Oesophageal and gastric cancer in Scotland 1960-90

A pooled analysis of dietary sugar/carbohydrate intake and esophageal and gastric cardia adenocarcinoma incidence and survival in the USA

Background

During the past 40 years, esophageal/gastric cardia adenocarcinoma (EA/GCA) incidence increased in Westernized countries, but survival remained low. A parallel increase in sugar intake, which may facilitate carcinogenesis by promoting hyperglycaemia, led us to examine sugar/carbohydrate intake in association with EA/GCA incidence and survival.

Methods

We pooled 500 EA cases, 529 GCA cases and 2027 controls from two US population-based case-control studies with cases followed for vital status. Dietary intake, assessed by study-specific food frequency questionnaires, was harmonized and pooled to estimate 12 measures of sugar/carbohydrate intake. Multivariable-adjusted odds ratios (ORs) and hazard ratios [95% confidence intervals (CIs)] were calculated using multinomial logistic regression and Cox proportional hazards regression, respectively.

Results

EA incidence was increased by 51-58% in association with sucrose (ORQ5vs.Q1 = 1.51, 95% CI = 1.01-2.27), sweetened desserts/beverages (ORQ5vs.Q1 = 1.55, 95% CI = 1.06-2.27) and the dietary glycaemic index (ORQ5vs.Q1 = 1.58, 95% CI = 1.13-2.21). Body mass index (BMI) and gastro-esophageal reflux disease (GERD) modified these associations (Pmultiplicative-interaction ≤ 0.05). For associations with sucrose and sweetened desserts/beverages, respectively, the OR was elevated for BMI < 25 (ORQ4-5vs.Q1-3 = 1.79, 95% CI = 1.26-2.56 and ORQ4-5vs.Q1-3 = 1.45, 95% CI = 1.03-2.06), but not BMI ≥ 25 (ORQ4-5vs.Q1-3 = 1.05, 95% CI = 0.76-1.44 and ORQ4-5vs.Q1-3 = 0.85, 95% CI = 0.62-1.16). The EA-glycaemic index association was elevated for BMI ≥ 25 (ORQ4-5vs.Q1-3 = 1.38, 95% CI = 1.03-1.85), but not BMI < 25 (ORQ4-5vs.Q1-3 = 0.88, 95% CI = 0.62-1.24). The sucrose-EA association OR for GERD < weekly was 1.58 (95% CI = 1.16-2.14), but for GERD ≥ weekly was 1.01 (95% CI = 0.70-1.47). Sugar/carbohydrate measures were not associated with GCA incidence or EA/GCA survival.

Conclusions

If confirmed, limiting intake of sucrose (e.g. table sugar), sweetened desserts/beverages, and foods that contribute to a high glycaemic index, may be plausible EA risk reduction strategies.

Effects of neutropenia and histological responses in esophageal squamous cell carcinoma with neo-adjuvant chemotherapy

BACKGROUND

Neo-adjuvant chemotherapy (NAC) followed by radical esophagectomy has been shown to prolong survival in patients with locally advanced esophageal squamous cell carcinoma (ESCC). However, neutropenia, one of the major adverse events due to NAC, influences the therapeutic course. The aim of this study is to clarify the relationship between neutropenia and therapeutic response in ESCC with NAC.

METHODS

A total of 117 patients with clinical stage II/III ESCC who had undergone NAC followed by radical esophagectomy were retrospectively analyzed in terms of the relationship between neutropenia and clinicopathological features or outcomes.

RESULTS

Neutropenia was the major adverse event observed in 56 % (66/117) and grade 3/4 neutropenia occurred in 29 % of patients. Grade 3/4 neutropenia correlated with a high histological response (Grade 1b-3) (p < 0.01). Correlative analysis identified grade 3/4 neutropenia and poor differentiation as independent predictors of a high histological response (odds ratio 5.13 and 3.25, p < 0.01 and p = 0.01, respectively). Survival analysis showed that patients with a high histological response had significantly longer survival than those with a low histological response (Grade 0-1a) (p = 0.03), whereas no significant differences were found for survival according to the grade of neutropenia (p = 0.45). In a subgroup analysis according to histological response, grade 3/4 neutropenia correlated with worse survival in patients with a low histological response (p = 0.05).

CONCLUSION

Severe neutropenia due to NAC correlates with a high histological response in ESCC. However, severe neutropenia may also result in a worse prognosis for patients with a low histological response.

Estrogen, male dominance and esophageal adenocarcinoma: is there a link?

Esophageal adenocarcinoma is a cancer with poor prognosis, and its incidence has risen sharply over recent decades. Obesity is a major risk factor for developing this cancer and there is a clear male gender bias in the incidence that cannot be fully explained by known risk factors. It is possible that a difference in the expression of estrogen, or its signaling axes, may contribute to this gender bias. We undertook a comprehensive literature search and analyzed the available data regarding estrogen and estrogen receptor expression, and the possible sex-specific links with esophageal adenocarcinoma development. Potentially relevant associations between visceral vs subcutaneous fat deposition and estrogen expression, and the effect of crosstalk between estrogen and leptin signaling were identified. We also found limited studies suggesting a role for estrogen receptor β expression in esophageal adenocarcinoma development. The current literature supports speculation on an etiological role for estrogen in the male gender bias in esophageal adenocarcinoma, but further studies are required.

Polymorphism in epidermal growth factor receptor intron 1 predicts prognosis of patients with esophageal cancer after chemoradiation and surgery

BACKGROUND

The EGFR gene has been demonstrated to be an important factor influencing treatment response for various cancers, and its expression has been shown to be modified by the polymorphic CA repeat length at the 5'-regulatory sequence in intron 1. We investigated whether this EGFR polymorphism is associated with prognosis in patients with esophageal cancer after concurrent chemoradiotherapy (CCRT) and esophagectomy.

METHODS

A cohort of 148 patients with esophageal cancer received cisplatin-based CCRT (concurrently combined with 40 Gy irradiation) and subsequent esophagectomy. Their EGFR genotypes were determined by polymerase chain reaction from leukocyte DNA, which was obtained before treatment and was correlated with patient survival.

RESULTS

Patients with the homozygous short allele (<20 CA) of the EGFR gene in intron 1 were more likely to have a shorter duration of survival after CCRT and surgery than those with the homozygous long allele [adjusted hazard ratio (HR) (95% confidence interval [CI]) of death: 1.88 (1.02-3.49); P = 0.045]. This unfavorable prognostic effect of EGFR homozygous short CA repeat was mainly manifested in patients with good response to CCRT [adjusted HR (95% CI) of death 3.40 (1.06-10.89); P = 0.039]; it was less evident in those with poor response to CCRT [adjusted HR (95% CI) 1.40 (0.65-3.02); P = 0.384].

CONCLUSIONS

The EGFR CA repeat genetic polymorphism may act as a valuable molecular predictor of clinical outcome of esophageal cancer after CCRT and esophagectomy, especially in those with good response to CCRT.

Adenocarcinoma of the esophagogastric junction: incidence, characteristics, and treatment strategies

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is dramatically increasing in Western countries, while it is not increasing in Eastern countries. Siewert type I tumors are observed less frequently in Eastern countries in comparison to Western countries. On the other hand, other clinicopathological features of AEG, including age, male-to-female ratio, pathological grade, tumor progression, and prognosis, are similar in Western and Eastern countries. Two surgical phase III trials have indicated that AEG type I should be treated surgically as esophageal cancer, while types II and III should be regarded as true gastric cancer. No phase III trials have demonstrated a significant interaction comparing hazard ratios for death between AEG and true gastric cancer in the subset analyses with regard to chemotherapy.

The mystery of male dominance in oesophageal cancer and the potential protective role of oestrogen

Oesophageal cancer is the sixth most common form of cancer death globally with almost 400,000 deaths annually. More than 90% of all cases are either adenocarcinomas (OAC) or squamous-cell carcinomas (OSCC). There is a strong male predominance with up to 8 and 3 men for every woman affected with OAC and OSCC, respectively. It has been hypothesised that sex hormonal factors may play a role in the development of oesophageal cancer or more specifically that oestrogen prevents such development. This article reviews the available literature on this topic. Basic science studies suggest an inhibitory effect of oestrogen in the growth of oesophageal cancer cells, and a possible mechanism of any oestrogen protection might be mediated through oestrogen receptors. But from the few epidemiological studies in which the hypothesis of oestrogen protection has been tested, no firm conclusions can yet be drawn of the role of oestrogen in human oesophageal cancer aetiology. More evidence from valid and large human studies is needed before any conclusions can be drawn.

Treatment modality and risk of development of dysplasia and adenocarcinoma in columnar-lined esophagus

Columnar metaplasia is the precursor lesion for esophageal adenocarcinoma, resulting from prolonged gastroesophageal reflux. The influence of the efficacy of reflux control on the development of neoplastic change in columnar-lined esophagus is not established. This study compares the rate of development of dysplasia and adenocarcinoma in patients with columnar metaplasia of the esophagus between patients treated pharmacologically and those treated with antireflux surgery. This study is a retrospective review of a cohort of patients enrolled in a multicenter national registry involving 738 patients from seven UK centers. Forty-one were treated with antireflux surgery, 42 with H2 receptor antagonist, 532 with proton pump inhibitor, and 114 with a combination of these medications. Nine had none of these medications or surgery. Total follow-up was 3697 years. Mean age and follow-up for patients treated medically were 61.6 and 4.96 years and surgically were 50.5 and 6.19 years, respectively. No patient in the surgical group developed high-grade dysplasia (HGD) or adenocarcinoma. Twenty patients treated medically developed adenocarcinoma and 10 developed HGD. Hazards ratio comparing pharmacological to surgical therapy for development of all grades of dysplasia and adenocarcinoma 1.77 (P = 0.272). Log rank test comparing antireflux surgery to pharmacological therapy for development of HGD or adenocarcinoma P = 0.1287 and for adenocarcinoma P = 0.2125. Although there was a trend towards greater efficacy of antireflux surgery over pharmacological therapy in reducing the development of dysplasia and adenocarcinoma, this did not reach statistical significance.

Trends in incidence of esophageal and gastric cardia cancer in high-risk areas in China

Incidence rates have risen for gastric cardia adenocarcinoma, whereas rates have remained stable for esophageal squamous cell carcinoma in many western countries. The aim of this study was to describe and analyze trends in incidence rates for esophageal cancer and gastric cardia cancer in Cixian county, which is one of the high-risk areas for esophageal cancer in China as well as in the world. The data were obtained from the Cixian Cancer Registry, which is a population-based registry. All the data were checked and analyzed using SPSS 11.5. Between the years 1988 and 2003 there were 11,183 cases of esophageal cancer in the county. The age-standardized incidence rate was 168.55 per 100,000. In 1988, the age-standardized incidence rate for male patients was 250.76/100,000; it declined to 160.05/100,000 in 2003, representing a decrease of 36.2%. The age-standardized incidence rate for female patients was 153.86/100,000 in 1988; it declined to 82.55/100,000 in 2003, showing a decrease of 46.3%. A slight decreasing trend was observed during the period, with a yearly decrease of 3.61% in male patients and 3.39% in female patients. For gastric cardia cancer, there were 1654 cases from 1988 to 2003. The age-standardized incidence rate was 25.58 per 100,000. The age-standardized incidence rate for male patients was 13.75/100,000 in 1988; it increased to 28.55/100,000 in 2003, with a yearly increase of 7.65%. The age-standardized incidence rate for female patients was 7.12/100,000 in 1988; it increased to 12.91/100,000, with a yearly increase of 5.44%. A statistically significant increasing trend of gastric cardia cancer was observed during the study period. Cixian county is a geographical region with a very high incidence of esophageal cancer and cardia cancer. The trend in the incidence rates of esophageal cancer had decreased slightly; on the other hand, gastric cardia cancer showed a significantly increased trend in the last 16 years. Detailed epidemiological analyses of demographic trends and risk factors will help to guide future cancer control strategies.

Barrett's columnar-lined oesophagus: demographic and lifestyle associations and adenocarcinoma risk

OBJECTIVES

Lifestyle and demographic risk factors for the development of oesophageal adenocarcinoma developing from columnar-lined oesophagus are not well defined.

METHODS

Demographic and lifestyle factors, endoscopy and histology reports were extracted from 1,761 subjects from seven UK centres. The associations of columnar-lined oesophagus with demographic and lifestyle factors and the development of adenocarcinoma were examined.

RESULTS

5.5% of patients had prevalent adenocarcinoma (more common in males, older patients, patients diagnosed earlier in the cohort and current or recent smokers). Adenocarcinoma incidence was 23 patients in 3,912 years or 0.59% per annum. Only increased age at diagnosis correlated with an increased risk of incident adenocarcinoma. There was no association with obesity or alcohol history.

CONCLUSIONS

Oesophageal adenocarcinoma occurs more commonly in older patients and is more frequent in males than females. Once columnar-lined oesophagus had been diagnosed, there were no other demographic or lifestyle factors which were predictive of the development of incident adenocarcinoma in this cohort.

Fat transforms ascorbic acid from inhibiting to promoting acid-catalysed N-nitrosation

BACKGROUND

The major potential site of acid nitrosation is the proximal stomach, an anatomical site prone to a rising incidence of metaplasia and adenocarcinoma. Nitrite, a pre-carcinogen present in saliva, can be converted to nitrosating species and N-nitroso compounds by acidification at low gastric pH in the presence of thiocyanate.

AIMS

To assess the effect of lipid and ascorbic acid on the nitrosative chemistry under conditions simulating the human proximal stomach.

METHODS

The nitrosative chemistry was modelled in vitro by measuring the nitrosation of four secondary amines under conditions simulating the proximal stomach. The N-nitrosamines formed were measured by gas chromatography-ion-trap tandem mass spectrometry, while nitric oxide and oxygen levels were measured amperometrically.

RESULTS

In absence of lipid, nitrosative stress was inhibited by ascorbic acid through conversion of nitrosating species to nitric oxide. Addition of ascorbic acid reduced the amount of N-nitrosodimethylamine formed by fivefold, N-nitrosomorpholine by >1000-fold, and totally prevented the formation of N-nitrosodiethylamine and N-nitrosopiperidine. In contrast, when 10% lipid was present, ascorbic acid increased the amount of N-nitrosodimethylamine, N-nitrosodiethylamine and N-nitrosopiperidine formed by approximately 8-, 60- and 140-fold, respectively, compared with absence of ascorbic acid.

CONCLUSION

The presence of lipid converts ascorbic acid from inhibiting to promoting acid nitrosation. This may be explained by nitric oxide, formed by ascorbic acid in the aqueous phase, being able to regenerate nitrosating species by reacting with oxygen in the lipid phase.

Influence of socio-economic deprivation on outcomes for patients diagnosed with oesophageal cancer

OBJECTIVE

To determine the influence of deprivation on outcomes for patients with oesophageal cancer.

MATERIAL AND METHODS

A total of 1196 consecutive patients with oesophageal carcinoma presenting to a regional multidisciplinary team between 1 January 1998 and 31 August 2005 were studied prospectively and deprivation scores calculated using the Indices of Multiple Deprivation (IMD) of the National Assembly for Wales. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median age 67 years versus 70 years, p = 0.01) and were more likely to have squamous cell carcinomas (SCCs) (p = 0.002) in comparison with patients from the least deprived areas (quintile 1). Stage of disease and morbidity did not correlate with deprivation quintile, but operative mortality was greater in quintile 1 versus 5 (1.9% versus 5.8%, p = 0.281). Overall 5-year survival for those patients undergoing oesophagectomy was unrelated to deprivation quintile (1 versus 5, 24% versus 33%, p = 0.8246), but was lower following definitive chemoradiotherapy (dCRT) for the least deprived quintiles (1, 2 & 3 versus 4 & 5, 35% versus 16%, p = 0.0272).

CONCLUSIONS

Although deprivation was associated with younger age, SCC and a trend towards higher operative mortality, survival after diagnosis and oesophagectomy were unrelated to deprivation.

Increasing incidence of adenocarcinoma of the gastroesophageal junction and distal stomach in Canada -- an epidemiological study from 1964-2002

BACKGROUND

The increasing incidence of esophageal and proximal gastric (cardia) adenocarcinoma and the decreasing incidence of distal gastric (antropyloric) adenocarcinoma has been documented in several populations. The aim of the present study was to examine incidence trends of these neoplasms in Ontario, Canada's most populous province, over a 39-year period.

METHODS

Analyses were based on data obtained from the Ontario Cancer Registry of Cancer Care Ontario. Number of cases and rates per 100,000 age-adjusted to the 1996 Canadian standard, were obtained for all esophageal and gastric carcinoma cases reported between 1964 and 2002. Rates were grouped into five-year periods to analyze trends over the 39-year period. Point and 95% CI estimates of average annual percentage change in incidence rates were calculated with a log-linear regression model.

RESULTS

The incidence of adenocarcinoma of the distal esophagus increased in men and women (average annual increase of 9.5% in men; 4.3% in women). The incidence of adenocarcinoma of the cardia increased in men and women (average annual increase of 7.3% in men; 5.8% in women). The incidence of antropyloric adenocarcinoma increased in men and women (average annual increase of 4.4% in men; 5.3% in women). The incidence of esophageal squamous cell carcinoma remained stable.

CONCLUSIONS

There has been a significant increase in the incidence of adenocarcinoma around the gastroesophageal junction in men over the 39-year study period. The increase in incidence of distal gastric adenocarcinoma is unexpected and may relate to a reclassification phenomenon, immigration trends in Ontario and a rising incidence of diffuse/signet ring cell adenocarcinoma.

Trend in incidence of gastric adenocarcinoma by tumor location from 1969-2004: a study in one referral center in Iran

AIM

In recent years several studies have shown increasing rate of upper gastric cancers regarding to decrease in distal gastric cancers. The aim of this study was to describe the trend of gastric cancers by location in Iran, which is one of the countries with high prevalence of gastric cancers.

METHODS

All registered cases of gastrectomy in Tehran Cancer Institute from 1969 through 2004 were re-evaluated clinicopathologically. The stomach was anatomically divided into the upper, middle, and lower third. The prevalence of gastric cancers in 5 year periods estimated by location and the changes trough the time was evaluated independently and in aspect of age and sex.

RESULTS

Over 36 years, the prevalence of cancers in the upper and middle third of the stomach have increased and that of the lower third has decreased. These changes were seen in both sexes and age groups under and over 50 and it was more significant in younger.

CONCLUSION

The results are the same as most previous reports in other countries. This can indicate different risk factors as well as confrontation with them. However in regard to few numbers of cases in this study, a population-based study is recommended for confirmation.

Association of GSTP1 polymorphism and survival for esophageal cancer

PURPOSE

Activity of glutathione S-transferase (GST) is associated with detoxification of xenobiotics and the maintenance of cell viability. Genetically variant GSTs produce different enzymatic activities. The clinical significance of this variation is still puzzling. We investigated whether genetic polymorphisms of GST including GSTP1, GSTM1, and GSTT1 affect survival among esophageal cancer patients.

EXPERIMENTAL DESIGN

From 1996 to 2002, 233 patients with pathologically proven esophageal cancer were recruited from the Department of Surgery, National Taiwan University Hospital. GST genotypes, including GSTT1, GSTM1, and GSTP1, were determined by PCR or PCR-RFLP. The influence of the genetic polymorphisms on patient survival was estimated using the method of Kaplan-Meier survival function and Cox proportional hazards models.

RESULTS

The mean survival times (months) of the GSTP1 Ile/Ile, Ile/Val, and Val/Val were 11, 10, and 7, respectively (P < 0.05). The more the patients carried GSTP1 variant Val alleles, the poorer the survival rate (adjusted hazard ratio, 1.36; 95% confidence interval, 1.01-1.84; Ptrend = 0.045). In contrast, no association of GSTT1 or GSTM1 genotypes with survival rate was noted.

CONCLUSION

The presence of the GSTP1 variant allele (Val) is associated with a poorer prognosis of esophageal cancer.

Influence of socio-economic deprivation on outcomes for patients diagnosed with gastric cancer

OBJECTIVE

Socio-economic deprivation has an influence on the outcome for patients diagnosed with breast, colorectal and bronchial cancer, but there are few data on its association with gastric cancer. The aim of this study was to determine the influence of socio-economic deprivation on outcomes for patients with gastric cancer.

MATERIAL AND METHODS

Three hundred and thirty consecutive patients with gastric adenocarcinoma presenting to a single hospital between 1 October 1995 and 30 June 2004 were studied prospectively and deprivation scores calculated using the National Assembly for Wales Indices of Multiple Deprivation. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median 70 years versus 74 years, p=0.007), and experienced longer delays in diagnosis (18 weeks versus 9 weeks, p=0.02) when compared with patients from the least deprived areas (quintile 1). Operative mortality was 3-fold higher for patients from the most deprived areas when compared with patients from less deprived areas (15% versus 5%, p=0.03). There was no correlation between stage of disease and socio-economic deprivation. For patients undergoing potentially curative surgery, the 5-year survival for patients from the most deprived areas was 32%, compared with 66% for patients from the least deprived areas (p=0.03).

CONCLUSIONS

Socio-economic deprivation was associated with younger age at diagnosis, longer diagnostic delay, greater operative mortality and a shorter duration of survival following R0 gastrectomy. These poorer outcomes were not explained by the stage of disease at diagnosis.

Significance of matrix metalloproteinase 9 and CD34 expressions in esophageal carcinoma: correlation with DNA content

BACKGROUND

Esophageal carcinoma is common in many countries, and it is characterized by poor prognosis and rapid clinical progression with a high frequency of lymph node metastasis and recurrence. The present study was carried out to evaluate the correlation between vascular endothelial cell marker (CD34), matrix metalloproteinase type 9 (MMP9), and DNA content in esophageal carcinoma.

METHODS

A total of 38 patients were classified with histopathologic examination as 8 cases with adenocarcinoma, 24 cases with squamous cell carcinoma, and the last 6 cases with undifferentiated carcinoma. The obtained results of the patient group were compared with the results of 6 cases with proven normal esophageal mucosa as a control group. The samples of patients and controls were subjected to immunohistochemical evaluation of CD34 and MMP9 expression along with DNA index determination using flow cytometry.

RESULTS

There was a significant difference between patients and normal cases in DNA index, CD34, and MMP9 pattern (P = 0.003, <0.001, and 0.002, respectively). DNA index was positively correlated with MMP9 (r = 0.574, P < 0.001) and with CD34 (r = 0.562, P < 0.001). MMP9 was correlated with CD34 (r = 0.55, P < 0.001). A significant difference was found in both microvessel density and MMP9 expression with respect to tumor grade and stage. The microvessel density in patients with highly positive staining for MMP9 was higher than in those with negative and weak staining for MMP9 (P = 0.002).

CONCLUSION

The analysis of DNA content along with detection of CD34 and MMP9 in esophageal cancer can successfully differentiate the different pathologic lesions and hence can be used powerfully in disease prognosis reflecting valuable information about the aggressiveness and activity of those lesions.

Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population based study

BACKGROUND

Complete surgical (R0) resection remains the only potentially curative intervention for patients with localised gastric cancer. To achieve a curative resection, patients may require complex operations with resection of contiguous organs. The aim of this study was to assess how the extent of surgical resection influenced morbidity, mortality and survival in an aged non-selected population with significant comorbid disease.

PATIENTS AND METHODS

Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of 1-year follow-up.

RESULTS

A total of 646 patients underwent surgical exploration for gastric cancer. A significantly higher incidence of chest infections (18.5 vs 11%, p< 0.05) and anastomotic leaks (14.3 vs 2.2%, p< 0.05) were associated with total gastrectomy (n=168) when compared to distal gastrectomy (n=272) resections. A 9.2% mortality rate and a 60% 1-year survival were associated with gastric resection alone. Removal of the spleen (n=131), pancreas (n=30) or liver resection (n=5) was associated with a significantly higher mortality rates, 18.3, 23.3 and 40%, respectively (p< 0.05), and significantly lower 1-year survival rates, 50.9, 39.1 and 20%, respectively (p< 0.05).

CONCLUSIONS

The risk of more extensive resection is not balanced by improved survival in this population based series. Extending gastric resection to involve contiguous organs should be confined to highly selected cases.

Trends in oesophago-gastric surgery in Scotland

BACKGROUND

The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes in gastro-oesophageal surgery in Scotland during this period.

METHODS

A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons.

RESULTS

There was a significant increase (p=0.001, chi2) in the number of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p<0.001, chi2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, chi2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units.

CONCLUSIONS

Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow.

Reflux, Barrett's oesophagus and adenocarcinoma: burning questions

The incidence of oesophageal adenocarcinoma is increasing rapidly in Western populations. Gastro-oesophageal reflux disease is a strong risk factor for both this tumour and the pre-cancerous lesion Barrett's oesophagus, but the underlying disease mechanisms remain unclear. Developing a better understanding of the aetiology and pathogenesis of Barrett's oesophagus, including the induction of DNA damage and genetic alterations, might provide opportunities for improved management of individuals with this disease. This could include a better rationale for screening and surveillance programmes, as well as targeted intervention strategies.

D2 lymphadenectomy in the management of gastric cancer

BACKGROUND

Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10-15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance.

AIMS

This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit.

METHODS

Sixty-two resections were performed for gastric cancer.

RESULTS

Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (D0 or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenectomy and three with a distal pancreatectomy. Post-operative complications occurred in 31% of patients. Thirty-day and 90-day mortality were zero. Median survival was 822 days in the D2 group (range 120-1,320).

CONCLUSIONS

These results show that a D2 gastrectomy can be performed with a low morbidity and mortality and a median survival of greater than two years.

The experience of dysphagia and its effect on the quality of life of patients with oesophageal cancer

This qualitative study was designed to explore the experience of dysphagia in oesophageal cancer and how this impacts on quality of life. The aim of the study was to add to the knowledge and comprehension of this poorly understood symptom. Data was collected through in-depth interview and administration of the EORTC QLQ-C30 and EORTC QLQ-OES24 quality of life tools with six people with incurable oesophageal cancer who had dysphagia. The interviews were tape-recorded and then transcribed verbatim for each participant. Through a thematic analysis of the interview data and a descriptive analysis of the questionnaires a detailed description of the experience of dysphagia and its impact on quality of life was obtained. Five basic themes emerged from the participant's accounts and these were recognizing dysphagia, the physical experience, the emotions evoked, the impact on social life and dysphagia and treatment. In conclusion dysphagia is a troublesome symptom which affects all aspects of quality of life.

Trends in oesophageal and gastric cancer incidence, mortality and survival in England and Wales 1971-1998/1999

BACKGROUND

In England and Wales, 7% of cancers diagnosed in 1997 were oesophageal or gastric cancer.

AIM

To review the epidemiology of these cancers in England and Wales using cancer registration data from 1971 to 1998 and mortality data from 1971 to 1999.

METHODS

We calculated age-specific and age-standardised incidence and mortality rates; crude and relative survival by age group; age-standardised relative survival; and relative survival by socio-economic status.

RESULTS

The age-standardised incidence of oesophageal cancer increased from 7.6 to 12.8 per 100,000 men and from 4.2 to 5.7 per 100,000 women. The incidence of gastric cancer decreased from 31.8 to 18.9 per 100,000 men and from 15.1 to 7.3 per 100,000 women. For both cancers, the 1- and 5-year age-standardised relative survival improved for men and women from 1971-1975 to 1992-1994; the 5-year age-standardised relative survival was significantly higher in women than in men diagnosed in 1992-1994; for some periods from 1971-1975 to 1986-1990, the 1-year relative survival was significantly higher in the least deprived men than in the most deprived men.

CONCLUSIONS

Survival improved for both cancers over the study period, but there were unexplained differences related to sex and deprivation.

Alteration of glutathione S-transferase levels in Barrett's metaplasia compared to normal oesophageal epithelium

OBJECTIVE

Oesophageal cancer associated with the premalignant condition Barrett's oesophagus has increased in incidence over the last few years. Phase II detoxifying enzymes, including glutathione S-transferases (GSTs) protect the mucosa from carcinogens, which can cause oxidative damage to cells. Therefore, a reduction in these anti-oxidant enzymes can increase the risk of carcinogenesis. The aim of this study was to compare the extent of GST expression in normal oesophageal tissue, Barrett's oesophagus and oesophageal adenocarcinoma.

DESIGN

Antibodies raised against GST alpha, GST mu, GST pi and microsomal GST were used to identify expression of these proteins in tissue sections.

METHOD

Paraffin-embedded sections were stained using standard immunohistochemical techniques to demonstrate the pattern of expression of GST proteins in biopsy specimens. Twelve sections of Barrett's metaplasia and an equal number of specimens from normal oesophageal tissue were examined, together with sections from adenocarcinoma and normal gastric mucosa.

RESULTS

Expression of the GST enzymes appeared to be reduced in Barrett's tissue compared to normal oesophageal tissue. Nuclear staining featured in some of the normal tissue sections, but not in Barrett's tissue.

CONCLUSION

The reduction in GST expression suggested in Barrett's tissue is an interesting finding, as it is possible that reduced expression of these detoxifying enzymes may contribute to the risk of development of adenocarcinoma in Barrett's mucosa.

Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis

BACKGROUND & AIMS

Esophageal carcinomas have high fatality rates, making chemoprevention agents desirable. We performed a systematic review with meta-analysis of observational studies evaluating the association of aspirin/nonsteroidal anti-inflammatory drug (NSAID) use and esophageal cancer.

METHODS

We evaluated the MEDLINE, BIOSIS, and Web of Science electronic databases (1980-2001); manually reviewed the literature; and consulted with experts. Studies were included if they: (1) evaluated exposure to NSAIDs, aspirin, or both; (2) evaluated esophageal cancer; and (3) reported relative risks or odds ratios or provided data for their calculation. Data were independently abstracted by 2 investigators. The primary and sensitivity analyses used both fixed and random-effects models.

RESULTS

Nine studies (2 cohort, 7 case control) containing 1813 cancer cases were identified. All primary summary estimates were homogeneous. Statistical pooling showed a protective association between any use of aspirin/NSAID and esophageal cancer (odds ratio [OR] = 0.57; 95% confidence interval [CI], 0.47-0.71). Both intermittent (OR = 0.82; CI, 0.67-0.99) and frequent medication use were protective (OR = 0.54; CI, 0.43-0.67), with greater protection with more frequent use. Stratified by medication type, aspirin use was protective (OR = 0.5; CI, 0.38-0.66), and NSAIDs had a borderline protective association (OR = 0.75; CI, 0.54-1.0). Any use was protective against both esophageal adenocarcinoma (OR = 0.67; CI, 0.51-0.87) and squamous cell carcinoma (OR = 0.58; CI, 0.43-0.78).

CONCLUSIONS

Pooled results support a protective association between aspirin and NSAIDs and esophageal cancer (of both histological types) and provide evidence for a dose effect. These findings support evaluating these agents in clinical trials of high-risk patients.

Continuing rising trend in oesophageal adenocarcinoma

Our study provides an update of the incidence of oesophageal cancer in the West Midland region of England and Wales from 1992-96. A total of 2,671 cases of oesophageal cancer were identified during the 5-year study period, with an age-standardised annual incidence (ASR) of 5.24 per 100,000 (95% CI: 5.02, 5.45). Similar numbers of adenocarcinoma and squamous cell carcinoma were found. Only 152 (5.6%) had no histology. There was a 5-fold difference in age-standardised annual incidence rates between males and females for adenocarcinoma of oesophagus, but no gender difference for squamous cell carcinoma. The parallel but higher ASR in males compared to females for adenocarcinoma of both oesophagus and cardia merits further investigation. The similarities in the patterns of age- and sex-specific rates and in the socioeconomic profiles could indicate a common aetiology for adenocarcinoma of oesophagus and gastric cardia. Quality control in Cancer Registries needs to focus on the accuracy and consistency of subsite classification to ensure that trends in incidence are identified. In the absence of accurate subsite classification of stomach cancers, the proportions of adenocarcinoma and squamous cell carcinoma of oesophagus (or the absolute rate of adenocarcinoma of oesophagus) may provide a useful tool in indicating whether adenocarcinoma of gastric cardia is likely to be increasing in incidence.

Marked regional variation in adenocarcinomas of the esophagus and the gastric cardia in the United States

BACKGROUND

Adenocarcinomas of the esophagus and the gastric cardia recently have experienced rapidly increasing incidence rates. Although these sites frequently are combined, they may have different risk factors.

METHODS

The authors compared regional incidence rates of esophageal adenocarcinoma, gastric cardia adenocarcinoma, and esophageal squamous cell carcinoma within the U.S. Surveillance, Epidemiology, and End Results (SEER) cancer registry for the years 1973-1998.

RESULTS

Regional incidence rates varied considerably. The Seattle-Puget Sound registry's recent average esophageal adenocarcinoma rates were over twice as high as those of the Utah registry (5.3 vs. 2.4 per 100,000 persons per year; P < 0.01); gastric cardia rates also differed (4.0 vs. 2.8 per 100,000 persons per year; P < 0.01). The incidence rate increase also varied markedly between regions. Since 1974, white male esophageal adenocarcinoma rates increased by 800% in Seattle compared with an increase of only 300% in Utah. In contrast, white male cardia adenocarcinoma rates increased by only 16% in Seattle (from 3.1 per 100,000 persons per year in 1974 to 3.6 per 100,000 persons per year in 1998) compared with 300% in Utah (from 0.7 to 2.2 per 100,000 persons per year). Both types of adenocarcinoma were more common in males and in the white population in all regions, but recent esophageal adenocarcinoma rates for black males in Connecticut were significantly higher than the U.S. black male average (3.1 vs. 0.8 per 100,000 persons per year; P < 0.01) and equaled the rates for the white population in some areas. Esophageal adenocarcinoma rates continued rising for white males through 1998, whereas cardia adenocarcinoma rates stabilized after 1988.

CONCLUSIONS

There are substantial regional, temporal, and ethnic differences between esophageal adenocarcinoma incidence rates and gastric cardia adenocarcinoma incidence rates within a single cancer registry system. Thus, these malignancies may differ in important ways and should not be combined routinely in research studies. Individual-level studies are needed to explain these substantial regional and ethnic differences.

Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973-1995

The purpose of our study was to examine the incidence patterns of 2 major histologic types of esophageal cancer, in selected countries world-wide and to identify components of birth cohort, period and age as determinants of observed time trends using regression modeling. The roles of temporal changes in specification of histology of tumors and of classification of cancers at the gastroesophageal junction as esophageal or gastric in origin were taken into consideration. In all, 56,426 esophageal cancer cases were included. The results indicate that the incidence rate of squamous cell carcinoma of the esophagus has been relatively stable in most of the countries analyzed, although increasing trends were observed in Denmark and the Netherlands (Eindhoven) among men and in Canada, Scotland and Switzerland among women. There was a significant increase in the incidence of esophageal adenocarcinomas in both sexes in the United States (among whites and blacks), Canada and South Australia and in 6 European countries (Scotland, Denmark, Iceland, Finland, Sweden and Norway). In France the increase was limited to men and in Switzerland the increase was observed only in women. Modeling was unable to distinguish which trends were the results of changes in risk between generations (as cohort effects), or changes in all age groups simultaneously (as a period effect).

The epidemic of esophageal adenocarcinoma

The incidence and mortality related to esophageal adenocarcinoma (EAC) have been increasing in the United States, several European countries, and Oceania for the past 2 to 3 decades. Survival remains dismal, with little improvement during the same time period. Variations in the coding, classification, and detection of gastroesophageal malignancy may have contributed partially to the observed trends. Remarkable differences related to gender, ethnicity, and geography characterize the epidemiology of EAC. Gastroesophageal reflux disease (GERD) is the main risk factor for Barrett's esophagus, which is the only known precursor lesion for EAC. Several risk factors that promote the development of GERD and/or Barrett's esophagus have been proposed to explain these rising trends; these factors include the declining rates of Helicobacter pylori infection, obesity, dietary factors, and certain drugs.

The changing spectrum of gastroesophageal reflux disease

The incidences of Barrett's oesophagus and oesophageal adenocarcinoma are rising. However there is no evidence on whether the incidence of gastroesophageal reflux disease is rising. This was a retrospective study investigating the incidence of gastroesophageal reflux disease at endoscopy from 1980 to 1995. The study took place in Tayside, Scotland. Using the Tayside endoscopy database, patients with new diagnoses of Barrett's oesophagus and endoscopic oesophagitis were identified. Cases and rates (per 1000 endoscopies) for oesophagitis, Barrett's oesophagus and combined group of oesophagitis + Barrett's oesophagus were calculated for each year. There was a significant decline in the incidence of oesophagitis. There was a significant large increase in the incidence of Barrett's oesophagus and a small but significant rise in the incidence of endoscopically identified gastroesophageal reflux disease (oesophagitis + Barrett's oesophagus). There was a significant decrease in the ratio of new cases of oesophagitis to new cases of Barrett's oesophagus. At endoscopy there has been a small increase in incidence of gastroesophageal reflux disease. There has, however, been a dramatic change in the spectrum of gastroesophageal reflux disease, with a larger proportion having Barrett's oesophagus than previously.

The pattern of recurrence of adenocarcinoma of the oesophago-gastric junction

Knowledge of the pattern of recurrence of surgically treated cases of adenocarcinoma of the oesophago-gastric junction is important both for better understanding of their biological nature and for future strategic planning of therapy. The aim of this study is to demonstrate and compare the pattern of dissemination and recurrence in patients with Type I and Type II adenocarcinoma of oesophago-gastric junction. A prospective audit of the clinico-pathological features of patients who had undergone surgery with curative intent for adenocarcinoma of oesophago-gastric junction between 1991 and 1996 was undertaken. Patients were followed up by regular clinical examination. Clinical evaluation was supported by ultrasound, computerised tomography, radio-isotope bone scan, endoscopy and laparotomy each with biopsy and histology where appropriate. One hundred and sixty-nine patients with oesophago-gastric junction tumours (94 Type I and 75 Type II) have been followed up for a median of 75.3 (57-133) months. One hundred and three patients developed proven recurrent disease. The median time to recurrence was 23.3 (14.2-32.4) months for Type I and 20.5 (11.6-29.4) for Type II cancers. The most frequent type of recurrence was haematogenous (56% of Type I recurrences and 54% of Type II) of which 56% were detected within 1 year of surgery. The most frequent sites were to liver (27%), bone (18%) brain (11%) and lung (11%). Local recurrence occurred in 33% of Type I cancer and 29% of Type II recurrences. Nodal recurrence occurred in 18 and 25% of Type I and Type II cancer recurrences, most frequently to coeliac or porta hepatis nodes (64%). Only 7% of Type I and 15% of Type II cancer recurrences were by peritoneal dissemination. Type I and Type II adenocarcinoma of the oesophago-gastric junction have a predominantly early, haematogenous pattern of recurrence. There is a need to better identify the group of patients with small metastases at the time of diagnosis who are destined to develop recurrent disease in order that they may be spared surgery and those with micro metastases in order that they can be offered multi-modality therapy including early post operative or neo-adjuvant chemotherapy.

Surveillance and survival in Barrett's adenocarcinomas: a population-based study

BACKGROUND & AIMS

Guidelines recommend periodic endoscopic surveillance of Barrett's esophagus (BE) patients to detect and treat early esophageal adenocarcinomas; however, no trials or population-based studies exist. We evaluated the association between endoscopic surveillance of BE and survival among esophageal/gastric cardia adenocarcinoma patients.

METHODS

We studied a cohort of 23 BE patients, among 589 esophageal or gastric cardia adenocarcinoma patients diagnosed between 1990-1998 at Northern California Kaiser Permanente (a large health maintenance organization). We measured the presence of BE, detection of cancer by endoscopic surveillance, cancer stage, mortality, and potential confounders.

RESULTS

BE was diagnosed in 135 of 589 adenocarcinoma patients, with 23 BE patients diagnosed greater than 6 months before cancer was diagnosed. Among these 23 patients, 73% of the surveillance-detected cancer patients (n = 15) were alive at the end of follow-up, compared with none of the patients without surveillance-detected cancers (n = 8; P = 0.001). All surveillance-detected cancer patients had low-stage disease and none died directly from cancer. The surveillance/survival association was not substantially altered by stratification for age at BE diagnosis or other potential confounders.

CONCLUSIONS

Surveillance-detected BE-associated adenocarcinomas were associated with low-stage disease and improved survival. Additional studies are needed to evaluate potential biases and whether screening/surveillance programs decrease mortality among all patients in surveillance. Few patients (3.9%) had a BE diagnosed before their cancer. Thus, even if current surveillance techniques are effective, they are unlikely to substantially impact the population's mortality from esophageal cancer; better methods are needed to identify at risk patients.

Site distribution of oesophagogastric cancer

AIMS

It has been suggested that adenocarcinomas of the lower oesophagus and gastric cardia should be reclassified as oesophagogastric junction (OGJ) cancers. This study aimed to define the frequency of OGJ cancers in a geographically defined population of 4.3 million people.

METHODS

All cases of oesophageal and gastric cancer occurring in 1993 were identified by the North Western Regional Cancer Registry. A total of 1192 hospital case notes were reviewed and a study group of 1067 patients was defined. Tumour involvement was documented at individual subsites in the oesophagus and stomach, allowing for tumour presence in more than one oesophageal/gastric subsite.

RESULTS

There were 627 tumours in men and 440 in women. The tumour was confined to the oesophagus in 281 (26.3%) cases and to the stomach in 454 (42.6%) cases. The tumour encroached upon or crossed the OGJ in 332 (31.1%) cases. Overall, tumours involved the cardia, OGJ, or lower oesophagus in 633 (59.3%) cases; in 179 (18.5%) cases the tumour involved the lower oesophagus but not the OGJ, and in another 122 (11.4%) cases the cardia was involved but not the OGJ.

CONCLUSIONS

Oesophagogastric cancers in this population predominantly involve the OGJ, lower oesophagus, and/or cardia.

Counting cancers at the junction - a problem of routine statistics

The increase over time in the incidence of cancer arising at the oesophagogastric junction has been the subject of many papers reviewing data obtained from cancer registries and other sources of routine statistics. The analysis of such data is beset with a number of problems, all of which compromise comparability over time and hence complicate interpretation. This makes it extremely difficult to assess with any degree of reliability the quantitative extent to which these cancers really are increasing. Some recent datasets, such as from the Eindhoven Cancer Registry, are now providing higher-quality information that can remedy this deficiency. In the absence of such routine information, useful insights can be obtained from analysis of appropriate clinical datasets that exist in Japan.

Oesophageal and gastric cardia adenocarcinomas: analysis of regional variation using the Cancer Incidence in Five Continents database

BACKGROUND

Adenocarcinomas of the oesophagus and proximal stomach are the most rapidly increasing malignancies in some countries; however, there are no comparative studies on global disease incidence, and the relationships between these two malignancies are undefined.

METHODS

We evaluated the cumulative rates and age-specific incidence rates per 100 000 population for adenocarcinomas of the oesophagus and proximal stomach for all countries in the Cancer Incidence in Five Continents database, and compared them with rates for oesophageal squamous cell carcinoma.

RESULTS

Substantial variations in cumulative cancer rates were found between genders, between countries, between different ethnicities within the same country, and within the same ethnicity residing in different countries. Cumulative rates (ages 0-74 years) for oesophageal adenocarcinoma varied from 0 (e.g. Thailand) to 0.6 (Scotland, males, 95% CI : 0.56, 0.64); for proximal stomach cancer from 0 (Singapore, Malay females, 95% CI : -0.01, 0.11) to 0.52 (The Netherlands, males, 95% CI : 0.49, 0.55); and for oesophageal squamous cell carcinomas from 0 (non-Jews in Israel, females) to 1.84 (Brazil, Porto Alegre, males, 95% CI : 1.42, 2.26). There was a continuous increase in age-specific incidence rates with advancing age for oesophageal/proximal stomach adenocarcinomas, but a decrease in age-specific incidence rates for oesophageal squamous cell carcinoma after age 75 years. The cumulative rate trends for adenocarcinomas of the oesophagus and proximal stomach were often dissimilar, and varied by country, gender, and ethnicity.

CONCLUSIONS

These results suggest that different risk factors may be associated with adenocarcinomas of the oesophagus versus the proximal stomach; the marked rate variation implies a substantial environmental component to the recent incidence changes.

Predictors of progression in Barrett's esophagus II: baseline 17p (p53) loss of heterozygosity identifies a patient subset at increased risk for neoplastic progression

OBJECTIVES

Most patients with Barrett's esophagus do not progress to cancer, but those who do seem to have markedly increased survival when cancers are detected at an early stage. Most surveillance programs are based on histological assessment of dysplasia, but dysplasia is subject to observer variation and transient diagnoses of dysplasia increase the cost of medical care. We have previously validated flow cytometric increased 4N fractions and aneuploidy as predictors of progression to cancer in Barrett's esophagus. However, multiple somatic genetic lesions develop during neoplastic progression in Barrett's esophagus, and it is likely that a panel of objective biomarkers will be required to manage the cancer risk optimally.

METHODS

We prospectively evaluated endoscopic biopsies from 325 patients with Barrett's esophagus, 269 of whom had one or more follow-up endoscopies, by a robust platform for loss of heterozygosity (LOH) analysis, using baseline 17p (p53) LOH as a predictor and increased 4N, aneuploidy, high-grade dysplasia, and esophageal adenocarcinoma as outcomes.

RESULTS

The prevalence of 17p (p53) LOH at baseline increased from 6% in negative for dysplasia to 57% in high-grade dysplasia (p < 0.001). Patients with 17p (p53) LOH had increased rates of progression to cancer (relative risk [RR] = 16, p < 0.001), high-grade dysplasia (RR = 3.6, p = 0.02), increased 4N (RR = 6.1, p < 0.001), and aneuploidy (RR = 7.5, p < 0.001).

CONCLUSIONS

Patients with 17p (p53) LOH are at increased risk for progression to esophageal adenocarcinoma as well as high-grade dysplasia, increased 4N, and aneuploidy. 17p (p53) LOH is a predictor of progression in Barrett's esophagus that can be combined with a panel of other validated biomarkers for risk assessment as well as intermediate endpoints in prevention trials.

Barrett's oesophagus: better left alone?

The risk of oesophageal adenocarcinoma in patients with Barrett's oesophagus is overrated in most publications, including meta-analyses. The upper limit of the overall risk is currently estimated at 0.5 per 100 patients per year. This means that one cancer may occur out of 200 patients followed for one year. Furthermore, a large fraction of patients with Barrett's oesophagus have a precarious health status, either from advanced age or from a chronic severe disease. Management is based upon a careful index endoscopy; accordingly, patients positive for dysplasia must be strictly observed or treated. Endoscopic surveillance protocols aiming at early detection of neoplasia--and treatment--in patients without dysplasia are unjustified in most cases. On the other hand, a minority of male patients--providing a good performance status--should enter into surveillance protocols when high-risk factors such as a long history of reflux symptoms and smoking habits are present.

The prescribing of acid suppressants prior to the endoscopic diagnosis of Barrett's oesophagus and oesophagitis

BACKGROUND

There has been a dramatic rise in incidences of Barrett's oesophagus and oesophageal adenocarcinoma. It has been suggested that the introduction and use of acid suppression therapy may be a factor in the rising incidences of Barrett's oesophagus and oesophageal adenocarcinoma.

METHODS

This was a record linkage study, using a prescribing database and an endoscopy database. Patients who had undergone their first endoscopy during the period 1992-1995 and received the diagnosis of Barrett's oesophagus or oesophagitis were identified. The prescribing of acid suppressants was compared for the 3 years prior to endoscopy, between those with Barrett's oesophagus and those with oesophagitis.

RESULTS

There was no significant difference between the Barrett's patients and the oesophagitis patients in the proportion that had been exposed to acid suppression therapy (53.4% vs. 51.7%, P=0.704). The mean number of days of prescribing among those who had been exposed to acid suppression therapy was higher in the Barrett's group (340.5 vs. 237.0 days, P=0.001).

CONCLUSIONS

Patients with Barrett's oesophagus have received more acid suppressant therapy prior to diagnosis. The reasons for this are not clear. However, 46.6% of Barrett's patients have not been exposed to acid suppressant therapy.

Endoscopic screening for early esophageal cancer by iodine staining in patients with other current or prior primary cancers

BACKGROUND

Although early diagnosis of esophageal carcinoma is an important determinant of outcome, early stage carcinomas are rarely detected on routine endoscopic examination. Iodine staining may be useful in the detection of early stage esophageal carcinoma, especially in high-risk populations. In a prior study, 29.2% (68/233) patients with superficial esophageal carcinoma (SEC) undergoing resection at our hospital had other nonesophageal primary carcinomas, suggesting that patients with nonesophageal primary cancers are at increased risk for the development of esophageal cancer. The aim of the current study was to determine whether endoscopic screening with iodine staining is useful for the detection of SEC in patients with a history of non-esophageal cancers.

PATIENTS AND METHODS

In a prospective study, 331 patients with nonesophageal primary cancers were screened for esophageal cancer by endoscopic examination with iodine staining. All patients were men 55 years of age or older.

RESULTS

Nine patients (2.7%) with SEC were identified. Among these patients, 7 with mucosal cancer were treated by endoscopic mucosal resection, and 2 with submucosal cancer were treated by surgical resection or radiation therapy. Five patients (1.5%) were found to have cancer confined to the epithelium or the lamina propria. These lesions were difficult to detect by conventional endoscopic screening and were cured by endoscopic mucosal resection. After exclusion of 51 patients with head and neck cancer, the incidence of SEC was still 2.1% (6/280), higher than reported in prior screening studies.

CONCLUSIONS

All men with a history of nonesophageal primary cancers should undergo endoscopic screening for esophageal cancer. Endoscopic iodine staining in such patients may be useful in screening for early stage esophageal carcinoma.

The epidemiology of oesophageal adenocarcinoma: has the cancer of gastric cardia an influence on the rising incidence of oesophageal adenocarcinoma?

BACKGROUND

Owing to overgrowth and definitional problems in classification, the cancer of gastric cardia may affect significantly the epidemiological analysis of oesophageal adenocarcinoma. The purpose of the present study was to evaluate the changes in the incidence of all the adenocarcinomas near the gastrooesophageal junction.

METHODS

Trends in the incidence rates of adenocarcinoma of the oesophagus and the gastric cardia were described through the Finnish Cancer Registry. The annual age-standardized incidence rates during 1976-95 were analysed by a linear regression technique.

RESULTS

The total incidence of oesophageal carcinoma remained around 3.5/100,000 in men, and decreased from 2.8 to 1.3/100,000 in women. The incidence of oesophageal adenocarcinoma increased from 0.28 to 0.77/100,000 (nearly 300%) in males, and from 0.08 to 0.11 per 100,000 in females. There were no significant changes with time in the incidence rate of gastric cardia cancer in either sex. Combined gastric cardia and oesophageal adenocarcinoma incidence rates remained stable in women, and increased slightly, but significantly, from 2.4 to 2.9/100,000 in men.

CONCLUSION

Oesophageal adenocarcinoma has increased significantly in men in Finland, but the combined incidence of cancers of the gastro-oesophageal junction has increased only slightly. To overcome the difficulties in classification of oesophageal adenocarcinoma and the cancer of gastric cardia in the epidemiological studies, the focus should be on all adenocarcinomas at or near the oesophagogastric junction.

Human oesophageal adenocarcinoma cell lines JROECL 47 and JROECL 50 are admixtures of the human colon carcinoma cell line HCT 116

In two recently described human oesophageal adenocarcinoma cell lines JROECL 47 and JROECL 50, derived from one tumour, we detected identical E-cadherin and beta-catenin gene mutations as in colon carcinoma cell line HCT 116. We demonstrate by HLA-typing, mutation analysis and microsatellite analysis that cell lines JROECL 47 and JROECL 50 are admixtures of the human colon adenocarcinoma cell line HCT 116.

Cancer incidences in the digestive tube: is cobalamin a small intestine cytoprotector?

Malignancies are common in the digestive tube, although with unequal distribution among segments. The aim of this paper was to compare available interpretations of the low cancer incidence in the small bowel and high in the large bowel. Supposed mechanisms include relatively small bacterial population, large secretion of liquid and rapid transit in the small bowel. Small bowel mucosa is the main absorptive part of the digestive tube with absorption rates for various nutrients so high that they can even be considered as clearances from the intestinal content. Consequently, these nutrients are not present in the large bowel. An alternative explanation is that an absorbable protective substance from the intraluminal content, might protect the mucosa from malignant transformations. It can be speculated that if there are any cytoprotective substances in the digested food their effect would be expressed mostly in the absorptive small intestine, leaving the large bowel mucosa unprotected. Vitamin B12 might be a possible candidate for this role. Cobalamin molecules are initially bound to haptocorrin (Hc) in the stomach, but in the small intestine B12 is transferred to intrinsic factor (IF) after the action of pancreatic trypsin on Hc. Cobalamin-IF complexes are absorbed in the terminal ileum leaving only a small fraction of B12 to enter the large bowel. We have tried to summarize available data regarding cancer incidences in digestive tube, segmental length and transit times of tube content. Cancer density is calculated as incidence per length and transit speed as length per transit time. Cancer incidences for seven intestinal segments were considered low if they were below one case per 100 000 inhabitants annually, while the low cancer density meant less than six cases per 100 000 inhabitants per metre. For instance, transverse colon was considered as a high cancer incidence place (2.15 cases), with low cancer density (4.3 cases/m). Transit speed more than 0.3 metre/hour was associated with low cancer incidences (accuracy 0.85) and low cancer density segments (accuracy 1.00). Cobalamin availability showed similar distribution, available in low incidence segments and unavailable in high incidence segments. Experimental studies are needed to quantify B12 availability in the large bowel and to determine whether small amounts of B12-IF or, perhaps, B12-haptocorrin complexes are absorbed by the small bowel mucosa. Without that, no cytoprotective effects of B12 in the digestive tube can be expected.

New classification of oesophageal and gastric carcinomas derived from changing patterns in epidemiology

The current ICD-O classification of carcinomas of the oesophagus and stomach causes epidemiological and clinical confusion. This study compares the epidemiological and clinical features of each subtype and subsite of adenocarcinomas of the oesophagus and stomach, to assess requirements for a new classification of these carcinomas. Data were extracted with appropriate validity checks on all cases of oesophageal and gastric carcinomas identified throughout the period 1974-1993 by the Merseyside and Cheshire Cancer Registry, which covers a population of 2.5 million. The incidence of adenocarcinomas of the lower oesophagus and cardia trebled in males, and doubled in females, whereas adenocarcinoma of the subcardia region of the stomach declined in both sexes. Adenocarcinomas of the lower oesophagus and of the cardia were similar for median age at diagnosis, male to female ratio, percentage of patients who smoked and survival; both were significantly different from carcinomas of the subcardia in these respects. These data imply that adenocarcinomas of the lower oesophagus and cardia are the same disease. A new subsite classification of oesophageal and gastric carcinomas is proposed that includes the gastro-oesophageal junction as a distinct subsite, to facilitate surveillance, management and research.

Changing patterns in the incidence of esophageal and gastric carcinoma in the United States

BACKGROUND

Incidence rates for esophageal adenocarcinoma previously were reported to be increasing rapidly, especially among white males. Rates for gastric cardia adenocarcinoma also were observed to be rising, although less rapidly. In this article, the authors update the incidence trends through 1994 and further consider the trends by age group.

METHODS

Surveillance, Epidemiology, and End Results (SEER) program data were used to calculate age-adjusted incidence rates for esophageal carcinoma by histologic type and gastric adenocarcinoma by anatomic subsite.

RESULTS

Among white males, the incidence of adenocarcinoma of the esophagus rose > 350% since the mid-1970s, surpassing squamous cell carcinoma around 1990. Rates also rose among black males, but remained at much lower levels. To a lesser extent, there were continuing increases in gastric cardia adenocarcinoma among white and black males, which nearly equaled the rates for noncardia tumors of the stomach in white men. The upward trend for both tumors was much greater among older than younger men. Although the incidence also rose among females, rates remained much lower than among males.

CONCLUSIONS

Previously reported increases of esophageal adenocarcinoma are continuing, most notably among white males. Cigarette smoking may contribute to the trend through an early stage carcinogenic effect, along with obesity, which may increase intraabdominal pressure and predispose to gastroesophageal reflux disease. Further research into esophageal and gastric cardia adenocarcinoma is needed to clarify the risk factors and mechanisms responsible for the upward trends as well as the racial and gender disparities in incidence.