analyses

Risk of Esophageal Adenocarcinoma After Helicobacter pylori Eradication Treatment in a Population-Based Multinational Cohort Study

BACKGROUND & AIMS

Helicobacter pylori infection is associated with a decreased risk of esophageal adenocarcinoma, and the decreasing prevalence of such infection might contribute to the increasing incidence of this tumor. We examined the hypothesis that eradication treatment of H pylori increases the risk of esophageal adenocarcinoma.

METHODS

This population-based multinational cohort, entitled "Nordic Helicobacter Pylori Eradication Project (NordHePEP)," included all adults (≥18 years) receiving H pylori eradication treatment from 1995-2018 in any of the 5 Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) with follow-up throughout 2019. Data came from national registers. We calculated standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) by dividing the cancer incidence in the exposed cohort by that of the entire Nordic background populations of the corresponding age, sex, calendar period, and country. Analyses were stratified by factors associated with esophageal adenocarcinoma (ie, education, comorbidity, gastroesophageal reflux, and certain medications).

RESULTS

Among 661,987 participants who contributed 5,495,552 person-years after eradication treatment (median follow-up, 7.8 years; range, 1-24 years), 550 cases of esophageal adenocarcinoma developed. The overall SIR of esophageal adenocarcinoma was not increased (SIR = 0.89; 95% CI, 0.82-0.97). The SIR did not increase over time after eradication treatment, but rather decreased and was 0.73 (95% CI, 0.61-0.86) at 11-24 years after treatment. There were no major differences in the stratified analyses. The overall SIR of esophageal squamous cell carcinoma, calculated for comparison, showed no association (SIR = 0.99; 95% CI, 0.89-1.11).

CONCLUSIONS

This absence on an increased risk of esophageal adenocarcinoma after eradication treatment of H pylori suggests eradication is safe from a cancer perspective.

Protective effect of folic acid on MNNG-induced proliferation of esophageal epithelial cells via the PI3K/AKT/mTOR signaling pathway

Recent research has revealed that N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) constitutes a significant risk factor in the development of esophageal cancer. Several investigations have elucidated the beneficial impact of folic acid (FA) in safeguarding esophageal epithelial cells against MNNG-induced damage. Therefore, we hypothesized that FA might prevent MNNG-induced proliferation of esophageal epithelial cells by interfering with the PI3K/AKT/mTOR signaling pathway. In vivo experiments, we found that FA antagonized MNNG-induced proliferation of rat esophageal mucosal epithelial echinocytes and activation of the PI3K/AKT/mTOR signaling pathway. In our in vitro experiments, it was observed that acute exposure to MNNG for 24 h led to a decrease in proliferative capacity and inhibition of the PI3K/AKT/mTOR signaling pathway in an immortalized human normal esophageal epithelial cell line (Het-1A), which was also ameliorated by supplementation with FA. We successfully established a Het-1A-T-cell line by inducing malignant transformation in Het-1A cells through exposure to MNNG. Notably, the PI3K/AKT2/mTOR pathway showed early suppression followed by activation during this transition. Next, we observed that FA inhibited cell proliferation and activation of the PI3K/AKT2/mTOR signaling pathway in Het-1A-T malignantly transformed cells. We further investigated the impact of 740Y-P, a PI3K agonist, and LY294002, a PI3K inhibitor, on Het-1A-T-cell proliferation. Overall, our findings show that FA supplementation may be beneficial in safeguarding normal esophageal epithelial cell proliferation and avoiding the development of esophageal cancer by decreasing the activation of the MNNG-induced PI3K/AKT2/mTOR signaling pathway.

The role of dietary carotenoids in preventing the development of esophageal squamous cell carcinoma

Background and aims: Experimental studies showed that carotenoids had anti-carcinogenic properties, but epidemiological studies on the association between dietary carotenoids and esophageal squamous cell carcinoma (ESCC) risk were limited, and the findings were inconsistent. This study aimed to investigate the roles of intake of dietary carotenoids in the development of ESCC among a rural Chinese population. Methods: A population-based case-control study was conducted in Southwest China. A total of 915 incident ESCC cases and 925 community-based controls were included. A validated food frequency questionnaire with 76-item was adopted to collect information about dietary consumption. Intake of dietary calories and each carotenoid was calculated according to the China food composition tables. Odds ratios (OR) with 95% confidence intervals (CI) were calculated by a logistic regression model, with adjustments for age, gender, body mass index, family cancer history, cigarette smoking, alcohol drinking, education, marital status, prudent pattern score, and total calories. Results: In comparison to the highest with lowest intake quartiles, intake of total carotenes (OR: 0.70, 95% CI: 0.52-0.96, Ptrend: 0.024), α-carotene (OR: 0.62, 95% CI: 0.46-0.83, Ptrend: 0.014), β-carotene (OR: 0.63, 95% CI: 0.46-0.86, P-trend: 0.005), and the sum of lutein and zeaxanthin (OR: 0.41, 95% CI: 0.29-0.56, Ptrend<0.001) was significantly associated with a decreased risk of ESCC after adjustment for confounders. Conclusions: The results indicated that a higher intake of total carotene, α-carotene, β-carotene, and the sum of lutein and zeaxanthin was associated with a lower risk of ESCC.

Spatiotemporal Distribution, Time to Treatment Outcome Clustering and Determinants of Esophageal Cancer in Ethiopia, a Scoping Study

INTRODUCTION

Esophageal cancer was the eighth and sixth leading cause of morbidity of all cancers in the world, and the 15th and 12th in Ethiopia, respectively. There is a lack of comprehensive data regarding Ethiopia's esophageal cancer hotspot, treatment outcome clustering, and other factors.

OBJECTIVE

This scoping review was designed to understand the extent and type of existing evidence regarding spatiotemporal distribution, time to treatment outcome clustering, and determinants of esophageal cancer in Ethiopia up to March 28, 2023.

METHODS

Three-step search strategies were employed for the scoping review from March 15 to 28, 2023. Targeted databases included PubMed/Medline, PubMed Central (PMC), Google Scholar, Hinari, and Cochrane for published studies and different websites for unpublished studies for evidence synthesis. Data were extracted using the Joanna Briggs Institute (JBI) manual format.

RESULTS

Our final analysis comprised 17 (16 quantitative and 1 qualitative) studies. Three studies attempted to depict the country's temporal distribution, whereas 12 studies showed the spatial distribution of esophageal cancer by proportion. The regional state of Oromia recorded a high percentage of cases. Numerous risk factors linked to the tumor have been identified in 8 investigations. Similarly, 5 studies went into detail regarding the likelihood of survival and the factors that contribute to malignancy, while 2 studies covered the results of disease-related treatments.

CONCLUSIONS

The substantial body of data that underpins this finding supports the fact that esophageal cancer has several risk factors and that its prevalence varies greatly across the country and among regions. Surgery, radiotherapy, or chemotherapy helped the patient live longer. However, no research has investigated which treatment is best for boosting patient survival and survival clustering. Therefore, research with robust models for regional distribution, clustering of time to treatment outcomes, and drivers of esophageal cancer will be needed.

Vegetarian diets and the risk of gastrointestinal cancers: a meta-analysis of observational studies

The systematic review aimed to assess the association between vegetarian diet and the risk of gastrointestinal tumorigenesis. PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to August 2022 for observational studies on vegetarian diets and the risk of gastrointestinal tumorigenesis. The primary outcome was morbidity due to gastrointestinal cancer. The Newcastle-Ottawa Scale was used to assess the quality of included studies. Pooled effects were analyzed using a random-effects model. The study protocol was registered in PROSPERO (no. CRD42022310187). Eight original studies (seven cohorts and one case-control), involving 686 691 participants, were included. Meta-analysis showed a negative correlation between vegetarian diets and gastrointestinal tumorigenesis risk [relative risk (RR) equals 0.77, 95% confidence interval (CI) is (0.65-0.90)], compared with non-vegetarian diets. Subgroup analysis indicated that vegetarian diets were negatively correlated with the risks of gastric cancer [RR = 0.41, 95% CI (0.28-0.61)] and colorectal cancer [RR = 0.85, 95% CI (0.76-0.95)], but not with that of upper gastrointestinal cancer (excluding stomach) [RR = 0.93, 95% CI (0.61-1.42)]. Vegetarian diets were negatively correlated with the risk of gastrointestinal tumorigenesis in men [RR = 0.57, 95% CI (0.36-0.91)], but were uncorrelated in women [RR = 0.89, 95% CI (0.71-1.11)]. Vegetarian diets were negatively correlated with the risk of gastrointestinal tumorigenesis in North American [RR = 0.76, 95% CI (0.61-0.95)] and Asian populations [RR = 0.43, 95% CI (0.26-0.72)] and were uncorrelated in the European population [RR = 0.83, 95% CI (0.68-1.01)]. Adhering to vegetarian diets reduces the risk of gastrointestinal tumorigenesis. More data from well-conducted cohort and other studies are needed.

Sex-specific effects of fruit, vegetable, and red meat intake on the risk of gastric and esophageal cancer in a large cohort

BACKGROUND

Dietary effects on gastric and esophageal cancer by sex and smoking has rarely been investigated.

METHODS

Individuals who had undergone national gastric cancer screening during 2008 and had no any cancer at baseline were enrolled and followed up to 2017. The gastric and esophageal cancer risk was measured using adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Among 3.645 million (44.1% men), 45,741 gastric cancers (67.7% men) and 3,550 esophageal cancers (89.5% men) developed during 9 years follow-up. In adjusted analysis, a frequent intake of fruit (≥ 7 servings per week) reduced the gastric cancer risk (aHR=0.91; 95% CI, 0.83-0.99) comparing to nearly no intake in women but slightly increased male gastric cancer risk (aHR=1.06; 95% CI, 1.00-1.13). A frequent intake of dietary fruit reduced the esophageal cancer risk only in men (aHR=0.75; 95% CI, 0.62-0.92). Frequent intake of red meat (3-4/week) slightly increased the gastric cancer risk only in men (aHR=1.04; 95% CI, 1.01-1.09). The favorable effect of fruit on the gastric and esophageal cancer risk was observed only in never smoker.

CONCLUSIONS

The effect of fruit and red meat intake on the gastric and esophageal cancer risk differed according to sex and smoking status.

Machine learning-based approaches for cancer prediction using microbiome data

Emerging evidence of the relationship between the microbiome composition and the development of numerous diseases, including cancer, has led to an increasing interest in the study of the human microbiome. Technological breakthroughs regarding DNA sequencing methods propelled microbiome studies with a large number of samples, which called for the necessity of more sophisticated data-analytical tools to analyze this complex relationship. The aim of this work was to develop a machine learning-based approach to distinguish the type of cancer based on the analysis of the tissue-specific microbial information, assessing the human microbiome as valuable predictive information for cancer identification. For this purpose, Random Forest algorithms were trained for the classification of five types of cancer-head and neck, esophageal, stomach, colon, and rectum cancers-with samples provided by The Cancer Microbiome Atlas database. One versus all and multi-class classification studies were conducted to evaluate the discriminative capability of the microbial data across increasing levels of cancer site specificity, with results showing a progressive rise in difficulty for accurate sample classification. Random Forest models achieved promising performances when predicting head and neck, stomach, and colon cancer cases, with the latter returning accuracy scores above 90% across the different studies conducted. However, there was also an increased difficulty when discriminating esophageal and rectum cancers, failing to differentiate with adequate results rectum from colon cancer cases, and esophageal from head and neck and stomach cancers. These results point to the fact that anatomically adjacent cancers can be more complex to identify due to microbial similarities. Despite the limitations, microbiome data analysis using machine learning may advance novel strategies to improve cancer detection and prevention, and decrease disease burden.

The contribution of smoking and smokeless tobacco to oesophageal squamous cell carcinoma risk in the African oesophageal cancer corridor: Results from the ESCCAPE multicentre case-control studies

Tobacco use is a well-established risk factor for oesophageal squamous cell carcinoma (ESCC) but the extent of its contribution to the disease burden in the African oesophageal cancer corridor has not been comprehensively elucidated, including by type of tobacco use. We investigated the contribution of tobacco use (smoking and smokeless) to ESCC in Tanzania, Malawi and Kenya. Hospital-based ESCC case-control studies were conducted in the three countries. Incident cases and controls were interviewed using a comprehensive questionnaire which included questions on tobacco smoking and smokeless tobacco use. Logistic regression models were used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of ESCC associated with tobacco, adjusted for age, sex, alcohol use, religion, education and area of residence. One thousand two hundred seventy-nine cases and 1345 controls were recruited between August 5, 2013, and May 24, 2020. Ever-tobacco use was associated with increased ESCC risk in all countries: Tanzania (OR 3.09, 95%CI 1.83-5.23), and in Malawi (OR 2.45, 95%CI 1.80-3.33) and lesser in Kenya (OR 1.37, 95%CI 0.94-2.00). Exclusive smokeless tobacco use was positively associated with ESCC risk, in Tanzania, Malawi and Kenya combined (OR 1.92, 95%CI 1.26-2.92). ESCC risk increased with tobacco smoking intensity and duration of smoking. Tobacco use is an important risk factor of ESCC in Tanzania, Malawi and Kenya. Our study provides evidence that smoking and smokeless tobacco cessation are imperative in reducing ESCC risk.

Determinants of survival outcomes among esophageal cancer patients at a national referral hospital in Kenya

Introduction

The overall 5-year survival rate for esophageal cancer patients in low- and middle-income countries was reported to be low, despite the availability of advanced treatments. Thus, this study aimed to assess determinants of survival outcomes among esophageal cancer patients in Kenya.

Methods

A retrospective cohort study was employed among 299 adult esophageal cancer patients. The data were collected using a data abstraction tool consisting of patients' clinical characteristics and survival outcome measuring parameters. Statistical Package for the Social Sciences (SPSS) statistical software (version 20.0, IBM. USA) was used to analyze the data. The Kaplan-Meier and Cox regression analyses were used to determine the survival outcome and determinants of mortality, respectively.

Results

The mortality rate was 43.1%, and 11.1% of patients demonstrated distant metastases in the follow-up period. Despite treatment, 20.1% had progressed disease, and 13.0% did not respond to treatment. Radiotherapy (AHR: 3.3, 95% CI: 1.4-7.8, p = 0.007), chemotherapy (AHR: 3.9, 95% CI: 1.2-6.1, p = 0.020), and chemoradiation (AHR: 5.6, 95%CI: 1.6-10.2, p = 0.006) were the significant determinants of survival in advanced stage (III and and IV) patients.

Conclusions

There was a high mortality rate, disease progression, and nonresponse of esophageal cancer patients. Hence, it is essential to improve the survival of patients through early detection and timely initiation of the available treatment options.

Smoking, alcohol consumption, and 24 gastrointestinal diseases: Mendelian randomization analysis

Background

Whether the positive associations of smoking and alcohol consumption with gastrointestinal diseases are causal is uncertain. We conducted this Mendelian randomization (MR) to comprehensively examine associations of smoking and alcohol consumption with common gastrointestinal diseases.

Methods

Genetic variants associated with smoking initiation and alcohol consumption at the genome-wide significance level were selected as instrumental variables. Genetic associations with 24 gastrointestinal diseases were obtained from the UK Biobank, FinnGen study, and other large consortia. Univariable and multivariable MR analyses were conducted to estimate the overall and independent MR associations after mutual adjustment for genetic liability to smoking and alcohol consumption.

Results

Genetic predisposition to smoking initiation was associated with increased risk of 20 of 24 gastrointestinal diseases, including 7 upper gastrointestinal diseases (gastroesophageal reflux, esophageal cancer, gastric ulcer, duodenal ulcer, acute gastritis, chronic gastritis, and gastric cancer), 4 lower gastrointestinal diseases (irritable bowel syndrome, diverticular disease, Crohn's disease, and ulcerative colitis), 8 hepatobiliary and pancreatic diseases (non-alcoholic fatty liver disease, alcoholic liver disease, cirrhosis, liver cancer, cholecystitis, cholelithiasis, and acute and chronic pancreatitis), and acute appendicitis. Fifteen out of 20 associations persisted after adjusting for genetically predicted alcohol consumption. Genetically predicted higher alcohol consumption was associated with increased risk of duodenal ulcer, alcoholic liver disease, cirrhosis, and chronic pancreatitis; however, the association for duodenal ulcer did not remain statistically significant after adjustment for genetic predisposition to smoking initiation.

Conclusions

This study provides MR evidence supporting causal associations of smoking with a broad range of gastrointestinal diseases, whereas alcohol consumption was associated with only a few gastrointestinal diseases.

Funding

The Natural Science Fund for Distinguished Young Scholars of Zhejiang Province; National Natural Science Foundation of China; Key Project of Research and Development Plan of Hunan Province; the Swedish Heart Lung Foundation; the Swedish Research Council; the Swedish Cancer Society.

Lifetime Exposure to Cigarette Smoke and Risk of Ovarian Cancer by T-cell Tumor Immune Infiltration

BACKGROUND

Exposure to cigarette smoke, particularly in early life, is modestly associated with ovarian cancer risk and may impact systemic immunity and the tumor immune response. However, no studies have evaluated whether cigarette smoke exposure impacts the ovarian tumor immune microenvironment.

METHODS

Participants in the Nurses' Health Study (NHS) and NHSII reported on early life exposure to cigarette smoke and personal smoking history on questionnaires (n = 165,760). Multiplex immunofluorescence assays were used to measure markers of T cells and immune checkpoints in tumor tissue from 385 incident ovarian cancer cases. We used Cox proportional hazards models to evaluate HRs and 95% confidence intervals (CI) for developing ovarian tumors with a low (<median) or high (≥median) immune cell percentage by cigarette exposure categories.

RESULTS

Women exposed versus not to cigarette smoke early in life had a higher risk of developing ovarian cancer with low levels of T cells overall (CD3+: HR: 1.54, 95% CI: 1.08-2.20) and recently activated cytotoxic T cells (CD3+CD8+CD69+: HR: 1.45, 95% CI: 1.05-2.00). These findings were not statistically significant at the Bonferroni-corrected P value of 0.0083. Adult smoking was not significantly associated with tumor immune markers after Bonferroni correction.

CONCLUSIONS

These results suggest early life cigarette smoke exposure may modestly increase risk of developing ovarian tumors with low abundance of total T cells and recently activated cytotoxic T cells.

IMPACT

Future research should focus on understanding the impact of exposures throughout the life course on the ovarian tumor immune microenvironment.

Development and Validation of Esophageal Squamous Cell Carcinoma Risk Prediction Models Based on an Endoscopic Screening Program

IMPORTANCE

Assessment tools are lacking for screening of esophageal squamous cell cancer (ESCC) in China, especially for the follow-up stage. Risk prediction to optimize the screening procedure is urgently needed.

OBJECTIVE

To develop and validate ESCC prediction models for identifying people at high risk for follow-up decision-making.

DESIGN, SETTING, AND PARTICIPANTS

This open, prospective multicenter diagnostic study has been performed since September 1, 2006, in Shandong Province, China. This study used baseline and follow-up data until December 31, 2021. The data were analyzed between April 6 and May 31, 2022. Eligibility criteria consisted of rural residents aged 40 to 69 years who had no contraindications for endoscopy. Among 161 212 eligible participants, those diagnosed with cancer or who had cancer at baseline, did not complete the questionnaire, were younger than 40 years or older than 69 years, or were detected with severe dysplasia or worse lesions were eliminated from the analysis.

EXPOSURES

Risk factors obtained by questionnaire and endoscopy.

MAIN OUTCOMES AND MEASURES

Pathological diagnosis of ESCC and confirmation by cancer registry data.

RESULTS

In this diagnostic study of 104 129 participants (56.39% women; mean [SD] age, 54.31 [7.64] years), 59 481 (mean [SD] age, 53.83 [7.64] years; 58.55% women) formed the derivation set while 44 648 (mean [SD] age, 54.95 [7.60] years; 53.51% women) formed the validation set. A total of 252 new cases of ESCC were diagnosed during 424 903.50 person-years of follow-up in the derivation cohort and 61 new cases from 177 094.10 person-years follow-up in the validation cohort. Model A included the covariates age, sex, and number of lesions; model B included age, sex, smoking status, alcohol use status, body mass index, annual household income, history of gastrointestinal tract diseases, consumption of pickled food, number of lesions, distinct lesions, and mild or moderate dysplasia. The Harrell C statistic of model A was 0.80 (95% CI, 0.77-0.83) in the derivation set and 0.90 (95% CI, 0.87-0.93) in the validation set; the Harrell C statistic of model B was 0.83 (95% CI, 0.81-0.86) and 0.91 (95% CI, 0.88-0.95), respectively. The models also had good calibration performance and clinical usefulness.

CONCLUSIONS AND RELEVANCE

The findings of this diagnostic study suggest that the models developed are suitable for selecting high-risk populations for follow-up decision-making and optimizing the cancer screening process.

Poultry Consumption and Human Health: How Much Is Really Known? A Systematically Searched Scoping Review and Research Perspective

This scoping review was conducted to systematically search and chronicle scientific literature pertinent to poultry intake and human health. The protocol (uploaded to Open Science Framework, https://osf.io/2k7bj/) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. Articles with observational and experimental research, narrative and systematic reviews, and meta-analyses were included. Among 13,141 articles identified, 525 met inclusion criteria. Among these 525 articles, 212 focused on cancer morbidity and mortality; 41 on cardiovascular disease (CVD) morbidity and mortality; 52 on CVD risk factors; 32 on type 2 diabetes mellitus (T2DM) morbidity and mortality; 33 on T2DM risk factors; and 42 on body weight and body composition. An "Other" category (181 articles) included nutrient status, psychological well-being/mental health, cognition, microbiome, chronic kidney disease, nonalcoholic fatty liver disease, skin disorders, and fertility, among others. Among the 525 included articles, 366 were observational, 64 were experimental, and 76 were reviews and meta-analyses. Eighty-three percent of articles focused on adults or older adults. A paucity of research exists to support poultry as health-promoting foods, with most research only indirectly assessing poultry intake compared with other foods of interest (e.g., red meats or plant-based protein foods). No randomized controlled trials and only 1% of OBS assessed the influence of processed poultry intake on human health. In the future, the relative health effects of consuming poultry will be compared with a widening array of traditional and new protein-rich food products, necessitating the need for research to assess poultry as foods of choice. Science and health professionals, the poultry industry, and the public will benefit from new observational and experimental research to address cutting-edge scientific, public policy, and consumer topics pertinent to poultry intake and human health.

The impact of a healthy lifestyle on the risk of esophageal and gastric cancer subtypes

Few prospective studies have been conducted on a combined healthy lifestyle and risk of esophageal and gastric cancer, and even less on subtypes: esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cardia adenocarcinoma (GCA), and gastric non-cardia adenocarcinoma (GNCA). The relationship of a healthy lifestyle score (HLS) with risk of these cancers was investigated in the Netherlands Cohort Study. In 1986, 120,852 men and women aged 55–69 years provided information on dietary and lifestyle habits. The HLS was derived from information on smoking, body mass index, physical activity, Mediterranean diet adherence, and alcohol intake. After 20.3 years of follow-up, multivariable case-cohort analyses were based on 333 incident esophageal and 777 gastric cancer cases, and 3720 subcohort members with complete data on lifestyles and confounders. The impact of changing to healthy lifestyles was estimated with the rate advancement period (RAP). The HLS was significantly inversely associated with risk of esophageal and gastric cancer, and subtypes (except EAC), in a linear fashion. The observed HR decrease per 1-point increase in HLS was 31% for esophageal, and 19% for gastric cancer, 49% for ESCC, 23% for GCA, and 18% for GNCA. The RAP per 1-point increase in HLS ranged from − 11.75 years for ESCC to − 2.85 years for GNCA. Also after excluding smoking, inverse associations between the HLS and esophageal and gastric cancer risk were still apparent. These results suggest that adhering to a combination of healthy modifiable lifestyle factors may substantially reduce the risk of esophageal and gastric cancer.

OUP accepted manuscript

Background

Accumulating evidence suggests a survival benefit after curative oesophageal cancer surgery in women compared with men. The aim of this study was to explore sex disparities in survival after surgery with curative intent in patients with oesophageal cancer.

Methods

This was a population-based cohort study, including all patients with oesophageal or gastric cancer who underwent surgery with a curative intent between 2006 and 2017 in Sweden. Female versus male mortality rate ratio (MRR) and excess mortality rate ratio (EMRR) were used as measures of survival. Two different parametric models were designed to account for potential confounders. Patients with gastric cancer were used as a comparison group as no differences in survival between sexes were expected among these patients.

Results

A total of 1301 patients underwent resection for oesophageal adenocarcinoma and 305 patients for oesophageal squamous cell carcinoma. Women had a lower EMRR (0.76, 95 per cent c.i. 0.58 to 1.01, P = 0.056; 0.52, 95 per cent c.i. 0.32 to 0.84, P = 0.007 respectively) in both histological subtypes. The effect was more profound in early clinical stages, in patients receiving neoadjuvant treatment, and without postoperative complications. No sex-related difference was observed in survival of patients with gastric cancer.

Conclusions

Women undergoing resection for oesophageal carcinoma have better survival compared with men.

Contributing factors common to COVID‑19 and gastrointestinal cancer

The devastating complications of coronavirus disease 2019 (COVID-19) result from the dysfunctional immune response of an individual following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events, ultimately leading to COVID-19. The authors have previously identified a number of contributing factors (CFs) common to myriad chronic diseases. Based on these observations, it was hypothesized that there may be a significant overlap between CFs associated with COVID-19 and gastrointestinal cancer (GIC). Thus, in the present study, a streamlined dot-product approach was used initially to identify potential CFs that affect COVID-19 and GIC directly (i.e., the simultaneous occurrence of CFs and disease in the same article). The nascent character of the COVID-19 core literature (~1-year-old) did not allow sufficient time for the direct effects of numerous CFs on COVID-19 to emerge from laboratory experiments and epidemiological studies. Therefore, a literature-related discovery approach was used to augment the COVID-19 core literature-based ‘direct impact’ CFs with discovery-based ‘indirect impact’ CFs [CFs were identified in the non-COVID-19 biomedical literature that had the same biomarker impact pattern (e.g., hyperinflammation, hypercoagulation, hypoxia, etc.) as was shown in the COVID-19 literature]. Approximately 2,250 candidate direct impact CFs in common between GIC and COVID-19 were identified, albeit some being variants of the same concept. As commonality proof of concept, 75 potential CFs that appeared promising were selected, and 63 overlapping COVID-19/GIC potential/candidate CFs were validated with biological plausibility. In total, 42 of the 63 were overlapping direct impact COVID-19/GIC CFs, and the remaining 21 were candidate GIC CFs that overlapped with indirect impact COVID-19 CFs. On the whole, the present study demonstrates that COVID-19 and GIC share a number of common risk/CFs, including behaviors and toxic exposures, that impair immune function. A key component of immune system health is the removal of those factors that contribute to immune system dysfunction in the first place. This requires a paradigm shift from traditional Western medicine, which often focuses on treatment, rather than prevention.

Association of Epstein–Barr Virus and Cytomegalovirus Infections with Esophageal Carcinoma

Background: Given the fact that viral infections play an important role, either directly or indirectly, in around 20 percent of human cancers, this study aimed at investigating the potential association of Epstein–Barr virus (EBV) and cytomegalovirus (CMV) infections in esophageal cancer that is the sixth most common cause of cancer-related deaths. Methods: In this case-control study, a total of 200 paraffin-embedded biopsies of cancerous and benign esophageal tissues were gathered from the biopsy bank of Imam Reza Hospital, Tabriz, Iran in 2017. All samples were first deparaffinized, and then subjected to commercial DNA extraction. The quality of extracted DNA was evaluated by amplification of the beta globulin gene. Identification of EBV and CMV DNA was performed using primers designed for the EBER region of EBV and the immediate early (IE) region of the CMV genome, respectively. Results: The mean age of the subjects in the test and control groups was 52.2 (17.1) and 59.9 (18.9), respectively. The distribution of gender (male/female) in patient and control groups was 54/46 and 53/47, respectively. Our results showed that the frequency of EBV (P < 0.001) and CMV (P < 0.001) in cancerous samples was statistically higher than control group. Moreover, in the cancerous group the rate of EBV was significantly higher in the esophageal adenocarcinomas (EAC) sample (12 out of 70) than esophageal squamous cell carcinomas (ESCC) (0 out of 30) (P = 0.016) but, in the ESCC group, 17 out of 30 subjects were positive for CMV which was significantly higher in comparison with EAC patients (1 out of 70) (P < 0.001). Conclusions: Findings indicated that EBV and CMV might be contributed to the pathogenesis of EAC and ESCC types of esophageal carcinoma, respectively, although further studies are warranted.

Detection of Incidental Esophageal Cancers on Chest CT by Deep Learning

Objective

To develop a deep learning-based model using esophageal thickness to detect esophageal cancer from unenhanced chest CT images.

Methods

We retrospectively identified 141 patients with esophageal cancer and 273 patients negative for esophageal cancer (at the time of imaging) for model training. Unenhanced chest CT images were collected and used to build a convolutional neural network (CNN) model for diagnosing esophageal cancer. The CNN is a VB-Net segmentation network that segments the esophagus and automatically quantifies the thickness of the esophageal wall and detect positions of esophageal lesions. To validate this model, 52 false negatives and 48 normal cases were collected further as the second dataset. The average performance of three radiologists and that of the same radiologists aided by the model were compared.

Results

The sensitivity and specificity of the esophageal cancer detection model were 88.8% and 90.9%, respectively, for the validation dataset set. Of the 52 missed esophageal cancer cases and the 48 normal cases, the sensitivity, specificity, and accuracy of the deep learning esophageal cancer detection model were 69%, 61%, and 65%, respectively. The independent results of the radiologists had a sensitivity of 25%, 31%, and 27%; specificity of 78%, 75%, and 75%; and accuracy of 53%, 54%, and 53%. With the aid of the model, the results of the radiologists were improved to a sensitivity of 77%, 81%, and 75%; specificity of 75%, 74%, and 74%; and accuracy of 76%, 77%, and 75%, respectively.

Conclusions

Deep learning-based model can effectively detect esophageal cancer in unenhanced chest CT scans to improve the incidental detection of esophageal cancer.

Dietary Habits and Risk of Esophagitis and Barrett's Esophagus: A Multicenter Italian Case-Control Study

BACKGROUND

Barrett's esophagus (BE) and esophagitis share potentially modifiable risk factors such as obesity, smoking, and alcohol. The role of diet on BE and esophagitis is still debated.

AIMS

The objective of this study was to examine the association between some dietary habits and the risk of BE and esophagitis in Italy.

METHODS

A multicenter case-control study involving 1285 individuals was carried out in 12 areas. Patients with a new diagnosis of BE (320) or esophagitis (359) and a group of endoscopic controls (606) were included. Information on personal history and dietary habits was collected using a structured questionnaire.

RESULTS

No clear monotonic significant dose-response relationship was found for most of the considered food items. Nevertheless, the most extreme consumption category of red meat, cold cuts, dairy products, and fried foods showed esophagitis risk excesses varying from 19 to 49%. A higher fat rich diet seemed to increase risk by 49% for BE and 94% for esophagitis. A downward tendency in esophagitis (- 27%) and BE risk (- 20%) was found associated with higher frequency of fresh fruit intake. In addition, a statistically significant twofold increased risk for both BE and esophagitis was found for subjects eating late evening snacks more than once every three days in comparison with the lowest intake category (no consumption).

CONCLUSIONS

BE and esophagitis patients appeared to be more likely than controls to follow a diet rich in fats and poor in fruit and vegetables. Late evening snacks were found to be associated with both disorders.

Development and Validation of an Esophageal Squamous Cell Carcinoma Risk Prediction Model for Rural Chinese: Multicenter Cohort Study

BACKGROUND

There are rare prediction models for esophageal squamous cell carcinoma (ESCC) for rural Chinese population. We aimed to develop and validate a prediction model for ESCC based on a cohort study for the population.

METHODS

Data of 115,686 participants were collected from esophageal cancer (EC) early diagnosis and treatment of cancer program as derivation cohort while data of 54,750 participants were collected as validation cohort. Risk factors considered included age, sex, smoking status, alcohol drinking status, body mass index (BMI), tea drinking status, marital status, annual household income, source of drinking water, education level, and diet habit. Cox proportional hazards model was used to develop ESCC prediction model at 5 years. Calibration ability, discrimination ability, and decision curve analysis were analyzed in both derivation and validation cohort. A score model was developed based on prediction model.

RESULTS

One hundred eighty-six cases were diagnosed during 556,949.40 person-years follow-up in the derivation cohort while 120 cases from 277,302.70 in the validation cohort. Prediction model included the following variables: age, sex, alcohol drinking status, BMI, tea drinking status, and fresh fruit. The model had good discrimination and calibration performance: R 2, D statistic, and Harrell's C statistic of prediction model were 43.56%, 1.70, and 0.798 in derivation cohort and 45.19%, 1.62, and 0.787 in validation cohort. The calibration analysis showed good coherence between predicted probabilities and observed probabilities while decision curve analysis showed clinical usefulness. The score model was as follows: age (3 for 45-49 years old; 4 for 50-54 years old; 7 for 55-59 years old; 9 for 60-64 years; 10 for 65-69 years), sex (5 for men), BMI (1 for ≤25), alcohol drinking status (2 for alcohol drinkers), tea drinking status (2 for tea drinkers), and fresh fruit (2 for never) and showed good discrimination ability with area under the curve and its 95% confidence interval of 0.792 (0.761,0.822) in the deviation cohort and 0.773 (0.736,0.811) in the validation cohort. The calibration analysis showed great coherence between predicted probabilities and observed probabilities.

CONCLUSIONS

We developed and validated an ESCC prediction model using cohort study with good discrimination and calibration capability which can be used for EC screening for rural Chinese population.

Microbiome and Cancers of the Esophagus: A Review

Esophageal cancer (EC) is an aggressive malignant disease ranking amongst the leading causes of cancer deaths in the world. The two main histologic subtypes, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), have distinct geographic and temporal patterns and risk factor profiles. Despite decades of research, the factors underlying these geo-temporal patterns are still not fully understood. The human microbiome has recently been implicated in various health conditions and disease, and it is possible that the microbiome may play an important role in the etiology of EC. Although studies of the microbiome and EC are still in their early stages, we review our current understanding of the potential links between ESCC, EAC, and bacterial communities in the oral cavity and esophagus. We also provide a summary of the epidemiology of EC and highlight some key challenges and future directions.

Subtype-Based Analysis of Cell-in-Cell Structures in Esophageal Squamous Cell Carcinoma

Cell-in-cell (CIC) structures are defined as the special structures with one or more cells enclosed inside another one. Increasing data indicated that CIC structures were functional surrogates of complicated cell behaviors and prognosis predictor in heterogeneous cancers. However, the CIC structure profiling and its prognostic value have not been reported in human esophageal squamous cell Carcinoma (ESCC). We conducted the analysis of subtyped CIC-based profiling in ESCC using "epithelium-macrophage-leukocyte" (EML) multiplex staining and examined the prognostic value of CIC structure profiling through Kaplan-Meier plotting and Cox regression model. Totally, five CIC structure subtypes were identified in ESCC tissue and the majority of them was homotypic CIC (hoCIC) with tumor cells inside tumor cells (TiT). By univariate and multivariate analyses, TiT was shown to be an independent prognostic factor for resectable ESCC, and patients with higher density of TiT tended to have longer post-operational survival time. Furthermore, in subpopulation analysis stratified by TNM stage, high TiT density was associated with longer overall survival (OS) in patients of TNM stages III and IV as compared with patients with low TiT density (mean OS: 51 vs 15 months, P = 0.04) and T3 stage (mean OS: 57 vs 17 months, P=0.024). Together, we reported the first CIC structure profiling in ESCC and explored the prognostic value of subtyped CIC structures, which supported the notion that functional pathology with CIC structure profiling is an emerging prognostic factor for human cancers, such as ESCC.

Human Gut Microbiota-associated Gastrointestinal Malignancies: A Comprehensive Review

The human gastrointestinal tract houses trillions of microbes. The gut and various types of microorganisms, including bacteria, viruses, fungi, and archaea, form a complex ecosystem known as the gut microbiota, and the whole genome of the gut microbiota is referred to as the gut microbiome. The gut microbiota is essential for homeostasis and the overall well-being of a person and is increasingly considered an adjunct "virtual organ," with a complexity level comparable to that of the other organ systems. The gut microbiota plays an essential role in nutrition, local mucosal homeostasis, inflammation, and the mucosal immune system. An imbalanced state of the gut microbiota, known as dysbiosis, can predispose to development of various gastrointestinal malignancies through three speculated pathogenic mechanisms: (a) direct cytotoxic effects with damage to the host DNA, (b) disproportionate proinflammatory signaling inducing inflammation, and (c) activation of tumorigenic pathways or suppression of tumor-suppressing pathways. Several microorganisms, including Helicobacter pylori, Epstein-Barr virus, human papillomavirus, Mycoplasma species, Escherichia coli, and Streptococcus bovis, are associated with gastrointestinal malignancies such as esophageal adenocarcinoma, gastric adenocarcinoma, gastric mucosa-associated lymphoid tissue lymphoma, colorectal adenocarcinoma, and anal squamous cell carcinoma. Imaging plays a pivotal role in diagnosis and management of microbiota-associated gastrointestinal malignancies. Appropriate use of probiotics, fecal microbiota transplantation, and overall promotion of the healthy gut are ongoing areas of research for prevention and treatment of malignancies. Online supplemental material is available for this article. ^©RSNA, 2021.

Outcome of microscopically non-radical oesophagectomy for oesophageal and oesophagogastric junctional cancer: nationwide cohort study

Background

Microscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival.

Methods

The Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression.

Results

The study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis.

Conclusion

R1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection.

Modeling historic incidence trends implies early field cancerization in esophageal squamous cell carcinoma

Patterns of cancer incidence, viewed over extended time periods, reveal important aspects of multistage carcinogenesis. Here we show how a multistage clonal expansion (MSCE) model for cancer can be harnessed to identify biological processes that shape the surprisingly dynamic and disparate incidence patterns of esophageal squamous cell carcinoma (ESCC) in the US population. While the dramatic rise in esophageal adenocarcinoma (EAC) in the US has been largely attributed to reflux related increases in the prevalence of Barrett’s esophagus (BE), the premalignant field in which most EAC are thought to arise, only scant evidence exists for field cancerization contributing to ESCC. Our analyses of incidence patterns suggest that ESCC is associated with a premalignant field that may develop very early in life. Although the risk of ESCC, which is substantially higher in Blacks than Whites, is generally assumed to be associated with late-childhood and adult exposures to carcinogens, such as from tobacco smoking, alcohol consumption and various industrial exposures, the temporal trends we identify for ESCC suggest an onset distribution of field-defects before age 10, most strongly among Blacks. These trends differ significantly in shape and strength from field-defect trends that we estimate for US Whites. Moreover, the rates of ESCC-predisposing field-defects predicted by the model for cohorts of black children are decreasing for more recent birth cohorts (for Blacks born after 1940). These results point to a potential etiologic role of factors acting early in life, perhaps related to nutritional deficiencies, in the development of ESCC and its predisposing field-defect. Such factors may explain some of the striking racial differences seen in ESCC incidence patterns over time in the US.

We used a cell-level carcinogenesis model to analyze incidence patterns of esophageal squamous cell carcinoma (ESCC) in the US. We found 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.

A Physically Active Status Affects the Circulating Profile of Cancer-Associated miRNAs

Circulating miRNAs are ideal diagnostics and prognostics biomarkers in cancer since altered levels of specific miRNAs have been associated to development/progression of several cancers. Physical activity is a recognized preventive strategy against several cancers, but it may also modify the baseline levels of cancer-associated miRNAs and, hence, may act as a confounding pre-analytical variable. This study aimed at understanding whether physical activity-dependent changes in cancer-associated circulating miRNAs profile could act as a confounding variable. A panel comprising 179 miRNAs was assayed in plasma from 20 highly trained and 10 sedentary men. RT-qPCR data were analyzed with the 2^−2ΔΔCT methods and normalized on hsa-miR-320d, as determined by bioinformatics analysis. miRNAs associated with the diagnosis of the most prevalent cancers were considered. Only those miRNAs, relevantly associated with cancers, found ≥2-fold up- or downregulated in highly trained subjects compared to sedentary were disclosed. The results reveal that chronic physical activity determined modifications altering the baseline level of several cancer-associated miRNAs and, hence, their diagnostic and prognostic potential. In conclusion, based on our results, a physically active status emerges as an important pre-analytical variable able to alter the basal level of circulating miRNAs, and these alterations might be considered as potentially misleading the analytical output.

Gut Microbiota and Acute Diverticulitis: Role of Probiotics in Management of This Delicate Pathophysiological Balance

How can the knowledge of probiotics and their mechanisms of action be translated into clinical practice when treating patients with diverticular disease and acute diverticulitis? Changes in microbiota composition have been observed in patients who were developing acute diverticulitis, with a reduction of taxa with anti-inflammatory activity, such as Clostridium cluster IV, Lactobacilli and Bacteroides. Recent observations supported that a dysbiosis characterised by decreased presence of anti-inflammatory bacterial species might be linked to mucosal inflammation, and a vicious cycle results from a mucosal inflammation driving dysbiosis at the same time. An alteration in gut microbiota can lead to an altered activation of nerve fibres, and subsequent neuronal and muscular dysfunction, thus favoring abdominal symptoms' development. The possible role of dysbiosis and mucosal inflammation in leading to dysmotility is linked, in turn, to bacterial translocation from the lumen of the diverticulum to perivisceral area. There, a possible activation of Toll-like receptors has been described, with a subsequent inflammatory reaction at the level of the perivisceral tissues. Being aware that bacterial colonisation of diverticula is involved in the pathogenesis of acute diverticulitis, the rationale for the potential role of probiotics in the treatment of this disease becomes clearer. For this review, articles were identified using the electronic PubMed database through a comprehensive search conducted by combining key terms such as "gut microbiota", "probiotics and gut disease", "probiotics and acute diverticulitis", "probiotics and diverticular disease", "probiotics mechanism of action". However, the amount of data present on this matter is not sufficient to draw robust conclusions on the efficacy of probiotics for symptoms' management in diverticular disease.

The complexity of cancer origins at the gastro-oesophageal junction

Chronic acid-biliary reflux and Helicobacter pylori infection are instrumental environmental drivers of cancer initiation and progression in the upper gastrointestinal tract. Remarkably, although these environmental carcinogens are quite dissimilar, the tumour progression cascade these carcinogens engender is highly comparable. For this reason, studies of malignant progression occurring at the anatomic borderland between the oesophagus and the stomach have traditionally lumped junctional adenocarcinomas with either oesophageal adenocarcinoma or gastric adenocarcinoma. Whilst studies have revealed remarkable epidemiological and genetic similarities of these cancers and their associated premalignant conditions, these works have also revealed some key differences. This highlights that further scientific effort demands a dedicated focus on the understanding of the cell-cell interaction between the epithelium and the local microenvironment in this anatomic region. We here review available evidence with regards to tumour progression occurring at the gastro-oesophageal junction and contrast it with available data on cancer evolution in the metaplastic oesophagus and distal stomach.

Upper Gastrointestinal Cancer in China: Spatial Epidemiologic Evidence from Screening Areas

Upper gastrointestinal cancer (UGIC) including esophageal cancer and gastric cancer, which has been a significant burden in China. Few studies have explored the spatial pattern and association of incidence and mortality using nationwide data. This study aims to explore the spatial pattern and association of incidence and mortality between esophageal cancer and gastric cancer, and identify high-risk areas of the cancers to provide scientific evidence for tailoring endoscopic screening programs. We collected UGIC data in 2014 from a National Cancer Report, and then adopted methods of correlation analysis and spatial statistics to identify high-risk areas on the cancers and to explore the pattern. The results show a spatial autocorrelation on the spatial distribution of incidence and mortality of esophageal and gastric cancers, and the relative risks were from 2.52 (95% CI (confidence interval), 2.37-2.67; P < 0.001) to 3.80 (95% CI, 3.46-4.18; P < 0.001) in primary risk areas, respectively. Moreover, esophageal cancer shows an upward and then downward trend from west to east, and from south to north, yet gastric cancer exhibits an upward and then downward trend only from south to north. This study indicates habitants in overlapping risk areas have heavier cancer burdens, and suggests esophageal cancer and gastric cancer have a significant correlation. Therefore, more endoscopic screening attention should focus on overlapping risk areas.

Augmenting cancer registry data with health survey data with no cases in common: the relationship between pre-diagnosis health behaviour and post-diagnosis survival in oesophageal cancer

Background

For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time.

Methods

Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, ‘at risk’ alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately.

Results

Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57).

Conclusions

We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

Cumulative evidence for the relationship between body mass index and the risk of esophageal cancer: An updated meta-analysis with evidence from 25 observational studies

BACKGROUND AND AIM

A large number of papers reporting the relationships between body mass index (BMI) and esophageal cancer (EC) risk have been published in the past few decades; however, these results are inconsistent. Therefore, we carried out meta-analyses to explore the relationships between BMI and the risk of EC (including esophageal squamous cell carcinoma [ESCC] and esophageal adenocarcinoma [EADC]).

METHODS

We used the Web of Science, PubMed, and Embase to identify all published/online articles before December 30, 2018, which yielded 25 articles eligible for data extraction (including 16,561 cases and 11,954,161 controls), and then pooled the relative risks (RRs) and corresponding 95% confidence intervals (CIs) using random-effects model.

RESULTS

Our study presented that underweight had statistically significant association with the risk of EC (RR = 1.78, 95% CI = 1.48, 2.14, P < 0.001) and ESCC (RR = 1.57, 95% CI = 1.20, 2.06, P = 0.001) when compared with normal weight. Interestingly, both overweight and obesity could increase the risk of EADC (RR = 1.56, 95% CI = 1.42, 1.71, P < 0.001; RR = 2.34, 95% CI = 2.02, 2.70, P < 0.001) while decrease the risk of ESCC (RR = 0.71, 95% CI = 0.60, 0.84, P < 0.001; RR = 0.63, 95% CI = 0.60, 0.84, P = 0.002). Additionally, obesity could increase the risk of EC (RR = 1.51, 95% CI = 1.21, 1.89, P < 0.001).

CONCLUSION

These meta-analyses provide a comprehensive and updated epidemiological evidence to confirm the associations between BMI and EC risk. These findings have public health implications with respect to better control bodyweight and then reduce the occurrence of EC (including ESCC and EADC).

Using estimated probability of pre-diagnosis behavior as a predictor of cancer survival time: an example in esophageal cancer

Background

Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior.

Methods

Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant’s demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression.

Results

Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84).

Conclusions

We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.

Characterization of Esophageal Cancer and ItsAssociation with Influencing Factors in GuangzhouCity, China

Epidemiological features of esophageal cancer (EC), as well as their associations withpotential influencing factors in a city, have seldom been seldom explored on a fine scale. The ECdeath cases in Guangzhou city during 2012-2017 were collected to describe the epidemiologicalcharacteristics such as EC mortality rate (ECMR) and health-seeking behaviors of deaths. Potentialinfluencing factors, including socioeconomic conditions (population density, gross domesticproduct density), medical resources, and ageing degree were also gathered for exploring theirrelationships with the epidemiological characteristics of EC. A total of 2,409 EC deaths werereported during 2012-2017 in Guangzhou with an age-standardized ECMR of 3.18/105. Theprevalence of EC in Guangzhou was spatially featured and was divided into three regions withobvious differentiated ECMR (ECMR of 6.41/105 in region A, ECMR of 5.51/105 in region B, ECMRof 2.56/105 in region C). The street/town-level ECMR was spatially clustered in Guangzhou city,especially two clusters of streets/towns with high ECMR were highlighted in region A and Brespectively. Meanwhile, demographic features including gender gap, death age, temporal intervalbetween diagnosis and death, health-seeking behaviors were remarkably different among the threeregions. Moreover, health-seeking behaviors (e.g., the proportion of hospital deaths) of the ECdeaths were obviously influenced by medical institution occupancy rate and socioeconomicconditions at street/town level. In addition, the street/town-level ECMR was significantly associatedwith ageing degree across Guangzhou city (r = 0.466, p < 0.01), especially in region A (r = 0.565, p <0.01). In contrast, the ECMR in region B was closely related to population density (r = -0.524, p <0.01) and gross domestic product density (r = -0.511, p < 0.01) when the ageing degree was controlled,while these associations were weak in region C. The epidemiological characteristics of EC inGuangzhou city were spatially featured and potentially associated with socioeconomic conditions,medical resources and ageing degree on a fine scale across Guangzhou city. This study couldprovide scientific basis for local authorities to implement more targeted EC interventions.

19q13 KRAB zinc-finger protein ZNF471 activates MAPK10/JNK3 signaling but is frequently silenced by promoter CpG methylation in esophageal cancer

Zinc-finger proteins (ZFPs) are the largest transcription factor family in mammals, involved in the regulation of multiple physiologic processes including cell differentiation, proliferation, apoptosis and neoplastic transformation. Approximately one-third of ZFPs are Krüppel-associated box domain (KRAB)-ZFPs.

Methods: ZNF471 expression and methylation were detected by reverse-transcription PCR and methylation-specific PCR. The impact and mechanism of ectopic ZNF471 expression in esophageal squamous cell carcinoma (ESCC) cells was evaluated in vitro and in vivo.

Results: We identified a 19q13 KRAB-ZFP, ZNF471, as a methylated target in ESCC. We further found that ZNF471 is significantly downregulated in ESCC tissues compared with adjacent non-cancer tissues, due to its aberrant promoter CpG methylation, and further confirmed by methylation analysis and treatment with demethylation agent. Restoration of ZNF471 expression in silenced ESCC cells significantly altered cell morphology, induced apoptosis and G0/G1 arrest, and inhibited tumor cell colony formation, viability, migration and invasion. Importantly, ZNF471 was found to activate the expression of MAPK10/JNK3 and PCDH family genes, and further enhance MAPK10 signaling and downstream gene expression through binding to the MAPK10/JNK3 promoter.

Conclusion: Our results demonstrate that ZNF471 is an important tumor suppressor and loss of ZNF471 functions hampers MAPK10/JNK3 signaling during esophageal carcinogenesis.

Introduction: Esophageal Squamous Cell Carcinoma-Current Status and Future Advances

Esophageal squamous cell carcinoma is the most common histological subtype of esophageal cancer. The carcinoma is more common in high-incidence areas such as in Central and Southeast Asia, Eastern and Southern Africa, South America, etc. Common risk factors associated with the cancer are tobacco smoking and excessive alcohol consumption. Dietary factors, genetic factors, microorganisms, and some other environmental factors may contribute to the etiopathogenesis of the disease. Despite the global incidence of esophageal squamous cell carcinoma decreases slightly in the recent years, esophageal squamous cell carcinoma is still a major cause of cancer-related morbidity and mortality worldwide. Further improvement of the outcomes of the patients with the disease could be achieved by early diagnosis, collaborative efforts of multidisciplinary clinical and research teams, use of standardized protocol for pathological reporting and staging of the disease, proper use of cancer tissue, as well as improvement in clinical, pathological, therapeutic, and research approaches to the cancer.

Liquid Biopsy for Investigation of Cancer DNA in Esophageal Squamous Cell Carcinoma

Early detection of cancer and the monitoring of cancer recurrence in treated patients are significant challenges in esophageal squamous cell carcinoma (ESCC). Liquid biopsy is the identification of tumor biomarkers from minimally invasive samples of biological fluids, including urine, blood, stool, saliva, or cerebrospinal fluid. Liquid biopsy offers a potential solution to the problems of detection and surveillance as DNA shed from cancer cells as cell-free DNA or in exosomes can be detected in body fluids. By detecting these DNAs, we can identify the presence of cancer-associated mutations for basic detection, as well as to obtain information on the recurrence and evolution of disease following initial treatment. These sources of information have the potential to significantly improve the management of patients with ESCC. In this chapter, we detail a method for the isolation of cell-free DNA from blood plasma and DNA associated with exosomes in blood from patients with esophageal squamous cell carcinomas.

Current management of Barrett esophagus and esophageal adenocarcinoma

Barrett esophagus is found in 5% to 15% of patients with gastroesophageal reflux disease and is a precursor of esophageal adenocarcinoma, yet the condition often goes undiagnosed. Patients with reflux disease who are male, over age 50, or white, and who smoke or have central obesity or a family history of Barrett esophagus or esophageal adenocarcinoma, should undergo initial screening endoscopy and, if no dysplasia is noted, surveillance endoscopy every 3 to 5 years. Dysplasia is treated with endoscopic eradication by ablation, resection, or both. Chemoprotective agents are being studied to prevent progression to dysplasia in Barrett esophagus. The authors discuss current recommendations for screening and management.

Proposal for an Organ-Specific Chronic Inflammation–Remodeling–Carcinoma Sequence

An organ-specific chronic inflammation–remodeling–carcinoma sequence has been proposed, mainly for the alimentary tract. As representative diseases, gastroesophageal reflux disease, chronic gastritis and inflammatory bowel disease (ulcerative colitis and Crohn’s disease of the colitis type) were adopted for this discussion. Tissue remodeling is such an important part of tumorigenesis in this sequence that an organ-specific chronic inflammation–remodeling–carcinoma sequence has been proposed in detail. Chronic inflammation accelerates the cycle of tissue injury and regeneration; in other words, cell necrosis (or apoptosis) and proliferation result in tissue remodeling in long-standing cases of inflammation. Remodeling encompasses epithelial cell metaplasia and stromal fibrosis, and modifies epithelial–stromal cell interactions. Further, the accumulation of genetic, epigenetic and molecular changes—as well as morphologic disorganization—also occurs during tissue remodeling. The expression of mucosal tissue adapted to chronic inflammatory injury is thought to occur at an early stage. Subsequently, dysplasia and carcinoma develop on a background of remodeling due to continuous, active inflammation. Accordingly, organ-specific chronic inflammation should be ameliorated or well controlled with appropriate monitoring if complete healing is unachievable.

Consumption of garlic and its interactions with tobacco smoking and alcohol drinking on esophageal cancer in a Chinese population

Garlic consumption has been associated inversely with esophageal cancer (EC); however, its interactions with tobacco smoking and alcohol consumption have never been evaluated in an epidemiological study. We evaluated the potential interactions between garlic intake and tobacco smoking as well as alcohol consumption in a population-based case-control study with 2969 incident EC cases and 8019 healthy controls. Epidemiologic data were collected by face-to-face interviews using a questionnaire. The adjusted odds ratio (OR) and 95% confidence interval (CI) were estimated and additive and multiplicative interactions were evaluated using unconditional logistic regression models, adjusting for potential confounding factors. Semi-Bayes (SB) adjustments were used to reduce potential false-positive findings. EC was associated inversely with raw garlic intake [SB-adjusted OR for more than once a week=0.68, 95% CI: 0.57-0.80], with a strong dose-response pattern in the overall analysis and in the stratified analyses by smoking and drinking. EC was associated positively with smoking and alcohol drinking, with SB-adjusted OR of 1.73 (95% CI: 1.62-1.85) and 1.37 (95% CI: 1.28-1.46) in dose-response effects of increased intensity and longer duration of smoking/drinking. Moreover, garlic intake interacts with smoking [synergy index (S)=0.83, 95% CI: 0.67-1.02; ratio of OR=0.88, 95% CI: 0.80-0.98] and alcohol drinking (S=0.73, 95% CI: 0.57-0.93; ratio of OR=0.86, 95% CI: 0.77-0.95) both multiplicatively and additively. Our findings suggested that high intake of raw garlic may reduce EC risk and may interact with tobacco smoking and alcohol consumption, which might shed a light on the development of EC as well as a potential dietary intervention among high-risk smokers and drinkers for EC prevention in the Chinese population.

Esophageal microbiota and esophageal diseases

The microbiota of the esophagus has been the least systematically studied among the organs of the gastrointestinal tract. Esophageal microbiota has been proved to be complex with a high diversity until recently. Alterations of its composition are associated with the development and progression of esophageal diseases. Immunoinflammatory responses caused by dysbiosis may play a role in the pathogenesis of esophageal disorders. This review addresses the characteristics of esophageal microbiota in physiological and pathological conditions, aiming to provide new insights into esophageal microecology-based intervention strategies for esophageal diseases.

A world map of esophagus cancer research: a critical accounting

Background

Esophageal cancer (EC) is one of the deadliest cancers worldwide. The contemporary strong increase of the adenocarcinomas in Western countries and the high mortality rates require the intensification of prospective multinational studies.

Methods

Therefore, this global health issue has been chosen for the bibliometric review of the global publication output. As source for meta and citation data, the Web of Science has been used and Density Equalizing Maps were applied for visualization.

Results

17,387 articles on EC could be identified. The years with publication and citation maxima correspond to the appearance of the most prolific articles. China is the most publishing country, followed by Japan and the USA. Germany and the UK ranked 4th and 5th. The analysis of the ratios articles and socio-economic parameters emphasizes the leading position of the Scandinavian countries and Japan. Here, the high-income countries come out on top. The high incidence regions are mainly represented by Chinese and Japanese research. The association of the publication output and the overall research funding could be shown.

Conclusions

A strengthened international network increasingly consisting of the scientifically best positioned countries as well as more of the high incidence countries worldwide is mandatory for future research. The findings deliver scientists, clinicians and decision makers backgrounds for future decisions all over the world.

Gene Expression Profiling Reveals Distinct Molecular Subtypes of Esophageal Squamous Cell Carcinoma in Asian Populations

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers worldwide, particularly in Asian populations, and responds poorly to conventional therapy. Subclassification of ESCCs by molecular analysis is a powerful strategy in extending conventional clinicopathologic classification, improving prognosis and therapy. Here we identified two ESCC molecular subtypes in Chinese population using gene expression profiling data and further validated the molecular subtypes in two other independent Asian populations (Japanese and Vietnamese). Subtype I ESCCs were enriched in pathways including immune response, while genes overexpressed in subtype II ESCCs were mainly involved in ectoderm development, glycolysis process, and cell proliferation. Specifically, we identified potential ESCC subtype-specific diagnostic markers (FOXA1 and EYA2 for subtype I, LAMC2 and KRT14 for subtype II) and further validated them in a fourth Asian cohort. In addition, we propose a few subtype-specific therapeutic targets for ESCC, which may guide future ESCC clinical treatment when further validated.

Conventional Western Treatment Associated With Chinese Herbal Medicine Ameliorates the Incidence of Head and Neck Cancer Among Patients With Esophageal Cancer

BACKGROUND

Because of advances in medical treatment, the survival of cancer patients is prolonged. In line with the prolonged survival time of cancer the incidence of second primary cancer has increased. There is currently no effective way to prevent the occurrence of secondary primary cancer (SPC).

OBJECTIVES

The aim of this study is to evaluate whether Chinese Herbal Medicine (CHM) is correlated with reduced occurrence of second primary cancer (SPC) of head and neck (H&N) in patients with esophageal cancer (EC).

METHOD

We identified 15,546 patients who were diagnosed with esophageal cancer between Jan 1, 2000, and Dec 31, 2010. The patients with H&N cancer before receiving CHM were excluded. After the selection and matching process, both CHM and non-CHM cohorts each contained 850 individuals. We compared the cumulative incidence of SPC of H&N with or without CHM treatment in patients with EC by the Kaplan-Meier method. NodeXL is used to run a network analysis of CHM to examine the association between herbs and formulas.

RESULTS

Compared with non-CHM users, CHM-users showed a reduced incidence rate of SPC of H&N among the patients with EC. Reduced cumulative incidence of SPC of H&N among patients with EC was noted in the CHM cohort compared to the non-CHM cohort. The most commonly used single herbs and formulas were associated with reducing SPC occurrence.

CONCLUSION

We propose that CHM as an adjuvant therapy may prevent the occurrence of SPC of H&N in patients with EC.

Physical Activity and Gastrointestinal Cancer Risk: A Review

Introduction: Western lifestyle characterized by increased consumption of red meat, fat, processed food, smoking, alcohol drinking, lower consumption of vegetables and physical inactivity has been associated with a higher gastrointestinal cancer risk. Digestive system cancers are diagnosed at late stages when they show poor response to treatment and are associated with a high mortality rate. Colorectal, gastric, esophageal and pancreatic cancers are among the most common cancers worldwide. Studies show that more than 50% of gastrointestinal cancers develop as a result of inappropriate lifestyle. An inverse association between physical activity and many chronic diseases has been proved so far. However, the association between physical activity and some gastrointestinal cancers is still controversial. This study was aimed to determine the association between physical activity and gastrointestinal cancers risk.

Methods: We conducted a comprehensive search of English and Persian databases from February 2007 till December 2017, for studies investigating the association of physical activity and risk of gastrointestinal cancers. Finally, after reading full text of articles, 123 studies were included.

Results: Physical activity can be helpful in reducing the risk of gastrointestinal cancer, especially colon and pancreatic cancers. The risk reduction is not similar for different types of gastrointestinal cancers and also among males and females.

Conclusion: Different types of physical activity are associated with a lower risk of gastrointestinal cancer. However, it is unknown which type and intensity of physical activity are associated with a protective effect against gastro-intestinal cancer.

Alcohol and gastrointestinal cancers

PURPOSE OF REVIEW

Alcohol is a type I carcinogen and the WHO stated that it caused 5% of all deaths in 2016, of which 13% because of cancers. Among digestive tract cancers, this association is clear for esophageal, liver and colorectal cancer, and more debated for gastric and pancreatic cancer. The present review will revise recent evidence on epidemiologic association and mechanisms linking alcohol with the risk of esophageal, gastric, colorectal and pancreatic cancers.

RECENT FINDINGS

Moderate alcohol intake increases the risk of esophageal squamous cell carcinoma and colorectal cancer. Heavy alcohol intake is associated with an increased risk of gastric and pancreatic cancers. These risks also depend on genetic variants and the interaction with smoking is inconsistent. The carcinogenic mechanisms are multiple with a key role of acetaldehyde because of its ability to cause DNA damage, alter telomere length and induce ROS. Data on the role of the gut microbiome as possible mediator of alcohol-induced carcinogenesis are limited.

SUMMARY

There is sufficient evidence for the association between alcohol consumption and cancers of the esophagus, stomach, colon-rectum and pancreas. Public health policies to prevent these cancer types should include modification of alcohol intake habits, especially among individuals at increased risk.

The Interplay between Immunity and Microbiota at Intestinal Immunological Niche: The Case of Cancer

The gut microbiota is central to the pathogenesis of several inflammatory and autoimmune diseases. While multiple mechanisms are involved, the immune system clearly plays a special role. Indeed, the breakdown of the physiological balance in gut microbial composition leads to dysbiosis, which is then able to enhance inflammation and to influence gene expression. At the same time, there is an intense cross-talk between the microbiota and the immunological niche in the intestinal mucosa. These interactions may pave the way to the development, growth and spreading of cancer, especially in the gastro-intestinal system. Here, we review the changes in microbiota composition, how they relate to the immunological imbalance, influencing the onset of different types of cancer and the impact of these mechanisms on the efficacy of traditional and upcoming cancer treatments.

Clinical and translational advances in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is among the most deadly forms of human malignancy characterized by late stage diagnosis, metastasis, therapy resistance and frequent recurrence. Clinical management of ESCC remains challenging and the disease presently lacks approved targeted therapeutics. However, emerging data from recent clinical and translational investigations hold great promise for future progress toward improving patient outcomes in this deadly disease. Here, we review current clinical perspectives in ESCC epidemiology, pathophysiology, and clinical care, highlighting recent advances with potential to impact ESCC prevention, diagnosis and management. We further provide an overview of recent translational investigations contributing to our understanding of the molecular mechanisms underlying ESCC development, progression and therapy response, including insights gained from genetic studies and various murine model systems. Finally, we discuss future perspectives in the clinical and translational realms, along with remaining hurdles that must be overcome to eradicate ESCC.

Differential diagnosis of multielements in cancerous and non-cancerous esophageal tissues

It is known that variations in the concentrations of certain elements in humans may be an indication of cancers. In this work, a method for the quantitative analysis of 22 elements in non-tumor and esophageal squamous cell carcinoma (ESCC) tissues from the same individual is reported. Based on the optimized platform combined with multivariate analysis, diagnostic models of ESCC were established using principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA), showing excellent classification of cancerous and non-cancerous group by metallomic profiling. Elemental concentrations of 10 elements (Mn, Se, Cu, Ti, Mg, Fe, Co, Zn, Sr, Ca) showed significant difference (p < 0.001) in tumor and non-tumor tissues, in which Mn, Se, Cu and Ti are the top 4 elements of statistical significance and a shift towards higher concentration levels has also been observed in the tumor samples. These results confirm the considerable potential of elemental studies for biomedical purposes. To our knowledge, previous studies on elemental concentration in esophageal cancer were performed in serum or plasma levels; and this is the first study to evaluate the association of tissue elemental concentrations with ESCC.

Prevalence of the integration status for human papillomavirus 16 in esophageal carcinoma samples

BACKGROUND/AIMS

To investigate the etiology of esophageal cancer (EC) related with human papillomavirus (HPV) infection.

MATERIALS AND METHODS

Fresh surgically resected tissue samples and clinical information were obtained from 189 patients. Genomic DNA was extracted, and HPV was detected using polymerase chain reaction (PCR) with HPV L1 gene primers of MY09/11; HPV16 was detected using HPV16 E6 type-specific primer sets. Copies of HPV16 E2, E6, and the human housekeeping gene β-actin were tested using quantitative PCR to analyze the relationship between HPV16 integration and esophageal squamous cell carcinoma and the relationship between the HPV16 integration status and clinical information of patients.

RESULTS

Of the 189 samples, 168 HPV-positive samples were detected, of which 76 were HPV16 positive. Among the HPV16 positive samples, 2 cases (E2/E6 ratio>1) were 2.6% (2/76) purely episomal, 65 (E2/E6 ratio between 0 and 1) were 85.6% (65/76) mixture of integrated and episomal, and 9 (E2/E6 ratio=0) were 11.8% (9/76) purely integrated. The results indicate that integration of HPV16 was more common in the host genome than in the episome genome. The prevalence rate of HPV16 integration is increasing with the pathological stage progression of esophageal carcinoma (EC).

CONCLUSION

A high prevalence of HPV16 suggested that HPV16 has an etiological effect on the progress of EC. Integration of HPV16 is more common than episome genome in the host cells, indicating that continuous HPV infection is the key to esophageal epithelial cell malignant conversion and canceration.