Sex differences in the incidence of gastrointestinal adenocarcinoma in Sweden 1970-2006

[Gender medicine in diseases of the upper gastrointestinal tract]

Benign and malignant diseases of the upper gastrointestinal tract show gender-specific differences. The frequent gastroesophageal reflux disease is a prime example: men have an erosive reflux disease more often than women and are also younger at the time of onset. The rate of progression to a metaplastic Barrett's esophagus is also higher in men. In the case of achalasia, there are indications that surgical treatment by laparoscopic Heller's myotomy and semifundoplication 180° according to Dor leads to a markedly better improvement in the symptoms in women compared to men, although they showed a more pronounced dilation of the tubular esophagus. The female hormone status influences the localization and histopathology of adenocarcinoma of the esophagogastric junction and gastric carcinoma. Premenopausal and postmenopausal carcinomas differ significantly in women. In addition, high microsatellite instability (MSI high) is more frequent in women and is associated with a generally significantly better prognosis. The MSI high gastric carcinomas of women show better survival than MSI high carcinomas of men. The future inclusion of gender-specific aspects in studies of the upper gastrointestinal tract is desirable in order to generate adequate data and to enable differentiated treatment stratification in the future.

Risk of colorectal adenocarcinoma in men receiving androgen deprivation therapy for prostate cancer; a nationwide cohort study

PURPOSE

To assess whether androgens play a role in explaining the sex related differences in the incidence of colorectal cancer (CRC).

METHODS

A nationwide matched cohort study was conducted employing the Prostate Cancer data Base Sweden (PCBaSe) 4.0 during the study period 2006-2016. Prostate cancer (PC) patients receiving androgen deprivation therapy (ADT) were treated as exposed. Prostate cancer-free men from the general population were randomly selected and matched to the index case by birth year and county of residence, forming the unexposed group. All were followed until a diagnosis of CRC, death, emigration, or end of the study period. The risk of CRC among ADT exposed PC patients compared to unexposed cancer-free men was calculated using a flexible parametric survival model and expressed as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

There was an increased risk of CRC among ADT exposed PC patients compared to unexposed cancer-free men (HR 1.27 [95% CI 1.15-1.41]), in particular an increased risk of adenocarcinoma of the colon (HR 1.33 [95% CI 1.17-1.51]) and more specifically an increased risk of adenocarcinoma of the distal colon (HR 1.53 [95% CI 1.26-1.85]). Examination of latency effects yielded significantly decreased HRs over time for CRC (p = 0.049 for trend).

CONCLUSIONS

This population-based study found an increased risk of CRC among PC patients exposed to ADT, specifically adenocarcinoma of the distal colon, which indicates an increased association between ADT (PC + ADT) and CRC but not a positive dose-response trend questioning a true causal effect.

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.

Incident Cancer Risk and Signatures Among Older MUTYH Carriers: Analysis of Population-Based and Genomic Cohorts

MUTYH carriers have an increased colorectal cancer risk in case-control studies, with loss of heterozygosity (LOH) as the presumed mechanism. We evaluated cancer risk among carriers in a prospective, population-based cohort of older adults. In addition, we assessed if cancers from carriers demonstrated mutational signatures (G:C>T:A transversions) associated with early LOH. We calculated incident risk of cancer and colorectal cancer among 13,131 sequenced study participants of the ASPirin in Reducing Events in the Elderly cohort, stratified by sex and adjusting for age, smoking, alcohol use, BMI, polyp history, history of cancer, and aspirin use. MUTYH carriers were identified among 13,033 participants in The Cancer Genome Atlas and International Cancer Genome Consortium, and somatic signatures of cancers were analyzed. Male MUTYH carriers demonstrated an increased risk for overall cancer incidence [multivariable HR, 1.66; 95% confidence interval (CI), 1.03-2.68; P = 0.038] driven by increased colorectal cancer incidence (multivariable HR, 3.55; 95% CI, 1.42-8.78; P = 0.007), as opposed to extracolonic cancer incidence (multivariable HR, 1.40; 95% CI, 0.81-2.44; P = 0.229). Female carriers did not demonstrate increased risk of cancer, colorectal cancer, or extracolonic cancers. Analysis of mutation signatures from cancers of MUTYH carriers revealed no significant contribution toward early mutagenesis from widespread G:C>T:A transversions among gastrointestinal epithelial cancers. Among cancers from carriers, somatic transversions associated with base-excision repair deficiency are uncommon, suggestive of diverse mechanisms of carcinogenesis in carriers compared with those who inherit biallelic MUTYH mutations.

PREVENTION RELEVANCE

Despite absence of loss of heterozygosity in colorectal cancers, elderly male MUTYH carriers appeared to be at increased of colorectal cancer.

Current status of surveillance for Barrett's esophagus in Japan and the West

Prospective studies in western countries have shown that the obvious risk factors for Barrett's esophageal cancer are male sex, smoking habit, a longer length of Barrett's esophagus, and low‐grade dysplasia. However, few reports have prospectively examined risk factors for adenocarcinoma development from Barrett's esophagus in Japan. In the West, where adenocarcinoma is common among esophageal cancer, endoscopic surveillance of Barrett's esophagus every 2–5 years is recommended for early detection of adenocarcinoma. However, there is no established surveillance method in Japan. In recent years, the incidence of adenocarcinoma from long‐segment Barrett's esophagus and short‐segment Barrett's esophagus longer than 2 cm in Japan has been reported to be similar to the West. For surveillance of adenocarcinoma arising from Barrett's esophagus, recognizing the characteristics of superficial adenocarcinoma and carefully observing the entire Barrett's esophagus are needed. It has been reported that representative characteristics of Barrett's adenocarcinoma are a reddish area or a lesion located on the anterior to the right sidewall. It is necessary to establish surveillance methods for Barrett's esophagus sooner in Japan.

Oestrogen receptors: A potential therapeutic target in oesophageal adenocarcinoma?

Oesophageal cancer is the seventh most common cancer in the world and adenocarcinoma is the dominant subtype in Western industrialised nations. The global 5-year relative survival rate for oesophageal adenocarcinoma is 12%. Chemotherapy is a standard treatment offered to patients with both resectable and unresectable disease. However, there are only a few established chemotherapeutic drug options and progress in this area is limited. Recent efforts have focused on targeted molecular therapies. Epidemiological evidence points towards hormonal influences on disease development, particularly sex hormones. Several research studies have demonstrated oestrogen receptor (ER) expression in oesophageal adenocarcinoma tissue, making them a possible option for targeting with ER modulating agents. ERs are also present in laboratory models of the disease and experiments in ER-positive cell lines suggest that ER modulator therapy may be effective. A deeper understanding of the roles of ERα and ERβ in this disease would be valuable for future translation into clinical practice. In this review, we discuss the association between oestrogens and the development of oesophageal adenocarcinoma and the potential to modulate ER signalling networks for therapeutic benefit.

Risk of esophageal and gastric adenocarcinoma in men receiving androgen deprivation therapy for prostate cancer

The aim of this study was to explore the male predominance in esophageal and gastric adenocarcinoma by evaluating the preventive potential of androgen deprivation therapy (ADT). This matched cohort study was based on a national Swedish database of prostate cancer patients in 2006-2013. Prostate cancer patients receiving ADT were the exposed group. Prostate cancer-free men from the general population were randomly selected and matched to the index case by birth year and county of residence, forming the unexposed control group. The participants were followed until a diagnosis of esophageal or gastric cancer, death, emigration, or end of the study period. The risk of esophageal adenocarcinoma, cardia gastric adenocarcinoma, non-cardia gastric adenocarcinoma, and esophageal squamous-cell carcinoma among ADT-exposed compared to unexposed was calculated by multivariable Cox proportional hazard regression. The hazard ratios (HRs) and 95% confidence intervals (CIs) were adjusted for confounders. There was a risk reduction of non-cardia gastric adenocarcinoma among ADT-users compared to non-users (HR 0.49 [95% CI 0.24-0.98]). No such decreased risk was found for esophageal adenocarcinoma (HR 1.17 [95% CI 0.60-2.32]), cardia gastric adenocarcinoma (HR 0.99 [95% CI 0.40-2.46]), or esophageal squamous cell carcinoma (HR 0.99 [95% CI 0.31-3.13]). This study indicates that androgen deprivation therapy decreases the risk of non-cardia gastric adenocarcinoma, while no decreased risk was found for esophageal adenocarcinoma, cardia gastric adenocarcinoma, or esophageal squamous-cell carcinoma.

Sexual Difference Matters: Females with High Microsatellite Instability Show Increased Survival after Neoadjuvant Chemotherapy in Gastric Cancer

Simple Summary

Here we report a sex- and age-specific analysis of 717 patients with gastric/gastro-esophageal adenocarcinomas treated with or without neoadjuvant chemotherapy (CTx) regarding overall survival (OS) and response to CTx. The analysis was also performed in molecular subtypes determined previously. Females demonstrated a significantly increased OS particularly in the group of patients treated with neoadjuvant CTx. Specifically in this patient group and taken into account the molecular subtypes, females with high microsatellite instability (MSI-H) showed the best survival followed by the male MSI-H, the female microsatellite stable (MSS) group and the male MSS group. Thus, we show an effect of sex on OS in gastric/gastro-esophageal cancer in particular for patients treated with neoadjuvant CTx. The superior survival of women with MSI-H tumors among the CTx patients implies that the combined consideration of these factors could contribute to an individualized treatment of the patients.

Abstract

We aimed to investigate patients with gastric/gastro-esophageal adenocarcinomas for sex- and age-specific differences regarding overall survival (OS) and response to neoadjuvant chemotherapy (CTx) under consideration of tumor specific molecular subtypes. Overall, 717 patients were analyzed, including 426 patients treated with and 291 treated without neoadjuvant CTx. Microsatellite instability (MSI) and Epstein-Barr virus positivity (EBV+) were determined previously. Females demonstrated a significantly increased OS (p = 0.035), particularly in the subgroup treated with CTx (p = 0.054). No significant differences regarding age were found. In the molecular subgroups, no sex-related differences were observed in the non-CTx group. However in the CTx group, females with MSI-high (H) tumors showed the best OS (p = 0.043), followed by the male MSI-H (p = 0.198) and female MSS (p = 0.114) compared to the male MSS group as reference. The interaction between sex and MSI in this patient group was noticeable (p = 0.053) and was included as a relevant factor in multivariable analyses. In conclusion, our results show an effect of sex on OS in gastric/gastro-esophageal cancer specifically for patients treated with neoadjuvant CTx. The superior survival of women with MSI-H tumors after neoadjuvant CTx implies that combined consideration of these factors could contribute to an individualized treatment of the patients.

Sex difference in the incidence of cardia and non-cardia gastric cancer in the United States, 1992-2014

Background

Gastric cancer is more common in men than in women, but underlying reasons have not been completely understood. This study aimed to assess patterns of the sex difference in the incidence of gastric cancer in the United States.

Methods

Using data from 13 cancer registries in the Surveillance, Epidemiology, and End Results Program, we analyzed the age-specific sex difference in the incidence of gastric cancer by ethnicity, anatomic site and histological type in the United States during 1992–2014. We assessed the temporal trends in the sex differences in the incidence of gastric cancer during the study period.

Results

The male-to-female incidence ratio of cardia cancer increased with age until peaking at ages 55–69 years and decreased thereafter, while the ratio for non-cardia gastric cancer increased with age before ages < 60 years and remained stable onwards. The age-specific patterns in the sex difference of gastric cancer incidence varied between intestinal and diffuse histological types. The sex difference in the incidence of cardia cancer remained relatively stable except for that the absolute difference between the sexes in whites decreased on average by 0.8% per year from 1992 to 2014. The absolute incidence difference between the sexes in non-cardia gastric cancer decreased over time in whites, blacks, and Asian and Pacific islanders by approximately 4% per year. The male-to-female incidence ratio of non-cardia gastric cancer decreased over time in whites and blacks, but remained relatively stable in Asian and Pacific islanders.

Conclusions

Both extrinsic and intrinsic factors may have contributed to the sex difference in gastric cancer. Sex hormones may play a role in the development of cardia cancer and intestinal type of gastric cancer.

The role of 5α-reductase inhibitors in gastro-oesophageal cancer risk: A nested case-control study

PURPOSE

The strong male predominance of gastro-oesophageal cancer suggests that sex hormones play an important role. 5α-Reductase (5AR) inhibitors have antiandrogen effects and have been shown to decrease cancer cell proliferation and metastasis. We conducted the first epidemiologic investigation into the association between 5AR inhibitor use and gastro-oesophageal cancer risk.

METHODS

We conducted a nested case-control study within the Scottish Primary Care Clinical Information Unit Research database. Male cases diagnosed with oesophageal or gastric cancer between 1999 and 2011 were matched to up to five male controls based on birth year, diagnosis year, and general practice. We used electronic prescribing records to ascertain medication use. We used conditional logistic regression to calculate odds ratios (ORs) for the association between 5AR inhibitor use and cancer risk, after adjusting for comorbidities and aspirin, statin, or proton pump inhibitor use.

RESULTS

The study included 2003 gastro-oesophageal cancer cases and 9650 controls. There was some evidence of reduced gastro-oesophageal cancer risk among 5AR inhibitor users (adjusted OR = 0.75; 95% CI, 0.56-1.02), particularly for finasteride (adjusted OR = 0.68; 95% CI, 0.50-0.94). These decreases were more marked among those who received at least 3 years of 5AR inhibitors (adjusted OR = 0.54; 95% CI, 0.27-1.05; P value = .071) or finasteride (adjusted OR = 0.49; 95% CI, 0.24-0.99; P value = .046).

CONCLUSIONS

We found evidence of reduced gastro-oesophageal cancer risk among users of 5AR inhibitors, particularly finasteride. However, larger epidemiological studies are required before randomised controlled trials are considered.

Enigmatic Differences by Sex in Cancer Incidence: Evidence From Childhood Cancers

We investigated the differences in cancer incidence between boys and girls. The incidence data for pediatric cancers were retrieved from the International Incidence of Childhood Cancer project (1990-2015). Poisson regression was applied to detect the sex differences in cancer incidence at global and regional levels. Boys were more susceptible to childhood cancers than girls, with a global boy-to-girl incidence rate ratio of 1.27 (95% confidence interval (CI): 1.26, 1.28) for leukemia, 1.48 (95% CI: 1.46, 1.51) for lymphomas, 1.10 (95% CI: 1.08, 1.11) for central nervous system neoplasms, 1.11 (95% CI: 1.08, 1.13) for neuroblastoma, 1.05 (95% CI: 1.02, 1.09) for retinoblastoma, and 1.39 (95% CI: 1.33, 1.45) for hepatic tumors. Incidence among girls was predominant only in renal tumors (incidence rate ratio = 0.90, 95% CI: 0.88, 0.92). Significant sex differences were observed in childhood cancers based on global-scale cancer data. The most pronounced disparities were observed mostly in developing countries, highlighting that data registration quality should be improved and that attention is needed for health-care access and service utilization for girls in these regions. Additionally, given the limited exposures to environmental risk factors in children, the differences might be mainly attributable to some endogenous risk factors and warrant further investigations.

The Epidemiology of Esophageal Adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has increased in many Western countries and is higher in men than women. Some risk factors for EAC have been identified-mainly gastroesophageal reflux disease, Barrett's esophagus, obesity, and tobacco smoking. It is not clear whether interventions to address these factors can reduce risk of EAC, although some evidence exists for smoking cessation. Although consumption of alcohol is not associated with EAC risk, other exposures, such as physical activity, nutrition, and medication use, require further study. Genetic variants have been associated with risk for EAC, but their overall contribution is low. Studies are needed to investigate associations between risk factors and the molecular subtypes of EAC. The prognosis for patients with EAC has slightly improved, but remains poor-screening and surveillance trials of high-risk individuals are needed.

Perioperative chemotherapy for resectable gastric cancer - what is the evidence?

The UK MAGIC trial published in 2006 was the first RCT to identify improved long-term survival rates using preoperative chemotherapy for resectable gastric or gastroesophageal cancer. Overnight, the treatment regimen impacted European guidelines. However, the majority of patients underwent limited lymph node dissection, and analyses of the rates of curative resection, downsizing and downstaging were not by intention to treat, rightfully raising concerns about their validity. For the subset of true gastric cancers, meta-analyses may even question the claims of improved long-term survival rates by present-day regimens. A rhetorical question can be posed as to whether downstaging and improved survival rates by preoperative (radio)-chemotherapy for cancers of the distal esophagus or gastric cardia, has confounded our conclusions on the (lack of) effect of present-day regimens of perioperative chemotherapy for true gastric cancers, let alone in a situation with proper lymph node dissection. At present, a plea can be made to move one step back and revert to an RCT with a surgery alone arm. Inclusion criteria and analyses of future RCTs must stratify on tumor location and the Lauren type and embrace the newly developed scheme of sub-classification of gastric cancers based on extensive molecular profiling as reported in the seminal Cancer Genome Atlas Study.

Sex disparities in cancer incidence in Jiashan County, China, 1995-2014

PURPOSE

To describe the sex-specific incidence rates and the male-to-female incidence-rate ratios (IRRs) of different cancer types, and to explore the corresponding sex disparities in an area of Eastern China.

METHODS

We used data from the Cancer Registry in Jiashan County, and calculated the sex-specific age-standardized (2010 China standard population) incidence rates and the male-to-female IRRs for different cancer types during the period 1995-2014.

RESULTS

The age-standardized incidence rates of all cancers for the whole period 1995-2014 were 151.48 per 100,000 person-years for males and 83.75 per 100,000 person-years for females, and the corresponding male-to-female IRR was 1.81 (95% confidence interval: 1.77-1.85). Specifically, males presented higher incidences in most types of cancer with the exceptions of cancers of connective and other soft tissues, gallbladder (including extrahepatic bile ducts), and thyroid gland. In addition, the age-specific incidences of the ten most common cancers in males were higher than those in females in most age groups.

CONCLUSIONS

Our results reveal a male predominance in incidence for a majority of cancers in Jiashan County, Eastern China. Possible explanations for these sex disparities in cancer incidence may include lifestyle factors, particularly smoking.

Sex differences and effects of oestrogen in rat gastric mucosal defence

AIM

To evaluate sex differences and the effects of oestrogen administration in rat gastric mucosal defence.

METHODS

Sex differences in gastric mucus thickness and accumulation rate, absolute gastric mucosal blood flow using microspheres, the integrity of the gastric mucosal epithelium in response to a chemical irritant and the effects of oestrogen administration on relative gastric mucosal blood flow in an acute setting was assessed in an in vivo rat experimental model. Subsequently, sex differences in the distribution of oestrogen receptors and calcitonin gene related peptide in the gastric mucosa of animals exposed to oestrogen in the above experiments was evaluated using immunohistochemistry.

RESULTS

The absolute blood flow in the GI-tract was generally higher in males, but only significantly different in the corpus part of the stomach (1.12 ± 0.12 mL/min•g in males and 0.51 ± 0.03 mL/min•g in females) (P = 0.002). After removal of the loosely adherent mucus layer the thickness of the firmly adherent mucus layer in males and females was 79 ± 1 µm and 80 ± 3 µm respectively. After 60 min the mucus thickness increased to 113 ± 3 µm in males and 121 ± 3 µm in females with no statistically significant difference seen between the sexes. Following oestrogen administration (0.1 followed by 1 µg/kg•min), mean blood flow in the gastric mucosa decreased by 31% [68 ± 13 perfusion units (PFU)] in males which was significantly different compared to baseline (P = 0.02). In females however, mean blood flow remained largely unchanged with a 4% (5 ± 33 PFU) reduction. The permeability of the gastric mucosa increased to a higher level in females than in males (P = 0.01) after taurocholate challenge. However, the calculated mean clearance increase did not significantly differ between the sexes [0.1 ± 0.04 to 1.1 ± 0.1 mL/min•100 g in males and 0.4 ± 0.3 to 2.1 ± 0.3 mL/min•100 g in females (P = 0.065)]. There were no significant differences between 17β-Estradiol treated males (mean ratio of positive staining ± SEM) (0.06 ± 0.07) and females (0.11 ± 0.11) in the staining of ERα (P = 0.24). Also, there were no significant differences between 17β-Estradiol treated males (0.18 ± 0.21) and females (0.06 ± 0.12) in the staining of ERβ (P = 0.11). Finally, there were no significant differences between 17β-Estradiol treated males (0.04 ± 0.05) and females (0.11 ± 0.10) in the staining of CGRP (P = 0.14).

CONCLUSION

Gastric mucosal blood flow is higher in male than in female rats and is reduced in male rats by oestrogen administration.

A population-based study on incidence rates, Lauren distribution, stage distribution, treatment, and long-term outcomes for gastric adenocarcinoma in Central Norway 2001-2011

BACKGROUND

Population-based studies for gastric adenocarcinoma are scarce, particularly studies conducted within a defined geographical area with publicly available censuses that allow incidence rates to be calculated.

MATERIAL AND METHODS

Population-based study in Central Norway from 2001 to 2011, covering a population of 636 000-680 000, respectively. Patients were identified through the Cancer Registry of Norway and the Norwegian Patient Register, and were characterized by data from individual electronic patient records. Outcomes were compared across the early and the late half of the study period.

RESULTS

A total of 878 patients were identified with a median age of 76.2 years. The male to female ratio was 1.72. Annual world age-standardized incidence was 8.0/10⁵ and 3.6/10⁵, respectively. The Lauren diffuse type was significantly more frequent among patients below 60 years, among females and for non-cardia cancers, compared to their counterparts (p < .001). The Lauren mixed type had a stable proportion of around 13% irrespective of age, sex or tumor location. Early gastric cancers (EGC) represented 8.3% of the cases, whereas 44% of all patients were diagnosed with metastatic disease. In males, the proportion of cardia cancers increased from 29.7% to 39.1% during the study period (p = .005). The five-year overall survival was 16%, and was substantially better for the Lauren intestinal type compared to the diffuse type, log-rank p = .003. The R0-R1 resection rate was 39%, with a corresponding five-year survival of 40.9%.

CONCLUSIONS

This study provides population-derived data lacking in hospital-based studies. Lauren categories with epidemiological aspects and clinical outcomes are displayed. Gastric cancer was associated with a dismal prognosis. Few patients had EGC and close to 50% had metastatic disease. Many were too old or frail to be considered for surgery.

A Systematic Review of the Burden of Pancreatic Cancer in Europe: Real-World Impact on Survival, Quality of Life and Costs

PURPOSE

The purpose of this study was to assess the overall burden of pancreatic cancer in Europe, with a focus on survival time in a real-world setting, and the overall healthy life lost to the disease.

METHODS

Real-world data were retrieved from peer-reviewed, observational studies identified by an electronic search. We performed two de novo analyses: a proportional shortfall analysis to quantify the proportion of healthy life lost to pancreatic cancer and an estimation of the aggregate life-years lost annually in Europe.

RESULTS

Ninety-one studies were included. The median, age-standardised incidence of pancreatic cancer per 100,000 was 7.6 in men and 4.9 in women. Overall median survival from diagnosis was 4.6 months; median survival was 2.8-5.7 months in patients with metastatic disease. The proportional shortfall analysis showed that pancreatic cancer results in a 98 % loss of healthy life, with a life expectancy at diagnosis of 4.6 months compared to 15.1 years for an age-matched healthy population. Annually, 610,000-915,000 quality-adjusted life-years (QALYs) are lost to pancreatic cancer in Europe. Patients had significantly lower scores on validated health-related quality of life instruments versus population norms.

CONCLUSIONS

To the best of our knowledge, this is the first study to systematically review real-world overall survival and patient outcomes of pancreatic cancer patients in Europe outside the context of clinical trials. Our findings confirm the poor prognosis and short survival reported by national studies. Pancreatic cancer is a substantial burden in Europe, with nearly a million aggregate life-years lost annually and almost complete loss of healthy life in affected individuals.

The Male Predominance in Esophageal Adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has increased rapidly during the past 4 decades in many Western populations, including North America and Europe. The established etiological factors for EAC include gastroesophageal reflux and obesity, Helicobacter pylori infection, tobacco smoking, and consumption of fruit and vegetables. There is a marked male predominance of EAC with a male-to-female ratio in incidence of up to 9:1. This review evaluates the available literature on the reasons for the male predominance, particularly an update on epidemiologic evidence from human studies during the past decade. The striking sex difference does not seem to be explained by established risk factors, given that the prevalence of the etiological factors and the strengths of associations between these factors and EAC risk are similar between the sexes. Sex hormonal factors may play a role in the development of EAC; estrogenic exposures may prevent such development, whereas androgens might increase the risk of EAC. However, continuing research efforts are still needed to fully understand the reasons for the male predominance of EAC.

Polymorphisms in Genes of Relevance for Oestrogen and Oxytocin Pathways and Risk of Barrett's Oesophagus and Oesophageal Adenocarcinoma: A Pooled Analysis from the BEACON Consortium

BACKGROUND

The strong male predominance in oesophageal adenocarcinoma (OAC) and Barrett's oesophagus (BO) continues to puzzle. Hormonal influence, e.g. oestrogen or oxytocin, might contribute.

METHODS

This genetic-epidemiological study pooled 14 studies from three continents, Australia, Europe, and North America. Polymorphisms in 3 key genes coding for the oestrogen pathway (receptor alpha (ESR1), receptor beta (ESR2), and aromatase (CYP19A1)), and 3 key genes of the oxytocin pathway (the oxytocin receptor (OXTR), oxytocin protein (OXT), and cyclic ADP ribose hydrolase glycoprotein (CD38)), were analysed using a gene-based approach, versatile gene-based test association study (VEGAS).

RESULTS

Among 1508 OAC patients, 2383 BO patients, and 2170 controls, genetic variants within ESR1 were associated with BO in males (p = 0.0058) and an increased risk of OAC and BO combined in males (p = 0.0023). Genetic variants within OXTR were associated with an increased risk of BO in both sexes combined (p = 0.0035) and in males (p = 0.0012). We followed up these suggestive findings in a further smaller data set, but found no replication. There were no significant associations between the other 4 genes studied and risk of OAC, BO, separately on in combination, in males and females combined or in males only.

CONCLUSION

Genetic variants in the oestrogen receptor alpha and the oxytocin receptor may be associated with an increased risk of BO or OAC, but replication in other large samples are needed.

Clinical-pathological characteristics and prognosis of a cohort of oesophageal cancer patients: a competing risks survival analysis

BACKGROUND

To determine the clinical course, follow-up strategies, and survival of oesophageal cancer patients using a competing risks survival analysis.

METHODS

We conducted a retrospective and prospective follow-up study. The study included 180 patients with a pathological diagnosis of oesophageal cancer in A Coruña, Spain, between 2003 and 2008. The Kaplan-Meier methodology and competing risks survival analysis were used to calculate the specific survival rate. The study was approved by the Ethics Review Board (code 2011/372, CEIC Galicia).

RESULTS

The specific survival rate at the first, third, and fifth years was 40.2%, 18.1%, and 12.4%, respectively. Using the Kaplan-Meier methodology, the survival rate was slightly higher after the third year of follow-up. In the multivariate analysis, poor prognosis factors were female sex (hazard ratio [HR] 1.94; 95% confidence interval [CI], 1.24-3.03), Charlson's comorbidity index (HR 1.17; 95% CI, 1.02-1.33), and stage IV tumours (HR 1.70; 95% CI, 1.11-2.59). The probability of dying decreased with surgical and oncological treatment (chemotherapy and/or radiotherapy) (HR 0.23; 95% CI, 0.12-0.45). The number of hospital consultations per year during the follow-up period, from diagnosis to the appearance of a new event (local recurrences, newly appeared metastasis, and newly appeared neoplasias) did not affect the probability of survival (HR 1.03; 95% CI, 0.92-1.15).

CONCLUSIONS

The Kaplan-Meier methodology overestimates the survival rate in comparison to competing risks analysis. The variables associated with a poor prognosis are female sex, Charlson's comorbidity score and extensive tumour invasion. Type of follow-up strategy employed after diagnosis does not affect the prognosis of the disease.

Age trend of the male to female sex ratio in surgical gastric cancer patients at a single institution

BACKGROUND

In previous reports concerning the association between sex disparity and age, gastric cancer (GC) patients were simply divided into younger and older groups by age. We analyzed the age trend of the male to female sex ratio (MFSR) in GC based on patient sequential age in order to observe the changing process of MFSR with age.

METHODS

One thousand seven hundred fifty-one surgical gastric adenocarcinoma patients aged 26 to 85 years were investigated between January 1996 and December 2010. The patients were grouped by age intervals of 5 years. The Cochran-Armitage trend test was used to determine how the MFSR changed with age.

RESULTS

The median age of the 1,751 patients with GC was 60 years (26 to 85 years). There were 1,334 male and 417 female patients (MFSR was 3.20). Cochran-Armitage trend test analysis showed that total MFSR increased significantly with age (Z = 5.964, P < 0.0001). Further studies on age groups of 26 to 60 years and 61 to 85 years were conducted. The trend test showed that MFSR increased significantly with age from 26 to 60 years (Z = 7.433, P < 0.0001). However, MFSR did not increase in ages 61 to 85 years (Z = -0.607, P = 0.544).

CONCLUSIONS

MFSR in GC presented an increasing trend until 60 years of age. The male GC patients showed an increasing tendency, and female GC patients showed a decreasing tendency with age. This trend reached a plateau phase after 60 years of age.

Hormone replacement therapy and oral contraceptives and risk of oesophageal adenocarcinoma: a systematic review and meta-analysis

There is an unexplained strong male predominance in the aetiology of oesophageal adenocarcinoma (OAC). The hypothesis that oestrogens are protective, deserves attention. A potential protective influence of exogenous oestrogen exposure, that is, hormone replacement therapy (HRT) and oral contraceptives (OC) has been addressed only in studies of limited statistical power, and the individual studies have not provided conclusive results. We conducted a systematic literature search and meta-analysis on HRT and OC and the risk of OAC. We used the databases PubMed and the Web of Science. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by the Mantel-Haenszel random-effect method. A total of five studies were included. Compared to never users, ever users of HRT had a statistically significantly decreased risk of OAC (pooled OR = 0.75; 95% CI: 0.58-0.98), and ever users of OC had a borderline significantly decreased risk of this cancer (pooled OR = 0.76; 95% CI: 0.57-1.00). In conclusion, HRT and OC use seems to be associated with a decreased risk of OAC. However, further research is warranted.

Review on novel concepts of columnar lined esophagus

BACKGROUND

Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts.

METHODS

Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE.

RESULTS

Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection.

CONCLUSIONS

SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).

Recent developments in esophageal adenocarcinoma

Answer questions and earn CME/CNE Esophageal adenocarcinoma (EAC) is characterized by 6 striking features: increasing incidence, male predominance, lack of preventive measures, opportunities for early detection, demanding surgical therapy and care, and poor prognosis. Reasons for its rapidly increasing incidence include the rising prevalence of gastroesophageal reflux and obesity, combined with the decreasing prevalence of Helicobacter pylori infection. The strong male predominance remains unexplained, but hormonal influence might play an important role. Future prevention might include the treatment of reflux or obesity or chemoprevention with nonsteroidal antiinflammatory drugs or statins, but no evidence-based preventive measures are currently available. Likely future developments include endoscopic screening of better defined high-risk groups for EAC. Individuals with Barrett esophagus might benefit from surveillance, at least those with dysplasia, but screening and surveillance strategies need careful evaluation to be feasible and cost-effective. The surgery for EAC is more extensive than virtually any other standard procedure, and postoperative survival, health-related quality of life, and nutrition need to be improved (eg, by improved treatment, better decision-making, and more individually tailored follow-up). Promising clinical developments include increased survival after preoperative chemoradiotherapy, the potentially reduced impact on health-related quality of life after minimally invasive surgery, and the new endoscopic therapies for dysplastic Barrett esophagus or early EAC. The overall survival rates are improving slightly, but poor prognosis remains a challenge.

Reproductive history and risk of small bowel cancer by histologic type: a population-based study

PURPOSE

The male predominance of the two main histologic malignancies of the small bowel cancer may reflect a role of sex hormones which will be examined in this study.

METHODS

This was a nationwide population-based nested case-control study, based on a cohort of subjects born between 1932 and 2008, as identified in the Swedish Multi-Generation Register. For each case of small bowel cancer, 10 age- and sex-matched controls were randomly selected. Number of children and age at having the first child were analyzed in relation to the risk of small bowel cancer using conditional logistic regression, providing odds ratios (ORs) and 95 % confidence intervals (CIs).

RESULTS

A total of 632 female cases and 894 male cases of small bowel cancer were included. No overall increased risk of small bowel cancer was found in parous compared to non-parous women (OR = 1.02, 95 % CI 0.67-1.54). There was no association between age at first birth and small bowel cancer (>30 years of age vs <20 years; OR = 1.04, 95 % CI 0.72-1.50). No associations were detected in separate analyses of adenocarcinoma or carcinoid of the small bowel. No distinct risk patterns were discerned in men compared to women.

CONCLUSIONS

Reproductive history does not seem to be associated with the risk of small bowel cancer, independent of histologic type.

Sex difference in the incidence of nasopharyngeal carcinoma in Hong Kong 1983-2008: suggestion of a potential protective role of oestrogen

BACKGROUND

Nasopharyngeal carcinoma (NPC) shows a male predominance in incidence while the underlying reasons have rarely been explored.

METHODS

We analysed incident cases of NPC recorded in Hong Kong Cancer Registry during the period 1983-2008. All cases were divided into 5-year age groups. Age group specific incidence rates of NPC by sex and male to female ratios in incidence rate by age group were calculated. A curve fitting approach was taken to quantitatively describe the age-specific incidence rates of NPC using non-linear regressions.

RESULTS

During the period 1983-2008, a total of 27,579 new cases of NPC were identified (20,060 males and 7519 females) in Hong Kong. The overall male to female ratio of the annual age-standardised incidence rates of NPC ranged 2.2-3.1. The male to female ratio of NPC incidence increased with age until peaking at ages 55-59 years and showed a decline thereafter. An additional minor increase at ages 15-19 years was also observed. Modelling of the age-specific incidence curves suggested divergent slopes for men and women and a delay in increasing incidence with age among females, by around 5-10 years before menopause ages.

CONCLUSION

The age-dependent pattern of the sex difference in the incidence of NPC could not be completely explained by known risk factors for NPC. The contributions of intrinsic exposures, such as sex hormones, merit consideration and further investigations.

Gastric cancer incidence and mortality in Zhuanghe, China, between 2005 and 2010

AIM: To investigate the incidence and mortality of gastric cancer (GC) in Zhuanghe region, northeast China and the influencing factors for their changing trends.

METHODS: All new cancer cases and deaths registered from 2005 to 2010 in Zhuanghe County were reviewed. The annual GC cases, constituent ratio, crude rates, age-standardized rates, their sex and age distribution and temporal trends were assessed. The method of annual percentage change (APC) was used to estimate the trends of GC.

RESULTS: Altogether 2634 new cases of GC and 1722 related deaths were registered, which accounted for 21.04% and 19.13% of all cancer-related incidence and deaths, respectively. The age-standardized incidence rate steadily decreased from 57.48 in 2005 to 44.53 in 2010 per 10⁵ males, and from 18.13 to 14.70 per 10⁵ females, resulting in a APC of -5.81% for males and -2.89% for females over the entire period. The magnitude of APC in GC mortality amounted to -11.09% and -15.23%, respectively, as the age-standardized mortality rate steadily decreased from 42.08 in 2005 to 23.71 in 2010 per 10⁵ males, and from 23.86 to 10.78 per 10⁵ females. Females had a significantly lower incidence (a male/female ratio 2.80, P < 0.001) and mortality (a male/female ratio 2.30, P < 0.001). In both genders, the peak incidence and mortality occurred in the 80-84 years age group. The age-standardized mortality/incidence ratio also decreased from the peak of 0.73 in 2005 to 0.53 in 2010 for males, and from 1.32 to 0.73 for females.

CONCLUSION: Encouraging declines of incidence and mortality of GC were observed in Zhuanghe region between 2005 and 2010, possibly due to the economic development and efficient GC control strategies.

Reproductive factors and risk of oesophageal and gastric cancer in the Million Women Study cohort

Background:

Hormonal factors may influence risk for upper gastrointestinal cancers in women. We examined risk of oesophageal and gastric cancers in relation to reproductive factors in a large UK cohort, the Million Women Study.

Methods:

Among 1 319 409 women aged on average 56 years at recruitment, 1186 incident cancers of the oesophagus and 1194 of the stomach were registered during 11.9 million person-years’ observation. Adjusted relative risks (RRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

Results:

Risks of both oesophageal and gastric cancer were significantly higher in postmenopausal than in pre- or peri-menopausal women (RRs 1.46, 1.07–2.00 and 1.59, 1.15–2.20, respectively; P⩽0.01 for both); and, among postmenopausal women, risk was higher the younger women were at menopause (RR, 95% CI per 5 years younger at menopause 1.18, 1.05–1.34 for oesophageal cancer and 1.18, 1.04–1.34 for stomach cancer, P_trend=0.01 for both). For factors relating to childbearing, including women's age at first birth, their number of children, and breastfeeding history, the only significant association was a higher risk of oesophageal cancer in nulliparous, compared with parous, women (RR 1.31, 1.11–1.55; P=0.002). When risks for squamous cell and adenocarcinomas of the oesophagus were compared, most did not differ significantly, but statistical power was limited.

Conclusion:

Both oesophageal and gastric cancer risks appeared to be related to menopausal status and age at menopause, but there was little consistent evidence for associations with factors related to childbearing.

Male predominance of upper gastrointestinal adenocarcinoma cannot be explained by differences in tobacco smoking in men versus women

BACKGROUND

Adenocarcinomas of the upper gastrointestinal tract (UGI) show remarkable male predominance. As smoking is a well-established risk factor, we investigated the role of tobacco smoking in the male predominance of UGI adenocarcinomas in the United States NIH-AARP Diet and Health Study.

METHOD

A questionnaire was completed by 281,422 men and 186,133 women in 1995-1996 who were followed until 31st December 2003. Incident UGI adenocarcinomas were identified by linkage to state cancer registries. We present age-standardised cancer incidence rates per 100,000-person years and male/female ratios (M/F) calculated from age-adjusted Cox proportional hazards models, both with 95% confidence intervals (CI).

RESULTS

After 2013,142-person years follow-up, 338 adenocarcinomas of the oesophagus, 261 of gastric cardia and 222 of gastric non-cardia occurred in men. In women, 23 tumours of oesophagus, 36 of gastric cardia and 88 of gastric non-cardia occurred in 1351,958-person years follow-up. The age-standardised incidence rate of all adenocarcinoma sites was 40.5 (37.8-43.3) and 11.0 (9.2-12.8) in men and women, respectively. Among smokers, the M/F of all UGI adenocarcinomas was 3.4 (2.7-4.1), with a M/F of 7.3 (4.6-11.7) for tumours in oesophagus, 3.7 (2.5-5.4) for gastric cardia and 1.7 (1.2-2.3) for gastric non-cardia. In non-smokers, M/F ratios were 14.2 (5.1-39.5) for oesophagus, 6.1 (2.6-14.7) for gastric cardia and 1.3 (0.8-2.0) for gastric non-cardia. The overall M/F ratio was 3.0 (2.2-4.3).

CONCLUSION

The male predominance was similar in smokers and non-smokers for these cancer sites. These results suggest that the male predominance of upper GI adenocarcinomas cannot be explained by differences in smoking histories.

Sex-specific exposure prevalence of established risk factors for oesophageal adenocarcinoma

BACKGROUND

There is an unexplained male predominance in the incidence of oesophageal adenocarcinoma, and the sex-specific distribution of its risk factors in the general population is not known.

METHODS

A random sample of Swedish citizens aged 40-79 years completed a questionnaire for assessment of the prevalence of five risk factors for oesophageal adenocarcinoma: reflux symptoms, body mass index, tobacco smoking habits, socioeconomic status, and use of non-steroidal anti-inflammatory drugs (NSAIDs). Logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate the association of these risk factors, separately and combined, with male sex, with women as reference.

RESULTS

Among 6969 invited people, 4906 (70.4%) completed the questionnaire. Adjusted prevalence estimates showed a negative association with male sex with regard to reflux disease (OR=0.70, 95% CI=0.58-0.84), whereas overweight (OR=1.98, 95% CI=1.72-2.27) and obesity (OR=1.22, 95% CI=1.01-1.47), previous smoking (OR=1.50, 95% CI=1.30-1.72), and no NSAID use (OR=1.35, 95% CI=1.15-1.49) were positively associated.

CONCLUSIONS

Exposure to some but not all established risk factors for oesophageal adenocarcinoma seems to be more common in men than in women, but the differences are small and unlikely to explain the male predominance of this tumour.