Comparing trends in esophageal adenocarcinoma incidence and lifestyle factors between the United States, Spain, and the Netherlands

Esophageal cancer global burden profiles, trends, and contributors

OBJECTIVE

This study aimed to provide a comprehensive overview of the global burden of esophageal cancer (EC) and determine the temporal trends and factors influencing changes in the global burden.

METHODS

The latest incidence and mortality data for EC worldwide were obtained from GLOBALCAN 2022. The mortality and disability-adjusted life years (DALYs) rates for EC from 1990-2019 were sourced from the 2019 Global Burden of Diseases. Trends in EC mortality and DALYs attributable to 11 risk factors or clusters of risk were analyzed using the joinpoint regression model. The trends in age-related EC burden were assessed using a decomposition approach.

RESULTS

An estimated 511,054 new cases of EC were diagnosed in 2022 with 445,391 deaths worldwide. Approximately 75% of cases and deaths occurred in Asia. Nearly 50% of global EC deaths and DALYs were attributed to tobacco use in men in 2019, while 20% were attributed to high body mass index (BMI) in women. From 1990-2019, EC deaths and DALYs attributable to almost all risk factors had declining trends, while EC deaths and DALYs attributed to high BMI in men had upward trends. The age-related EC burden exhibited an upward trend driven by population growth and aging, which contributed to 307.4 thousand deaths and 7.2 million DALYs due to EC.

CONCLUSIONS

The EC burden remains substantial worldwide. Effective tobacco and obesity control measures are critical for addressing the risk-attributable burden of EC. Population growth and aging pose challenges for EC prevention and control efforts.

Depletion of Gr1+ myeloid cells attenuates high-fat-diet-aggravated esophageal squamous cell carcinoma in mice

Obesity is a leading cause of multiple cancers, but whether it promotes esophageal squamous cell carcinoma (ESCC) and its underlying cancer-promoting mechanism remains unclear. To evaluate the effect of a high-fat diet (HFD) on ESCC and explore the role and mechanism of myeloid-derived suppressor cells (MDSCs) in HFD-induced ESCC, C57BL/6J mice were treated with 4-nitroquinoline 1-oxide (4NQO) to induce ESCC and randomly assigned to an HFD or a normal-fat diet. An anti-Gr1 monoclonal antibody was used to deplete MDSCs in the context of experimental diets and ESCC induction. The expression of MDSC markers CD11b and Gr1 and immune checkpoints (ICs) PD1, TIM3, and VISTA in lesions were detected by immunohistochemistry. The correlation between myeloid cell markers (CD11b and CD33) and ICs and their relationship with ESCC patient prognosis were further analyzed using the The Cancer Genome Atlas dataset. The results showed that HFD accelerated esophageal carcinogenesis, induced MDSC expansion, and upregulated IC expression, whereas depletion of Gr1+ myeloid cells significantly suppressed tumor growth, decreased the number of MDSCs, and downregulated IC expression in HFD mice. PD1, TIM3, and VISTA expressions were positively correlated with myeloid cell marker expression in human ESCC. Moreover, the high expression of IC molecules was associated with poor survival in patients with ESCC. These data indicate that HFD promotes the initiation and development of ESCC. Gr1+ myeloid cell targeting significantly inhibited ESCC formation in HFD mice, which may be associated with IC downregulation.

A blood-based circulating microbial metagenomic panel for early diagnosis and prognosis of oesophageal adenocarcinoma

BACKGROUND

Emerging evidence indicates the potential clinical significance of specific microbial signatures as diagnostic and prognostic biomarkers, in multiple cancers. However, to date, no studies have systematically interrogated circulating metagenome profiling in oesophageal adenocarcinoma (EAC) patients, particularly as novel non-invasive, early detection, surveillance and prognostic classifiers.

METHODS

Metagenome sequencing was performed on 81 serum specimens collected across EAC spectrum, with sequencing reads classified using Bracken and MetaPhlAn3. Followed by the Linear Discriminant Analysis effect size (LEfSe) method to identify microbial profiles between groups. Logistic regression and Kaplan-Meier analyses were used to build classifiers.

RESULTS

A significant loss of alpha and beta diversity was identified in serum specimens from EAC patients. We observed a shift in microbial taxa between each group-at the phylum, genus, and species level-with Lactobacillus sakei as the most prominent species in gastroesophageal reflux (GERD) vs other patient groups. Interestingly, LEfSe analysis identified a complete loss of Lactobacillus (L. Sakei and L. Curvatus), Collinsella stercoris and Bacteroides stercoris but conversely a significant increase in Escherichia coli in patients with EAC. Finally, we developed a metagenome panel that discriminated EAC from GERD patients with an AUC value of 0.89 (95% CI: 0.78-0.95; P < 0.001) and this panel in conjunction with the TNM stage was a robust predictor of overall survival (≥24 months; AUC = 0.84 (95% CI: 0.66-0.92; P = 0.006)).

CONCLUSION

This study firstly describes unique blood-based microbial profiles in patients across EAC carcinogenesis, that are further utilised to establish a novel circulating diagnostic and prognostic metagenomic signature for EAC.

TRANSLATIONAL RELEVANCE

Accumulating data indicates the clinical relevance of specific microbial signatures as diagnostic and prognostic biomarkers, in multiple cancers. However, to date, no studies have systematically interrogated circulating metagenome profiling in patients with oesophageal adenocarcinoma (EAC). Herein, we performed metagenome sequencing in serum specimens from EAC patients 81 collected across EAC spectrum and observed a significant loss of alpha and beta diversity, with a shift in microbial taxa between each group-at the phylum, genus, and species level-with Lactobacillus sakei as the most prominent species in gastroesophageal reflux (GERD) vs other patient groups. Interestingly, LEfSe analysis identified a complete loss of Lactobacillus (L. Sakei and L. Curvatus), Collinsella stercoris and Bacteroides stercoris but conversely a significant increase in Escherichia coli in patients with EAC. Finally, we developed a metagenome panel that discriminated EAC from GERD patients with an AUC value of 0.89 and this panel, in conjunction with the TNM stage, was a robust predictor of overall survival. This study for the first time describes unique blood-based microbial profiles in patients across EAC carcinogenesis, that are further utilised to establish a novel circulating diagnostic and prognostic metagenomic signature for EAC.

UBCH5 Family Members Differentially Impact Stabilization of Mutant p53 via RNF128 Iso1 During Barrett's Progression to Esophageal Adenocarcinoma

BACKGROUND & AIMS

TP53 mutations underlie Barrett's esophagus (BE) progression to dysplasia and cancer. During BE progression, the ubiquitin ligase (E3) RNF128/GRAIL switches expression from isoform 2 (Iso2) to Iso1, stabilizing mutant p53. However, the ubiquitin-conjugating enzyme (E2) that partners with Iso1 to stabilize mutant p53 is unknown.

METHODS

Single-cell RNA sequencing of paired normal esophagus and BE tissues identified candidate E2s, further investigated in expression data from BE to esophageal adenocarcinoma (EAC) progression samples. Biochemical and cellular studies helped clarify the role of RNF128-E2 on mutant p53 stability.

RESULTS

The UBE2D family member 2D3 (UBCH5C) is the most abundant E2 in normal esophagus. However, during BE to EAC progression, loss of UBE2D3 copy number and reduced expression of RNF128 Iso2 were noted, 2 known p53 degraders. In contrast, expression of UBE2D1 (UBCH5A) and RNF128 Iso1 in dysplastic BE and EAC forms an inactive E2-E3 complex, stabilizing mutant p53. To destabilize mutant p53, we targeted RNF128 Iso1 either by mutating asparagine (N48, 59, and 101) residues to block glycosylation to facilitate β-TrCP1-mediated degradation or by mutating proline (P54 and 105) residues to restore p53 polyubiquitinating ability. In addition, either loss of UBCH5A catalytic activity, or disruption of the Iso1-UBCH5A interaction promoted Iso1 loss. Consequently, overexpression of either catalytically dead or Iso1-binding-deficient UBCH5A mutants destabilized Iso1 to degrade mutant p53, thus compromising the clonogenic survival of mutant p53-dependent BE cells.

CONCLUSIONS

Loss of RNF128 Iso2-UBCH5C and persistence of the Iso1-UBCH5A complex favors mutant p53 stability to promote BE cell survival. Therefore, targeting of Iso1-UBCH5A may provide a novel therapeutic strategy to prevent BE progression.

Global burden and epidemiology of Barrett oesophagus and oesophageal cancer

Oesophageal cancer is a global health problem; in 2018 there were more than 572,000 people newly diagnosed with oesophageal cancer worldwide. There are two main histological subtypes of oesophageal cancer, oesophageal adenocarcinoma (EAC) and oesophageal squamous cell carcinoma (ESCC), and there has been a dramatic shift in its epidemiology. While the incidence of EAC and its precursor lesion, Barrett oesophagus, has increased in Western populations over the past four decades, the incidence of ESCC has declined in most parts of the world over the same period. ESCC still accounts for the vast majority of all oesophageal cancer cases diagnosed worldwide each year. Prognosis for patients with oesophageal cancer is strongly related to stage at diagnosis. As most patients are diagnosed with late-stage disease, overall 5-year survival for oesophageal cancer remains <20%. Knowledge of epidemiology and risk factors for oesophageal cancer is essential for public health and clinical decisions about risk stratification, screening and prevention. The goal of this Review is to establish the current epidemiology of oesophageal cancer, with a particular focus on the Western world and the increasing incidence of EAC and Barrett oesophagus.

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.

International Trends in Esophageal Squamous Cell Carcinoma and Adenocarcinoma Incidence

INTRODUCTION

We aimed to improve our understanding of the epidemiology of squamous cell carcinoma and adenocarcinoma of the esophagus.

METHODS

We estimated average annual percent change and analyzed age-period-cohort trends on population-based cancer data.

RESULTS

We found decreases in squamous cell carcinoma incidence in half of male populations (largest decrease in US black males [average annual percent change -7.6]) and increases in adenocarcinoma incidence in nearly a third of populations. Trends may be associated with a mix of birth cohort and period effects.

DISCUSSION

More complete data and evidence are needed to conclude the reasons for the observed trends (see Visual Abstract, Supplementary Digital Content 4, http://links.lww.com/AJG/B823).

The role of long noncoding RNAs in regulating invasion and metastasis of malignant tumors

Long noncoding RNAs (lncRNAs) are a group of non-protein-coding transcripts exceeding 200 nucleotides in length, which are emerging as key players in various fundamental biological processes. Furthermore, it is increasingly recognized that mutation and dysregulation of lncRNAs contribute importantly to a variety of human diseases, particularly human cancers. Previous studies have revealed that altered lncRNAs have a close association with tumorigenesis, metastasis, prognosis and diagnosis of cancers. The present review aims to exhibit a brief overview of the associated reports of lncRNAs in cancers, including colorectal cancer, gastric cancer, lung adenocarcinoma, nasopharyngeal carcinoma, cervical cancer and esophageal cancer. Altogether, we argue that lncRNAs have potential as new biomarkers in cancer prognosis and diagnosis, and as promising therapeutic targets for the prevention and treatment of human cancers.

Length of Barrett's esophagus in the presence of low-grade dysplasia, high-grade dysplasia, and adenocarcinoma

INTRODUCTION

The identification and follow-up of ultra-short Barrett's esophagus (BE) is controversial. BE surveillance guidelines emphasize mainly on long-segment BE. However, in practice a substantial proportion of esophageal adenocarcinoma (EAC) are found close to the gastro-esophageal junction (GEJ). Our study aims to chart the length of BE when low-grade dysplasia (LGD), high-grade dysplasia (HGD) and EAC arise in BE.

METHODS

Endoscopic findings from all cases with a diagnosis of LGD and HGD in BE between June 2014 and June 2019, and 100 consecutive cases of EAC diagnosed between June 2018 and August 2019, were reviewed. Additionally, 438 consecutive gastroscopies were reviewed to identify 100 cases of non-dysplastic BE.

RESULTS

99 cases of LGD and 61 cases of HGD were reviewed. LGD and HGD when diagnosed, was located in BE ≤ 1 cm in 20% and 18% cases, respectively. LGD and HGD when diagnosed, was located in BE ≤ 3 cm in 48.5% and 40.9% cases, respectively. LGD and HGD when diagnosed in BE ≤ 3 cm was found at index endoscopy in 67% and 42% cases, respectively. Of the 100 cases of EAC, only 23 had concurrent visible BE, with BE higher than the level of EAC in seven. EAC when found, had its proximal extent ≤ 1 cm from GEJ in 22% and ≤ 3 cm from GEJ in 40% cases. Of the 100 non-dysplastic BE, 53% were ≤ 1 cm and 78% were ≤ 3 cm long.

CONCLUSION

Almost 20% of all dysplasia in BE occurs in BE < 1 cm. Over 40% occurs in BE < 3 cm. Similarly, 20% of EAC occurs within 1 cm of GEJ and 40% occur within 3 cm. A majority of dysplasia diagnosed within 3 cm of the GEJ is found on index endoscopy. We propose that all lengths of columnar lined epithelium above the GEJ are recognized as BE and subjected to a thorough biopsy protocol.

Trends in Mortality Rates for Gastrointestinal Cancers in Fars Province, Iran (2005-2015)

PURPOSE

In Iran, cancers are the third leading cause of death, and gastrointestinal cancers are the primary cause of mortality among all the cancers. This study aimed to determine the trend of crude and age-standardized mortality rates (ASMR) for different types of gastrointestinal cancers over an 11-year period in Fars province (Iran).

METHODS

In this study, all the mortality data for gastrointestinal cancers were derived from the Electronic Death Registration System (EDRS) between 2005 and 2015. Subsequently, we calculated the crude and age-standardized mortality rates (ASMR) and their trends for different types of gastrointestinal cancers based on age groups and gender over the study period.

RESULTS

A total of 6547 deaths from gastrointestinal cancers were identified, with an average age of 66.0 ± 16.4 years. The crude and age-standardized mortality rates for gastrointestinal cancers were respectively 10.9 and 15.0 per 100,000 population in 2005 which significantly increased to 17.4 and 19.4 per 100,000 population in 2015 (P < 0.001). The ASMR for colon, pancreatic, and oral cancers showed an increasing trend; for small intestine cancers, a decreasing trend; and for esophageal, gastric, rectal, and hepatobiliary cancers displayed an almost constant trend.

CONCLUSIONS

Our study shows a higher ASMR and an increasing trend of gastrointestinal cancers in Fars province. Prevention and early diagnosis programs with screening techniques should be implemented to control the mortality rate of gastrointestinal cancers in the future.

Geographic distribution and time trends of esophageal cancer in Brazil from 2005 to 2015

The purpose of the present study was to investigate the geographical distribution and time trends of the incidence and lethality of esophageal cancer (EC) in Brazil. The present study conducted an ecological study of EC using records from January 2005 to December 2015 in the Health Informatics Department of the Brazilian Ministry of Health (DATASUS) registry. In addition to demographical data on the population, EC incidence and lethality rates were estimated from hospitalizations and in-hospital mortalities and were adjusted by total available hospital beds. The adjusted EC rates per 100,000 increased from 9.1 in 2005 to 12.1 in 2015. The prevalence among males increased from 69 to 78%, while the female rates remained stable over the same period. Although EC was the most common in South and Southeast Brazil, the rates increased proportionately more in the other regions of the country, especially among males. Geographical analysis revealed higher rates of EC in more urbanized areas, with a coast-to-inland gradient. While rates increased in people older than 50 years, they decreased among people below this age. However, the lethality rates remained stable and high during the study period, overlapping with hospital admission rates. The recent increasing trend in the EC incidence, with shifts from the south towards the north and from more urbanized towards rural areas, suggests that environmental factors are crucial in EC pathogenesis. The concentration of EC in South Brazil may reflect the presence of major environmental factors in association with a possible genetic predisposition. The unchanging high mortality associated with EC in the rapidly aging population suggests that EC will continue to impose a significant social and economic burden in the future.

Recent advances in Barrett's esophagus

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma, one of the few cancers with increasing incidence in developed countries. The pathogenesis of BE is unclear with regard to either the cellular origin of this metaplastic epithelium or the manner in which malignant transformation occurs, although recent data indicate a possible junctional origin of stem cells for BE. Treatment of BE may be achieved using endoscopic eradication therapy; however, there is a lack of discriminatory tools to identify individuals at sufficient risk for cancer development in whom intervention is warranted. Reduction in gastroesophageal reflux of gastric contents including acid is mandatory to achieve remission from BE after endoscopic ablation, and can be achieved using medical or nonmedical interventions. Research topics of greatest interest include the mechanism of BE development and transformation to cancer, risk stratification methods to identify individuals who may benefit from ablation of BE, optimization of eradication therapy, and surveillance methods to ensure that remission is maintained after eradication is achieved.

Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands

Extent of mediastinal lymphadenectomy during esophagectomy is clearly different between two representative countries of the Eastern and Western world, such as Japan and the Netherlands. In Japan, a clear policy is the standard complete two- or three-field type of lymphadenectomy whereas, in the Netherlands, a limited form is usually carried out. Reasons for these differences can be found in the different types of tumor, 80% of adenocarcinomas in the West and almost 95% of squamous cell cancer in Japan. Moreover, location of the tumors, distally located in the Netherlands whereas, in Japan, the majority are located in the middle and proximal thoracic esophagus. Also, type of neoadjuvant therapy, namely chemoradiotherapy in the Netherlands, and chemotherapy in Japan, are different. Arguments for more extended mediastinal lymphadenectomy are currently challenged in the West, first by the systematic use of chemoradiotherapy as neoadjuvant therapy and, second, the retrospective analysis of large data. According to two studies, the importance of extended lymphadenectomy is shown to be relative and less clear, especially in esophageal adenocarcinomas after neoadjuvant therapy. International efforts such as the TIGER study will help to standardize and find a relationship between the type and location of esophageal cancer, use of neoadjuvant therapy, extent of lymphadenectomy and survival.

Trends and projections in adenocarcinoma and squamous cell carcinoma of the oesophagus in England from 1971 to 2037

BACKGROUND

The aim of this study was to assess the incidence and trends of oesophageal adenocarcinomas (OACs) and squamous cell carcinomas (OSCCs) in England from 1971 to 2037.

METHODS

Data on 220,026 oesophageal cancers diagnosed in England between 1971 and 2013 were extracted. Multiple imputation was used to predict morphology data were missing. Incidence rates were modelled and extrapolated to 2037 using age-period-cohort models.

RESULTS

The OAC age-standardised incidence rate (ASRs) increase was greatest from 1972 to 1992 (from 4.8 to 12.3 for men and 1.1 to 3 per 100,000 for women) and slowed from 1992 to 2012 (with an increase to 17 for men and 3.8 per 100,000 for women). OSCCs rates decreased from 7.5 to 4.9 from 1972 to 2012 for men. For women, ASRs increased from 5.5 to 5.9 between 1972 and 1992 and then decreased to 4.7 per 100,000 until 2012. Rates until 2032 are predicted to stay stable for OACs and further decrease for OSCCs.

CONCLUSIONS

Imputing missing morphology allowed accurate and up-to-date estimates of trends and projections. We observed a slowing down of the increase in OAC ASRs and an overall decrease in OSCC ASRs.

Costs associated with Barrett's esophagus screening in the community: an economic analysis of a prospective randomized controlled trial of sedated versus hospital unsedated versus mobile community unsedated endoscopy

BACKGROUND AND AIMS

Data on the economic impact associated with screening for Barrett's esophagus (BE) are limited. As part of a comparative effectiveness randomized trial of unsedated transnasal endoscopy (uTNE) and sedated EGD (sEGD), we assessed costs associated with BE screening.

METHODS

Patients were randomly allocated to 3 techniques: sEGD or uTNE in a hospital setting (huTNE) versus uTNE in a mobile research van (muTNE). Patients were called 1 and 30 days after screening to assess loss of work (because of the screening procedure) and medical care sought after procedure. Direct medical costs were extracted from billing claims databases. Indirect costs (loss of work for subject and caregiver) were estimated using patient reported data. Statistical analyses including multivariable analysis accounting for comorbidities were conducted to compare costs.

RESULTS

Two hundred nine patients were screened (61 sEGD, 72 huTNE, and 76 muTNE). Thirty-day direct medical costs and indirect costs were significantly higher in the sEGD than the huTNE and muTNE groups. Total costs (direct medical + indirect costs) were also significantly higher in the sEGD than in the uTNE group. The muTNE group had significantly lower costs than the huTNE group. Adjustment for age, sex, and comorbidities on multivariable analysis did not change this conclusion.

CONCLUSIONS

Short-term direct, indirect, and total costs of screening are significantly lower with uTNE compared with sEGD. Mobile uTNE costs were lower than huTNE costs, raising the possibility of mobile screening as a novel method of screening for BE and esophageal adenocarcinoma.

Optimizing the diagnosis and therapy of Barrett's esophagus

The incidence of Barrett's esophagus (BE) in the Western world has increased over the last decades. BE is considered a premalignant lesion that can progress to esophageal adenocarcinoma (EAC), a highly aggressive malignancy with poor survival rates. The close association between BE and EAC highlights the need for an early diagnosis in order to improve survival and outcomes in this group of patients. Although the evidence for BE screening with conventional endoscopy is controversial and limited by cost-effectiveness studies, screening can be suggested in patients with chronic gastroesophageal reflux disease (GERD) and two or more risk factors for EAC. Less invasive techniques with lower costs and higher acceptability by the patients may be useful for screening in the general population. Several novel techniques have been described to aid in the early diagnosis and management of BE and dysplasia. However, these techniques have shown variable results with higher costs, the need of specific training, and variable inter-observer imaging interpretation, making its widespread implementation problematic. High-definition/high-resolution white-light endoscopy (WLE) continues to be a well-accepted technique for the evaluation and surveillance of patients with BE. Further studies are required in order to establish the efficacy of less invasive methods that can be performed in an outpatient setting for BE screening in higher risk individuals.

The natural history of gastro-esophageal reflux disease: a comprehensive review

Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.

ESOPHAGEAL CARCINOMA: IS SQUAMOUS CELL CARCINOMA DIFFERENT DISEASE COMPARED TO ADENOCARCINOMA? A transversal study in a quaternary high volume hospital in Brazil

BACKGROUND

Esophageal cancer is one of the leading causes of mortality among the neoplasms that affect the gastrointestinal tract. There are several factors that contribute for development of an epidemiological esophageal cancer profile in a population.

OBJECTIVE

This study aims to describe both clinically and epidemiologically the population of patients with diagnosis of esophageal cancer treated in a quaternary attention institute for cancer from January, 2009 to December, 2011, in Sao Paulo, Brazil.

METHODS

The charts of all patients diagnosed with esophageal cancer from January, 2009, to December, 2011, in a Sao Paulo (Brazil) quaternary oncology institute were retrospectively reviewed.

RESULTS

Squamous cell cancer made up to 80% of the cases of esophageal cancer. Average age at diagnosis was 60.66 years old for esophageal adenocarcinoma and 62 for squamous cell cancer, average time from the beginning of symptoms to the diagnosis was 3.52 months for esophageal adenocarcinoma and 4.2 months for squamous cell cancer. Average time for initiating treatment when esophageal cancer is diagnosed was 4 months for esophageal adenocarcinoma and 4.42 months for squamous cell cancer. There was a clear association between squamous cell cancer and head and neck cancers, as well as certain habits, such as smoking and alcoholism, while adenocarcinoma cancer showed more association with gastric cancer and gastroesophageal reflux disease. Tumoral bleeding and pneumonia were the main causes of death. No difference in survival rate was noted between the two groups.

CONCLUSION

Adenocarcinoma and squamous cell carcinoma are different diseases, but both are diagnosed in advanced stages in Brazil, compromising the patients' possibilities of cure.

Trends in net survival from esophageal cancer in six European Latin countries: results from the SUDCAN population-based study

Esophageal cancer represents a major clinical challenge because of its poor prognosis. The aim of the SUDCAN collaborative study was to compare the net survival from esophageal cancer between six European Latin countries (Belgium, France, Italy, Portugal, Spain, and Switzerland) and report the trends in net survival and the dynamics of excess mortality rates (EMRs) up to 5 years after diagnosis. The data were extracted from the EUROCARE-5 database. First, net survival was studied over the period 2000-2004 using the Pohar-Perme estimator. For trend analyses, the study period was specific to each country. The results were reported from 1992 to 2004 in France, Italy, Spain, and Switzerland and from 2000 to 2004 in Belgium and Portugal. These trend analyses were carried out using a flexible excess rate modeling strategy. There were some differences between countries in age-standardized net survival (2000-2004). The 5-year net survival ranged between 9 (Spain) and 21% (Belgium). The small increase in net survival from 1992 and 2004 was mostly observed at ages 55 and 65, but was less marked at age 75. There was a slight decrease in EMR between 1992 and 2004 until ∼24 months after diagnosis. Beyond this period, the decrease in the EMR was moderate and the same in all countries irrespective of the year of diagnosis. Some improvement in the 5-year net survival was observed in all countries limited to the 24 months after diagnosis. However, survival differences between countries persisted. Further improvement is expected from innovative treatments.

Is Obesity Associated with Barrett's Esophagus and Esophageal Adenocarcinoma?

Barrett's esophagus is a premalignant condition portending increased risk of esophageal adenocarcinoma. Given the significant morbidity and mortality of esophageal adenocarcinoma, identification of risk factors for Barrett's esophagus and esophageal adenocarcinoma is crucial. There are a plethora of studies investigating the relationship of obesity with these pathologies. Recent studies reveal that this relationship may specifically be with central adiposity. Increased cell turnover and eventual carcinogenesis is likely precipitated by increased intragastric pressure but also is affected by the complex interplay of increased insulin resistance in patients with increased fat tissue. Further studies are warranted to evaluate if weight loss can decrease progression of Barrett's esophagus.

Yesterday and today of Barrett's esophagus: Historical evolution and research hotspots

It has been more than 60 years since the concept of Barrett's esophagus (BE) was put forward, and over these a few decades, we have made great progress in the diagnosis and treatment of BE. BE does not cause clinical symptoms, but it attracts wide attention, because it is an important precursor lesion of esophageal adenocarcinoma. The purpose of this article is to review the process of the recognition of BE and the current research hotspots as well as to discuss the current status of esophageal adenocarcinoma screening in BE patients. We aim to provide clinicians with an overview of the ins and outs of the disease, which will help them improve the diagnosis and treatment of BE in clinical practice and provide patients with beneficial treatment.

Barrett’s esophagus in 2016: From pathophysiology to treatment

Esophageal complications caused by gastroesophageal reflux disease (GERD) include reflux esophagitis and Barrett’s esophagus (BE). BE is a premalignant condition with an increased risk of developing esophageal adenocarcinoma (EAC). The carcinogenic sequence may progress through several steps, from normal esophageal mucosa through BE to EAC. A recent advent of functional esophageal testing (particularly multichannel intraluminal impedance and pH monitoring) has helped to improve our knowledge about GERD pathophysiology, including its complications. Those findings (when properly confirmed) might help to predict BE neoplastic progression. Over the last few decades, the incidence of EAC has continued to rise in Western populations. However, only a minority of BE patients develop EAC, opening the debate regarding the cost-effectiveness of current screening/surveillance strategies. Thus, major efforts in clinical and research practice are focused on new methods for optimal risk assessment that can stratify BE patients at low or high risk of developing EAC, which should improve the cost effectiveness of screening/surveillance programs and consequently significantly affect health-care costs. Furthermore, the area of BE therapeutic management is rapidly evolving. Endoscopic eradication therapies have been shown to be effective, and new therapeutic options for BE and EAC have emerged. The aim of the present review article is to highlight the status of screening/surveillance programs and the current progress of BE therapy. Moreover, we discuss the recent introduction of novel esophageal pathophysiological exams that have improved the knowledge of the mechanisms linking GERD to BE.

Trends in Gastrointestinal Cancer Mortality Rate in Hungary

The aim of this study was to investigate the annual death trends for gastrointestinal cancer in Hungary between 1963 and 2012. Data on the numbers of cancer deaths were obtained from the published nationwide population register. Numbers of deaths from esophageal, gastric and colorectal cancer were available during the study period. However, the mortality data for hepatic, pancreatic and gallbladder cancer have been published only since 1979. Joinpoint regression was applied to investigate the annual trends in the rates of cancer mortality. The annual mortality rates of gastric and gallbladder cancer decreased throughout the study period. Furthermore, declines in mortality from esophageal and hepatic cancers have been observed since 1998 and 1995, respectively. However, the rates of colorectal and pancreatic cancer mortality have been increasing in the past few years. Nevertheless, the mortality rates of colorectal and pancreatic cancers have increased in males aged 40-59 years during the study period. Moreover, significantly higher risks of gastrointestinal cancer-related deaths have been observed in males as compared with females except for death related to cancer of the gallbladder. The presented data suggest that the Hungarian mortality rates are particularly high. The detection of gastrointestinal cancers at an early stage would significantly improves the outcome of these malignancies.

The epidemic of oesophageal carcinoma: Where are we now?

Since the early 1970s, the incidence of oesophageal adenocarcinoma has increased dramatically in most Western populations. In contrast, the incidence of oesophageal squamous-cell carcinoma has decreased in these same populations. Epidemiological studies conducted over the past decade have provided great insights into the etiology of oesophageal cancer. These studies have identified gastro-oesophageal reflux disease, obesity and cigarette smoking as risk factors for oesophageal adenocarcinoma, while use of nonsteroidal anti-inflammatory drugs and infection with Helicobacter pylori are associated with reduced risk of oesophageal adenocarcinoma. For oesophageal squamous-cell carcinoma, alcohol and cigarette smoking are the two major risk factors underlying most cases. This review combines a synthesis of these studies with an analysis of data from the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program to discuss the change in incidence of oesophageal cancer and summarize current knowledge of risk factors.

Dietary and demographical risk factors for oesophageal squamous cell carcinoma in the Eastern Anatolian region of Turkey where upper gastrointestinal cancers are endemic

BACKGROUND

Oesophageal squamous cell carcinoma (ESCC) is endemic in the Eastern Anatolian region of Turkey. The present study was performed to identify risk factors for ESCC that specifically reflect the demography and nutritional habits of individuals living in this region.

MATERIALS AND METHODS

The following parameters were compared in 208 ESCC patients and 200 control individuals in the Eastern Anatolian region: age, sex, place of living, socioeconomic level, education level, smoking, alcohol intake, nutritional habits, and food preservation methods.

RESULTS

The mean age of ESCC patients was 56.2 years, and 87 (41.8%) were 65 years-old or older. The ratio of women to men in the patient group was 1.39/1. ESCC patients consumed significantly less fruit and yellow or green vegetables and more hot black tea, 'boiled yellow butter', and mouldy cheese than did control individuals. Residence in rural areas, smoking, and cooking food by burning animal manure were also significantly associated with ESCC.

CONCLUSIONS

The consumption of boiled yellow butter and mouldy cheese, which are specific to the Eastern Anatolian region, and the use of animal manure for food preparation were identified as risk factors in this region. Further studies are required to potentially identify the carcinogenic substances that promote the development of ESCC in this region.

Worldwide Inverse Association between Gastric Cancer and Esophageal Adenocarcinoma Suggesting a Common Environmental Factor Exerting Opposing Effects

OBJECTIVES

The incidence of esophageal adenocarcinoma (EAC) is increasing while adenocarcinoma of the stomach is decreasing. We have investigated whether the incidences of these two cancers and their time trends might be inversely related pointing to a common environmental factor exerting opposite effects on these cancers.

METHODS

For cross-sectional analyses data were abstracted from "Cancer Incidence in Five Continents" (CI5) Volume X and GLOBOCAN 2012. Relevant ICD-10 codes were used to locate esophageal and gastric cancers anatomically, and ICD-O codes for the histological diagnosis of EAC. For longitudinal analyses, age standardized rates (ASRs) of EAC and total gastric cancer (TGC) were extracted from CI5C-Plus.

RESULTS

Estimated (2012) ASRs were available for 51 countries and these showed significant negative correlations between EAC and both TGC (males: correlation coefficient (CC)=-0.38, P=0.006, females: CC=-0.41, P=0.003) and non-cardia gastric cancer rates (males: CC=-0.41, P=0.003 and females: CC=-0.43, P=0.005). Annual incidence trends were analyzed for 38 populations through 1989-2007 and showed significant decreases for TGC in 89% and increases for EAC in 66% of these, with no population showing a fall in the latter. Significant negative correlation between the incidence trends of the two cancers was observed in 27 of the 38 populations over the 19-50 years of available paired data. Super-imposition of the longitudinal and cross-sectional data indicated that populations with a current high incidence of EAC and low incidence of gastric cancer had previously resembled countries with a high incidence of gastric cancer and low incidence of EAC.

CONCLUSIONS

The negative association between gastric cancer and EAC in both current incidences and time trends is consistent with a common environmental factor predisposing to one and protecting from the other.

Length of Barrett's oesophagus and cancer risk: implications from a large sample of patients with early oesophageal adenocarcinoma

OBJECTIVE

Although it is well understood that the risk of oesophageal adenocarcinoma increases with Barrett length, transition risks for cancer associated with different Barrett lengths are unknown. We aimed to estimate annual cancer transition rates for patients with long-segment (≥3 cm), short-segment (≥1 to <3 cm) and ultra-short-segment (<1 cm) Barrett's oesophagus.

DESIGN

We used three data sources to estimate the annual cancer transition rates for each Barrett length category: (1) the distribution of long, short and ultra-short Barrett's oesophagus among a large German cohort with newly diagnosed T1 oesophageal adenocarcinoma; (2) population-based German incidence of oesophageal adenocarcinoma; and (3) published estimates of the population prevalence of Barrett's oesophagus for each Barrett length category.

RESULTS

Among 1017 patients with newly diagnosed T1 oesophageal adenocarcinoma, 573 (56%) had long-segment, 240 (24%) short-segment and 204 (20%) ultra-short-segment Barrett's oesophagus. The base-case estimates for the prevalence of Barrett's oesophagus among the general population were 1.5%, 5% and 14%, respectively. The annual cancer transition rates for patients with long, short and ultra-short Barrett's oesophagus were 0.22%, 0.03% and 0.01%, respectively. To detect one cancer, 450 patients with long-segment Barrett's oesophagus would need to undergo annual surveillance endoscopy; in short segment and ultra-short segment, the corresponding numbers of patients would be 3440 and 12,364. Similar results were obtained when applying US incidence data.

CONCLUSIONS

The large number of patients, who need to undergo endoscopic surveillance to detect one cancer, raises questions about the value of surveillance endoscopy in patients with short segment or ultra-short segment of Barrett's oesophagus.

Obesity and the Incidence of Upper Gastrointestinal Cancers: An Ecological Approach to Examine Differences across Age and Sex

BACKGROUND

Esophageal and gastric cancers differ in their epidemiology but have several risk factors in common. The aim of this study was to assess age and sex differences in the burden of esophageal and gastric cancers in the context of the global obesity epidemic.

METHODS

Data from 50 countries were obtained from Cancer Incidence in Five Continents Volume X and GLOBOCAN 2012. Age-specific and age-standardized incidence rates of esophageal adenocarcinoma and squamous cell carcinoma (ESCC), as well as cardia (CGC) and noncardia (NCGC) gastric cancer, were estimated. Countries were grouped and analyzed according to their obesity prevalence.

RESULTS

A gradient across quartiles of obesity prevalence was found for esophageal adenocarcinoma, with the highest incidence rates in high prevalence countries (ASR 3.0 vs. 0.8 per 100,000 in highest vs. lowest obesity quartiles, males). In contrast, for ESCC as well as for CGC and NCGC the reverse was true, with the highest rates observed in countries with the lowest obesity prevalence (ESCC, 2.2 vs. 11.5; CGC, 2.8 vs. 7.8; NCGC, 3.9 vs. 17.4 in highest vs. lowest obesity quartiles, males). Although for esophageal adenocarcinoma, sex and age differences in incidence were most pronounced in countries with a high prevalence of obesity, these differences were much smaller for the other cancer sites assessed.

CONCLUSIONS

Variation in obesity prevalence may partly explain age and sex differences in the incidence of esophageal adenocarcinomas.

IMPACT

Ecologic studies can help assess relationships between risk factors and cancer, and generate new hypotheses that may be pursued through more directed research.

The impact of lifestyle on Barrett's Esophagus: A precursor to esophageal adenocarcinoma

BACKGROUND

Barrett's Esophagus (BE), particularly long-segment Barrett's Esophagus, and the age of onset of Barrett's Esophagus are risk factors for esophageal adenocarcinoma. However, it is unknown if lifestyle factors such as alcohol abuse, tobacco use, weight gains that increase the risk of developing BE and esophageal adenocarcinoma affect its length or age at diagnosis.

METHODS

In a retrospective, cross-sectional analysis, we analyzed 158 newly diagnosed adult BE patients at a 600-bed tertiary care center in the United States from 1999 to 2008. We constructed generalized linear models for the outcomes of BE length and age at diagnosis. Predictors of interest included current or prior alcohol abuse, tobacco use, weight gain over the last 5 years, and body mass index (BMI).

RESULTS

71 (45%) had length ≥ 3 cm. Barrett's Esophagus length was positively correlated with hiatal hernia length (r=0.67, p<0.001) and heartburn duration (r=0.36, p<0.001). Multivariate results showed no significant relationship between alcohol abuse, tobacco use, weight gain or BMI and BE length. Patients with weight gain, current tobacco use, and male gender were diagnosed at a significantly younger age than their peers (for example, the adjusted mean age at diagnosis for current tobacco users vs. non-smokers was 49.2 years vs. 54.7 years, p=0.029).

CONCLUSIONS

Lifestyle factors did not appear to affect Barrett's Esophagus length but weight gains, smoking, and male gender were associated with a diagnosis at a significantly younger age.

Methylated B3GAT2 and ZNF793 Are Potential Detection Biomarkers for Barrett's Esophagus

BACKGROUND

Barrett's esophagus (BE) is a preneoplastic condition in which normal esophageal squamous epithelium (SQ) is replaced by specialized intestinal metaplasia. It is the presumed precursor for esophageal adenocarcinoma (EAC) as well as the strongest risk factor for this cancer. Unfortunately, many patients with BE go undiagnosed under the current BE screening guidelines. The development of noninvasive and accurate BE detection assays could potentially identify many of these undiagnosed BE patients.

METHODS

DNA methylation is a common epigenetic alteration in BE. Therefore, we conducted a genome-wide methylation screen to identify potential BE biomarkers. Samples from SQ (N = 12), stomach (N = 28), and BE (N = 29) were analyzed and methylation levels at over 485,000 CpG sites were compared. Pyrosequencing assays were used to validate the results and MethyLight assays were developed to detect the methylated alleles in endoscopic brushings.

RESULTS

We discovered two genes, B3GAT2 and ZNF793, that are aberrantly methylated in BE. Clinical validation studies confirmed B3GAT2 and ZNF793 methylation levels were significantly higher in BE samples (median = 32.5% and 33.1%, respectively) than in control tissues (median = 2.29% and 2.52%, respectively; P < 0.0001 for both genes). Furthermore, gene-specific MethyLight assays could accurately detect BE (P < 0.0001 for both) in endoscopic brushing samples.

CONCLUSION

B3GAT2 and ZNF793 are hypermethylated in BE, and the methylation status of these genes can be used to detect BE in tissue samples.

IMPACT

These findings support the development of methylated B3GAT2 and ZNF793 as biomarkers for noninvasive assays for the detection of BE.

Genetic Insights in Barrett's Esophagus and Esophageal Adenocarcinoma

Beginning in the 1980s, an alarming rise in the incidence of esophageal adenocarcinoma (EA) led to screening of patients with reflux to detect Barrett's esophagus (BE) and surveillance of BE to detect early EA. This strategy, based on linear progression disease models, resulted in selective detection of BE that does not progress to EA over a lifetime (overdiagnosis) and missed BE that rapidly progresses to EA (underdiagnosis). Here we review the historical thought processes that resulted in this undesired outcome and the transformation in our understanding of genetic and evolutionary principles governing neoplastic progression that has come from application of modern genomic technologies to cancers and their precursors. This new synthesis provides improved strategies for prevention and early detection of EA by addressing the environmental and mutational processes that can determine "windows of opportunity" in time to detect rapidly progressing BE and distinguish it from slowly or nonprogressing BE.

Role of Obesity in the Pathogenesis and Progression of Barrett's Esophagus

Central obesity is involved in the pathogenesis and progression of Barrett's esophagus to esophageal adenocarcinoma. Involved are likely both mechanical and nonmechanical effects. Mechanical effects of increased abdominal fat cause disruption of the gastroesophageal reflux barrier leading to increased reflux events. Nonmechanical effects may be mediated by inflammation, via classically activated macrophages, pro-inflammatory cytokines, and adipokines such as Leptin, all of which likely potentiate reflux-mediated inflammation. Insulin resistance, associated with central obesity, is also associated with both Barrett's pathogenesis and progression to adenocarcinoma. Molecular pathways activated in obesity, inflammation and insulin resistance overlap with those involved in Barrett's pathogenesis and progression.

Smoking as an independent determinant of Barrett's esophagus and, to a lesser degree, of reflux esophagitis

PURPOSE

To evaluate the role of smoking in Barrett's esophagus (BE) and erosive esophagitis (E) compared to endoscopic controls with no BE or E. Smoking is considered a cause of both BE and E, but results on this topic are quite controversial.

METHODS

Patients with BE (339), E (462) and controls (619: 280 with GERD (gastroesophageal reflux disease)-negative and 339 with GERD-positive anamnesis) were recruited in 12 Italian endoscopy units. Data were obtained from structured questionnaires.

RESULTS

Among former smokers, a remarkable upward linear trend was found in BE for all smoking-related predictors. In particular, having smoked for more than 32 years increased the risk more than two times (OR 2.44, 95 % CL 1.33-4.45). When the analysis was performed in the subgroup of subjects with GERD-negative anamnesis, the risk of late quitters (<9 years) passed from OR 2.11 (95 % CL 1.19-3.72) to OR 4.42 (95 % CL 1.52-12.8). A noticeably positive dose-response relationship with duration was seen also among current smokers. As regards E, no straightforward evidence of association was detected, but for an increased risk of late quitters (OR 1.84, 95 % CL 1.14-2.98) in former smokers and for early age at starting (OR 3.63, 95 % CL 1.19-11.1) in GERD-negative current smokers.

CONCLUSIONS

Smoking seems to be an independent determinant of BE and, to a lesser degree, of E. The elevation in risk is independent from GERD and is already present in light cigarette smokers. Smoking cessation may reduce, but not remove this risk.

Global incidence of oesophageal cancer by histological subtype in 2012

OBJECTIVE

The two major histological types of oesophageal cancer--adenocarcinoma (AC) and squamous cell carcinoma (SCC)--are known to differ greatly in terms of risk factors and epidemiology. To date, global incidence estimates for individual subtypes are still lacking. This study for the first time quantified the global burden of oesophageal cancer by histological subtype.

DESIGN

Where available, data from Cancer Incidence in Five Continents Vol. X (CI5X) were used to compute, age-specific, sex-specific and country-specific proportions of AC and SCC. Nine regional averages were computed for countries without CI5X data. The proportions were then applied to all oesophageal cancer cases from GLOBOCAN 2012 and age-standardised incidence rates calculated for both histological types.

RESULTS

Worldwide, an estimated 398,000 SCCs and 52,000 ACs of the oesophagus occurred in 2012, translating to incidence rates of 5.2 and 0.7 per 100,000, respectively. Although SCCs were most common in South-Eastern and Central Asia (79% of the total global SCC cases), the highest burden of AC was found in Northern and Western Europe, Northern America and Oceania (46% of the total global AC cases). Men had substantially higher incidence than women, especially in the case of AC (male to female ratio AC: 4.4; SCC: 2.7).

CONCLUSIONS

These first global estimates of oesophageal cancer incidence by histology suggested a high concentration of AC in high-income countries with men being at much greater risk. This quantification of incidence will aid health policy makers to plan appropriate cancer control measures in the future.

The role of HGF/MET and FGF/FGFR in fibroblast-derived growth stimulation and lapatinib-resistance of esophageal squamous cell carcinoma

BACKGROUND

Although advanced esophageal squamous-cell carcinoma (ESCC) is treated using a multidisciplinary approach, outcomes remain unsatisfactory. The microenvironment of cancer cells has recently been shown to strongly influence the biologic properties of malignancies. We explored the effect of supernatant from esophageal fibroblasts on the cell growth and chemo-resistance of ESCC cell lines.

METHODS

We used 22 ESCC cell lines, isolated primary human esophageal fibroblasts and immortalized fibroblasts. We first examined cell proliferation induced by fibroblast supernatant. The effect of supernatant was evaluated to determine whether paracrine signaling induced by fibroblasts can influence the proliferation of cancer cells. Next, we examined the effects of adding growth factors HGF, FGF1, FGF7, and FGF10, to the culture medium of cancer cells. These growth factors are assumed to be present in the culture supernatants of fibroblasts and may exert a paracrine effect on the proliferation of cancer cells. We also examined the intrinsic role of HGF/MET and FGFs/FGFR in ESCC proliferation. In addition, we examined the inhibitory effect of lapatinib on ESCC cell lines and studied whether the fibroblast supernatants affect the inhibitory effect of lapatinib on ESCC cell proliferation. Finally, we tested whether the FGFR inhibitor PD-173074 could eliminate the rescue effect against lapatinib that was induced by fibroblast supernatants.

RESULTS

The addition of fibroblast supernatant induces cell proliferation in the majority of cell lines tested. The results of experiments to evaluate the effects of adding growth factors and kinase inhibitors suggests that the stimulating effect of fibroblasts was attributable in part to HGF/MET or FGF/FGFR. The results also indicate diversity in the degree of dependence on HGF/MET and FGF/FGFR among the cell lines. Though lapanitib at 1 μM inhibits cell proliferation by more than 50% in the majority of the ESCC cell lines, fibroblast supernatant can rescue the growth inhibition of ESCC cells. However, the rescue effect is abrogated by co-treatment with FGFR inhibitor.

CONCLUSION

These results demonstrate that cell growth of ESCC depends on diverse receptor tyrosine kinase signaling, in both cell-autonomous and cell-non-autonomous manners. The combined inhibition of these signals may hold promise for the treatment of ESCC.

Childhood body mass index in relation to future risk of oesophageal adenocarcinoma

Background:

Middle-aged obese adults are at substantially elevated risk of oesophageal adenocarcinoma. It is unclear whether this risk originates earlier in life.

Methods:

We assessed associations between childhood body mass index (BMI) and height—measured annually between ages 7 and 13—with adult oesophageal adenocarcinoma in a cohort from the Copenhagen School Health Records Register. Analyses included 255 053 children born during 1930–1971. Danish Cancer Registry linkage provided outcomes. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression.

Results:

During 5.4 million person-years of follow-up, 254 (216 males) incident oesophageal adenocarcinomas occurred. At each examined age, cancer risk increased linearly per unit BMI z-score, although associations were only statistically significant for ages 9–13. The HR for the age of 13 years was 1.31 (95% CI: 1.13, 1.51) per unit BMI z-score. Associations were similar in men and women and across birth cohorts. Childhood height was not related to cancer risk in men but was in women, although these analyses included just 38 female cases. HRs per unit height z-score at the age of 13 years were 1.04 (0.90, 1.19) in males and 1.77 (1.27, 2.47) in females, with similar results observed at the other examined ages.

Conclusion:

Individuals with higher childhood BMI were at elevated risk of oesophageal adenocarcinoma, even though these cancers occurred many decades later in life. Although the mechanisms require further investigation, our findings provide additional evidence for the long-term health risks of childhood obesity.

Risk factors for Barrett's esophagus

PURPOSE OF REVIEW

To summarize the emerging data on the risk factors for Barrett's esophagus and risk stratification tools.

RECENT FINDINGS

Obesity, particularly abdominal obesity, is associated with Barrett's esophagus, likely because of both mechanical effects promoting gastroesophageal reflux and nonmechanical effects. Circulating peptides related to obesity alter the risk of Barrett's esophagus and may work synergistically with gastroesophageal reflux. Tobacco use is an underappreciated risk for Barrett's esophagus. A number of genetic variants have been associated with Barrett's esophagus, involving pathways in esophageal development. Risk stratification tools are becoming available that have modest discriminatory capability and good calibration.

SUMMARY

The developing understanding of risk factors for Barrett's esophagus is shifting the clinical guidelines to a nuanced approach incorporating multiple risk factors to select patients for screening for Barrett's esophagus.