Effects of Nutrition Intervention on Total and Cancer Mortality: 25-Year Post-trial Follow-up of the 5.25-Year Linxian Nutrition Intervention Trial

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Recent Advances on the Role of B Vitamins in Cancer Prevention and Progression

Water-soluble B vitamins, mainly obtained through dietary intake of fruits, vegetables, grains, and dairy products, act as co-factors in various biochemical processes, including DNA synthesis, repair, methylation, and energy metabolism. These vitamins include B1 (Thiamine), B2 (Riboflavin), B3 (Niacin), B5 (Pantothenic Acid), B6 (Pyridoxine), B7 (Biotin), B9 (Folate), and B12 (Cobalamin). Recent studies have shown that besides their fundamental physiological roles, B vitamins influence oncogenic metabolic pathways, including glycolysis (Warburg effect), mitochondrial function, and nucleotide biosynthesis. Although deficiencies in these vitamins are associated with several complications, emerging evidence suggests that excessive intake of specific B vitamins may also contribute to cancer progression and interfere with therapy due to impaired metabolic and genetic functions. This review discusses the tumor-suppressive and tumor-progressive roles of B vitamins in cancer. It also explores the recent evidence on a comprehensive understanding of the relationship between B vitamin metabolism and cancer progression and underscores the need for further research to determine the optimal balance of B vitamin intake for cancer prevention and therapy.

Blood trace elements in association with esophageal squamous cell carcinoma risk, aggressiveness and prognosis in a high incidence region of China

Toxic elements exposure and imbalance in essential element homeostasis remain incomprehensive in esophageal squamous cell carcinoma (ESCC) carcinogenesis, especially in tumor progression. To reveal the toxic and essential elements inside body associated with ESCC occurrence, aggressive features and outcomes, whole blood concentrations of eight trace elements were quantified in 150 ESCC cases and 177 controls using inductively coupled plasma-mass spectrometry (ICP-MS). Concentrations of cadmium (Cd), lead (Pb), chromium (Cr), copper (Cu), arsenic (As), and selenium (Se) showed significant differences between the case and control subjects. The restricted cubic spline (RCS) analysis showed As, Zinc (Zn), and manganese (Mn) was linked with ESCC risk in a U-shaped pattern, whereas an inverted U-shaped curve for Cd (all P-non-linear < 0.05). Contrary to Se, the elements Pb, Cr and Cu were positively associated with ESCC risk. By Bayesian Kernel Machine Regression models, the mixtures of the eight trace elements were found to be significantly associated with ESCC risk and metastasis, with Cr, Mn, Cu, Zn, and Pb having a PIP of 1.000 for occurrence risk and Mn being the main contributor for metastatic risk (PIP = .6570). The weighted quantile sum (WQS) model consistently showed that Cu, Cr, Pb, and Cd ranked as the top four positive elements for ESCC risk. Multivariable logistic regression analysis indicated Pb and As were positively associated with tumor invasion (adjusted OR 3.024 [1.053-8.689]; OR 4.385 [1.271-15.126], respectively), whereas Se had the opposite trend (adjusted OR 0.261 [0.074-0.927). Patients with high Cr, Mn, or Pb showed worse overall survival (OS), and high Mn were linked to inferior progression-free survival (PFS) (all P < 0.05). Zn and Pb, and Mn and Cu were identified as independent prognostic factors for OS and PFS, respectively. This study suggests trace element disbalance in human body contributes to the risk of onset and progression of ESCC, especially in a high-incidence region. Further epidemiological and experimental studies were needed to clarify the probable pathogenic processes underpinning the potential link between trace element mixtures and ESCC.

Risk of serum circulating environmental chemical residues to esophageal squamous cell carcinoma: a nested case-control metabolome-wide association study

Esophageal squamous cell carcinoma (ESCC) is the primary histological subtype of esophageal carcinoma, yet research on environmental exposure risks and associated metabolic alterations preceding ESCC is limited. In a nested case-control cohort of 396 adults (199 diagnosed with ESCC and 197 healthy controls (HC)), we combined exposomics and metabolomics to assess circulating chemical residues and early serum metabolic changes linked to ESCC risk. A cell experiment further evaluated the proliferative impact of 1H,1H,2H,2H-perfluorooctanesulfonic acid (6:2 FTS), identifying it as a risk factor for ESCC, primarily through lipid metabolism-related chronic inflammation. Significant metabolic disruptions were observed in ESCC cases, characterized by increased carnitines, phosphatidylcholines (PCs), and triglycerides (TGs) alongside reduced lysophosphatidylcholines (LPCs) and ether lysophosphatidylcholines (LPC-Os). An early-warning biomarker panel, including glutamic acid, methionine, choline, LPC-O 18:0, TG (14:0_18:2_20:5), and PC (18:0_20:4)/LPC 18:0, showed improved predictive capacity when combined with 6:2 FTS. Metabolome-exposome-wide association studies largely confirmed 6:2 FTS as a potential ESCC risk factor through lipid mediation. This study offers novel insights for ESCC prevention and early diagnosis through a combined biomarker panel integrating metabolic and environmental risk indicators.

Community prevention and standardized clinical treatment jointly improve cancer outcome: Real-world evidence from an esophageal cancer patient cohort study

Extensive efforts have been put into reducing the heavy burden of esophageal squamous cell carcinoma (ESCC) in China. However, the joint impact of prevention and treatment on the long-term overall survival (OS) of ESCC patients remains largely unknown. We consecutively recruited 13,255 ESCC patients from two Chinese centers: the Northern center, located in a high-risk area with abundant screening programs; and the Southern center, situated in a non-high-risk area with improved clinical practices. Inter-center comparison, longitudinal intra-center comparison, and a simulation analysis were conducted to investigate the influence of tumor downstaging and high-quality clinical treatment on OS. During a follow-up period of 12.52 years, the Northern center exhibited higher median survival than the Southern center (6.22 vs. 3.15 years; HRadjusted = 0.73, 95% CI: 0.69-0.77). Mediation analysis demonstrated that its OS advantage was largely (77.7%) attributed to earlier TNM stage (stage 0-II: 51.3% vs. 24.6%). In temporal analyses, patient survival in the Southern center gradually improved (median survival during 2015-2018 vs. 2009-2014: 3.58 vs. 2.93 years; HRadjusted = 0.86, 95% CI: 0.79-0.94), coinciding with the progress of treatment-related indices (completeness of TNM staging in discharge diagnosis [from 53.7% to 99.6%], adoption of minimally invasive esophagectomy [from 0.0% to 51.1%] and right thoracic esophagectomy [from 12.4% to 86.4%], etc.). Simulation analysis further demonstrated that integrating both downstaging and high-quality treatment would lead to the best survival. Tumor downstaging and high-quality clinical treatment have a joint impact on ESCC patient survival. Establishing a comprehensive strategy that integrates cancer prevention with optimal clinical treatment is crucial for alleviating the ESCC burden.

Clinicopathological and therapeutic comparisons of esophageal cancer between China and the USA: a multicenter hospital-based study

Background

Esophageal cancer (EC) remains a global health challenge due to its poor prognosis. China and the United States of America (USA) represent two distinct epicenters of EC burden. Understanding the EC disparities in these two countries is vital for tailoring prevention strategies, optimizing treatment, and enhancing outcomes in both countries. Yet, there lacks a comprehensive comparison of EC characteristics between the two countries.

Methods

In this multicenter, retrospective hospital-based study, we enrolled primary EC patients who received their initial treatment at one of 23 hospitals in China during 2016-2017. Using electronic medical records and cancer registration records, information on demographics, lifestyle, and clinicopathological characteristics (including tumor site, pathology, stage, metastases, differentiation, and treatment) were collected. Additionally, we compared these data with the clinicopathological information of invasive EC patients diagnosed in 2016-2017 from the Surveillance, Epidemiology, and End Results (SEER) database in the USA.

Results

A total of 6,658 EC patients in China and 8,555 EC patients in the USA were included finally. 85.5% (n = 5,694) of EC were esophageal squamous cell carcinoma (ESCC) in China, while esophageal adenocarcinoma (EAC) was prominent in the USA (58.9%, n = 5,041). Among EC patients with known staging, the proportion of early stage was higher in China compared to the USA (48.3% vs. 30.5%). Among ESCC patients, early-stage cases were higher in China than in the USA (49.8% vs. 31.8%), while among EAC patients, late-stage cases were higher in China than in the USA (77.3% vs. 68.5%) (all P < 0.001). In China, EC mainly occurred in the middle third (60.2%) of the esophagus, whereas in the USA, it was more common in the lower third (59.9%) of the organ. Compared with EC patients with known metastatic status in the USA, China had fewer cases of lymph node metastases (51.4% vs. 57.7%) and distant metastases (7.9% vs. 33.8%). Regarding treatment, China had more surgical therapy (53.7% vs. 22.6%), less radiotherapy (35.6% vs. 53.3%), and less chemotherapy (46.7% vs. 59.7%) compared to the USA.

Conclusions

This study reveals notable disparities in EC between China and the USA, encompassing epidemiological, clinicopathological, and treatment dimensions. These findings provide insight for tailored strategies addressing regional variations in clinicopathological and therapeutic characteristics.

One-carbon metabolism biomarkers and upper gastrointestinal cancer in the Golestan Cohort Study

Incidence of esophageal and gastric cancer has been linked to low B-vitamin status. We conducted matched nested case-control studies of incident esophageal squamous cell carcinoma (ESCC; 340 case-control pairs) and gastric cancer (GC; 352 case-control pairs) within the Golestan Cohort Study. The primary exposure was plasma biomarkers: riboflavin and flavin mononucleotide (FMN) (vitamin B2), pyridoxal phosphate (PLP) (B6), cobalamin (B12), para-aminobenzoylglutamate (pABG) (folate), and total homocysteine (tHcy); and indicators for deficiency: 3-hydroxykyurenine-ratio (HK-r for vitamin B6) and methylmalonic acid (MMA for B12). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression adjusting for matching factors and potential confounders. High proportions of participants had low B-vitamin and high tHcy levels. None of the measured vitamin B levels was associated with the risk of ESCC and GC, but elevated level of MMA was marginally associated with ESCC (OR = 1.42, 95% CI = 0.99-2.04) and associated with GC (OR = 1.53, 95% CI = 1.05-2.22). Risk of GC was higher for the highest versus lowest quartile of HK-r (OR = 1.95, 95%CI = 1.19-3.21) and for elevated versus non-elevated HK-r level (OR = 1.59, 95% CI = 1.13-2.25). Risk of ESCC (OR = 2.81, 95% CI = 1.54-5.13) and gastric cancer (OR = 2.09, 95%CI = 1.17-3.73) was higher for the highest versus lowest quartile of tHcy. In conclusion, insufficient vitamin B12 was associated with higher risk of ESCC and GC, and insufficient vitamin B6 status was associated with higher risk of GC in this population with prevalent low plasma B-vitamin status. Higher level of tHcy, a global indicator of OCM function, was associated with higher risk of ESCC and GC.

Vitamin and Mineral Supplementation, Weight Gain, and Poor Appetite in Patients With Cancer: Many Questions and Fewer Answers

Patients with cancer or with a history of cancer often seek nutritional advice. In turn, cancer health care providers are often asked questions related to nutrition and cancer. Should I take high-dose vitamins or other high-dose supplements? Should I take a regular-dose vitamin or other regular-dose nutritional supplements? Will I experience weight loss during postoperative chemotherapy? What should be my weight goals during and after adjuvant therapy? In the setting of advanced cancer, what should I do to keep my appetite and weight up? This review attempts to provide data-driven answers to some of these commonly posed questions.

Association between the dietary inflammatory index and all-cause mortality in the U.S. cancer survivors: A prospective cohort study using the National Health and Nutrition Examination Survey database

Background

Cancer remains one of the leading causes of mortality worldwide. Diet can impact inflammation and consequently affect cancer outcomes. The Dietary Inflammatory Index (DII) can serve as a tool to assess the inflammatory potential of cancer survivors' diets and further predict their survival.

Objectives

To investigate the relationship between the DII and the survival of cancer survivors in National Health and Nutrition Examination Survey (NHANES).

Methods

An overall sample of 2359 U.S. cancer survivors from the 2005-2014 cohorts of the NHANES were studied. The DII scores were calculated using 28 dietary components and the mortality status was ascertained until December 31, 2015. Based on the multiple analyses, the relationship between DII and all-cause mortality was examined.

Results

The weighted mean age at baseline was 65.17 ± 14.46 years, 53.16 % were female and 71.30 % were non-Hispanic white. The average DII was 1.51 ± 1.97. After accounting for multiple covariates, positive associations were observed (P < 0.01). Based on Kaplan-Meier survival curves, their significant relationship remains same and the survival probability was decreased among the groups of anti-inflammatory diets (DII < 0) versus pro-inflammatory diets (DII ≥ 0) significantly (Log rank test; P = 0.03). Further analyses were conducted on subgroups and the results are still robust.

Conclusions

An elevated DII was associated with a rising mortality rate among cancer survivors. DII might serve as a potential inflammatory predictor of cancer mortality prognosis, as well as guide nutritional care and even clinical treatment of cancer survivors.

Selenium - a scoping review for Nordic Nutrition Recommendations 2023

Selenium is an essential trace element in humans, critical to the normal physiology in all animal species. The main form of selenium in food is selenomethionine, selenocysteine and a variety of organic compounds, while inorganic salts mainly occur in food supplements. In animals and humans, selenium occurs as selenocysteine in selenoproteins encoded by 25 genes (specific selenium pool). Several selenoproteins are part of the antioxidant enzyme system and serve as oxido-reductases and in thyroid hormone regulation. SelenoproteinP (SELENOP) transports selenium to peripheral tissues, is the main plasma selenoprotein, and has been used as biomarker of selenium status and intake. SELENOP in plasma represents a saturable pool of selenium and is maximised at a selenium concentration in plasma of about 110 µg/L or an intake of selenomethionine at about 1.2 µg/kg body weight in adults. In Finland, with an estimated selenium intake of 88 µg/day in men and 68 µg/day in women, the average selenium concentration in plasma is about 110 µg/L. Imported wheat from selenium rich areas is an important dietary source in Norway. Dietary intakes in the Nordic and Baltic area vary from 39 to 88 µg/day in men and 22 to 68 µg/day in women, the highest levels were from Finland. Most intervention trials on the effect of selenium supplementation on health outcomes have been carried out in 'selenium-replete'-populations and show no beneficial effect, which from a nutritional point of view would rather not be expected. Some intervention studies conducted in populations low in selenium have showed a beneficial effect. Observational studies suggest an inverse relationship between selenium status and risk of cardiovascular diseases (CVDs), cancer and all-cause mortality, and some other outcomes at low levels of intake (<55 µg/day) or in plasma or serum (<100 µg/L). However, a lack of quantitative data and inconsistencies between studies precludes these studies to be used to derive dietary reference values. At high intakes above 330 to 450 µg/day selenium may cause toxic effects affecting liver, peripheral nerves, skin, nails, and hair. An upper tolerable level (UL) of 255 µg selenium/day in adults was established by EFSA.

Identification of plasma proteomic signatures associated with the progression of cardia gastric cancer and precancerous lesions

Objective

Considering that there are no effective biomarkers for the screening of cardia gastric cancer (CGC), we developed a noninvasive diagnostic approach, employing data-independent acquisition (DIA) proteomics to identify candidate protein markers.

Methods

Plasma samples were obtained from 40 subjects, 10 each for CGC, cardia high-grade dysplasia (CHGD), cardia low-grade dysplasia (CLGD), and healthy controls. Proteomic profiles were obtained through liquid chromatography-mass spectrometry (LC-MS/MS-based DIA proteomics. Candidate plasma proteins were identified by weighted gene co-expression network analysis (WGCNA) combined with machine learning and further validated by the Human Protein Atlas (HPA) database. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of the biomarker panel.

Results

There was a clear distinction in proteomic features among CGC, CHGD, CLGD, and the healthy controls. According to the WGCNA, we found 42 positively associated and 164 inversely associated proteins related to CGC progression and demonstrated several canonical cancer-associated pathways. Combined with the results from random forests, LASSO regression, and immunohistochemical results from the HPA database, we identified three candidate proteins (GSTP1, CSRP1, and LY6G6F) that could together distinguish CLGD (AUC = 0.91), CHGD (AUC = 0.99) and CGC (AUC = 0.98) from healthy controls with excellent accuracy.

Conclusions

The panel of protein biomarkers showed promising diagnostic potential for CGC and precancerous lesions. Further validation and a larger-scale study are warranted to assess its potential clinical applications, suggesting a potential avenue for CGC prevention in the future.

Changes in Geographic Variation and Socioeconomic Inequalities in Esophageal Cancer Mortality in China, 1973-2017

BACKGROUND

Geographic variability in esophageal cancer has been reported in China, but data are lacking at the local level. We aimed to investigate changes in disparities in esophageal cancer-related mortality among Chinese counties and whether county-level socioeconomic status was associated with this variation.

METHODS

We used data from a nationwide survey and population-based cancer registries to calculate esophageal cancer-related mortality rates for 782 Chinese counties for the periods of 1973-1975 and 2015-2017. We performed hotspot analysis to identify spatial clusters. We used a multivariable negative binomial regression model to estimate the associations between county-level socioeconomic factors and mortality.

RESULTS

From 1973-1975 to 2015-2017, the age-standardized esophageal cancer-related mortality rate decreased from 27 to 8 per 100,000 person-years in China. By county, 577 (74%) of 782 counties experienced decreasing mortality. Geographic disparities in mortality substantially narrowed, with the gap in mortality rates between 90th and 10th percentile counties decreasing from 55 per 100,000 person-years in 1973-1975 to 16 in 2015-2017. However, clusters of elevated rates persisted across north-central China. Rurality [adjusted mortality rate ratio (MRR) 1.15; 95% confidence interval (CI), 1.10-1.21], per capita gross domestic product (adjusted MRR, 0.95; 95% CI, 0.91-0.98), and percentage of people with a high-school diploma (adjusted MRR, 0.86; 95% CI, 0.84-0.87) in a county were significantly associated esophageal cancer-related mortality rates.

CONCLUSIONS

China has made substantial progress in reducing esophageal cancer-related mortality and disparities, but the intercounty differences remain large.

IMPACT

Continued efforts are needed to address the geographical and socioeconomic disparities in esophageal cancer.

Diet Quality and Subsequent Incidence of Upper Gastrointestinal Cancers: Results from the Golestan Cohort Study

BACKGROUND

Recent evidence suggests overall diet quality, as assessed by dietary scores, may play a role in the development of upper gastrointestinal (UGI) cancers. However, the existing dietary scores are derived from high-income countries with different dietary habits than regions with the highest burden of UGI cancers, where limited data is available. This study aimed to investigate the association between overall diet quality and risk of esophageal and stomach cancers in a high-risk region for UGI cancers.

METHODS

We recruited 50045 individuals aged 40-75 between 2004-2008 from northeastern Iran and followed them annually through July 2020. Data on demographics, diet, and various exposures were collected using validated questionnaires. Diet quality was assessed by calculating the Healthy Eating Index (HEI), Alternative Healthy Eating Index (AHEI), Alternative Mediterranean Diet (AMED), Dietary Approaches to Stop Hypertension (DASH), and World Cancer Research Fund-American Institute for Cancer Research (WCRF-AICR) scores.

RESULTS

During an average 12 years of follow-up, 359 participants developed esophageal cancer and 358 developed stomach cancer. After adjustments, each standard deviation increase in baseline dietary scores was associated with up to 12% reduction in esophageal cancer risk and up to 17% reduction in stomach cancer risk. Esophageal cancer showed stronger inverse associations with adherence to AMED (HRQ4-vs-Q1=0.69 (0.49-0.98), P-trend=0.038). Stomach cancer showed stronger inverse correlation with WCRF-AICR (HRQ4-vs-Q1=0.58 (0.41-0.83), P-trend=0.004), and DASH (HRC4-vs-C1=0.72 (0.54-0.96), P-trend=0.041). These associations were comparable across different population subgroups. We did not observe significant associations between HEI and AHEI scores and UGI cancers in this population.

CONCLUSION

Despite the differences in consuming individual food groups, adherence to the available dietary recommendations (derived from high-income countries) was associated with lower risk for subsequent esophageal and gastric cancers in this high-risk population. Educating the public to have a healthy eating pattern might be an effective strategy towards prevention of UGI cancers in high-risk regions.

Short-term and long-term effect of nutrition intervention in the Linxian Dysplasia Nutrition Intervention Trial and the reason for disappearance of the intervention effect: A cohort study

BACKGROUND

The objective of this study was to determine the short-term and long-term effects of a nutrition intervention in using 37 years of follow-up data.

METHODS

The Linxian Dysplasia Population Nutrition Intervention Trial was a randomized, double-blind, placebo-controlled trial with 7 years of intervention and 30 years of follow-up. The Cox proportional hazard model was used for analyses. Subgroup analyses were conducted in age and sex subgroups, and the 30 years of follow-up were divided into two 15-year early and late periods.

RESULTS

The results at 37 years did not indicate any effects on mortality from cancers or other diseases. In the first 15 years, the intervention decreased the overall risk of gastric cancer deaths in all participants (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.58-1.00) and in the subgroup participants younger than 55 years (HR, 0.64; 95% CI, 0.43-0.96). In addition, in the group younger than 55 years (HR, 0.58; 95% CI, 0.35-0.96), the intervention decreased the risk of death from other diseases; and, in the group aged 55 years and older (HR, 0.75; 95% CI, 0.58-0.98), the intervention reduced the risk of death from heart disease. There were no significant results in the later 15 years, which indicated the disappearance of the intervention effect. Comparing demographic characteristics between those who died during the two periods, the participants who died later included more women, had a higher education level, had a lower smoking rate, were younger, and also more had a mild degree of esophageal dysplasia, representing a better lifestyle and health condition.

CONCLUSIONS

Long-term follow-up indicated no effect of nutrition on deaths in a population with esophageal squamous dysplasia, further supporting the significance of continuous nutritional intervention for cancer protection. The pattern of protective effect of a nutrition intervention on gastric cancer in patients with esophageal squamous dysplasia was similar to that in the general population. Participants who died in the later period had more protective factors than those who died in the earlier period, contributing to the obvious effect of the intervention in early stage disease.

Association between type of drinking water and upper gastrointestinal cancer incidence in the Linxian General Population

BACKGROUND

This study aimed to explore the association between drinking water source and risk of upper gastrointestinal (UGI) cancer, including esophageal cancer (EC) and gastric cancer (GC), in the Linxian General Population Nutrition Intervention Trial (NIT) cohort.

METHODS

In this study, we used data from the Linxian NIT cohort, which included 29,584 healthy adults aged 40 to 69 years. Subjects were enrolled in April 1986 and followed up until March 2016. Tap water drinking status and demographic characteristics were collected at baseline. Subjects who drank tap water were treated as the exposed group. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using the Cox proportional hazard model.

RESULTS

A total of 5,463 cases of UGI cancer were identified during the 30-year follow-up period. After adjusting for multiple factors, the incidence rate of UGI cancer in participants who drank tap water was significantly lower compared with individuals in the control (HR = 0.91, 95% CI: 0.86-0.97). A similar association was observed between tap water drinking and EC incidence (HR = 0.89, 95% CI: 0.82-0.97). The association between drinking tap water and risk of UGI cancer and EC incidence did not vary across the subgroup by age and gender (All P_interaction > 0.05). For EC incidence, an interaction effect was observed for riboflavin/niacin supplements and drinking water source (P_interaction = 0.03). No association was observed between drinking water source and GC incidence.

CONCLUSIONS

In this prospective cohort study in Linxian, participants who drank tap water had a lower risk of EC incidence. As a source of drinking water, use of tap water may reduce the risk of EC by avoiding exposure to nitrate/nitrite. Measures should be taken to improve the quality of drinking water in high-incidence areas of EC.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov (NCT00342654, 21/06/2006), and the trial name is Nutrition Intervention Trials in Linxian Follow-up Study.

Current Status and Future Prospects for Esophageal Cancer

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

Investigating Causal Associations of Diet-Derived Circulating Antioxidants with the Risk of Digestive System Cancers: A Mendelian Randomization Study

Molecular mechanisms and observational studies have found that diet-derived antioxidants are associated with digestive system cancers, whereas there is a lack of causal evidence from randomized clinical trials. In this study, we aimed to assess the causality of these associations through a Mendelian randomization (MR) study. Single nucleotide polymorphisms of diet-derived circulating antioxidants (i.e., α- and γ-tocopherol, ascorbate, retinol, β-carotene, lycopene, and urate), accessed by absolute levels and relative metabolite concentrations, were used as genetic instruments. Summary statistics for digestive system cancers were obtained from the UK Biobank and FinnGen studies. Two-sample MR analyses were performed in each of the two outcome databases, followed by a meta-analysis. The inverse-variance weighted MR was adopted as the primary analysis. Five additional MR methods (likelihood-based MR, MR-Egger, weighted median, penalized weighted median, and MR-PRESSO) and replicate MR analyses for outcomes from different sources were used as sensitivity analyses. Genetically determined antioxidants were not significantly associated with five digestive system cancers, after correcting for multiple tests. However, we found suggestive evidence that absolute ascorbate levels were negatively associated with colon cancer in UK Biobank-the odds ratio (OR) per unit increase in ascorbate was 0.774 (95% confidence interval [CI] 0.608-0.985, p = 0.037), which was consistent with the results in FinnGen, and the combined OR was 0.764 (95% CI 0.623-0.936, p = 0.010). Likewise, higher absolute retinol levels suggestively reduced the pancreatic cancer risk in FinnGen-the OR per 10% unit increase in ln-transformed retinol was 0.705 (95% CI 0.529-0.940, p = 0.017), which was consistent with the results in UK Biobank and the combined OR was 0.747 (95% CI, 0.584-0.955, p = 0.020). Sensitivity analyses verified the above suggestive evidence. Our findings suggest that higher levels of antioxidants are unlikely to be a causal protective factor for most digestive system cancers, except for the suggestive protective effects of ascorbate on colon cancer and of retinol on pancreatic cancer.

Association Between Beta-Carotene Supplementation and Mortality: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Aging is a phenomenon universally involving all organisms, genetically determined, and epigenetically influenced by the environment. Numerous observational studies have shown the positive impact of non-pharmacological approaches started in younger age on chronic conditions affecting the elderly health and survival. This meta-analysis aimed to investigate the effect of beta-carotene on the total and cause-specific mortality as reported by randomized controlled trials (RCTs).

Methods

We searched Medline, Scopus, Web of Science, and CENTRAL Cochrane from inception to September 2021. Studies were eligible if enrolled adults with any health condition, compared beta-carotene supplements at any dose with placebo or no intervention, provided information on deaths from any cause, and were RCTs, in English. The risk of bias was assessed by the Cochrane risk of bias tool and the GRADE. Risk ratios and their 95% confidence intervals were used and a P-value less than 0.05 was considered statistically significant.

Results

Among 3,942 articles searched, 44 articles on 31 RCTs, which included 216,734 total subjects, 108,622 in beta-carotene supplement groups, and 108,112 in the placebo or no-intervention groups, were involved in the final analyses. In a random-effects meta-analysis of all 31 trials, beta-carotene supplements were found to have no preventive effect on mortality (risk ratio 1.02, 95% confidence interval 0.98–1.05, I2 = 42%). Further, the analysis showed no preventive effect on cancer, cardiovascular, cerebrovascular, and other mortality causes. Instead, beta-carotene supplementation significantly increased the risk of lung cancer mortality (RR 1.14, 95% CI 1.02, 1.27, I2 = 3%) but decreased the risk of human immunodeficiency virus-related mortality (RR 0.55, 95% CI 0.33, 0.92, I2 = 0).

Conclusion

More studies should be performed to better define the role of beta-carotene on survival, to confirm or deny our results. Therefore, the possible beneficial or harmful effects of the beta-carotene supplementation on mortality must not be overstated.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=259354], identifier [CRD42021259354].

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

Objective

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

Methods

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

Results

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

Conclusion

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

Combined risk factors and risk of upper gastrointestinal cancer mortality in the Linxian general population

We aimed to explore the association of combined risk factors with risk of death from upper gastrointestinal (UGI) cancer, including esophageal squamous cell carcinoma (ESCC), gastric cardia carcinoma (GCC) and gastric noncardia carcinoma (GNCC) in the Linxian Nutrition Intervention Trial (NIT) cohort. The NIT cohort included 29 584 healthy adults. A combined risk score (CRS) was calculated using a point system method based on 10 risk factors collected at baseline, including gender, smoking, alcohol drinking, body mass index, family history of UGI cancer, drinking tap water, tooth loss and consumption of fresh fruit, eggs and meat. Possible score ranged from 0 to 31, and higher score indicated as poorer health status. Subjects were divided into three groups by the CRS (<12 points, 12 to 20 points and >20 points). The group of CRS <12 points was considered as the reference. During the 30-year follow-up, we identified 4553 UGI cancer deaths. Compared to subjects with a CRS <12 points, the adjusted HRs for CRS of 12 to 20 points and >20 points were 1.69 (95% CI: 1.56-1.83) and 3.06 (95% CI: 2.82-3.33) for UGI cancer mortality, respectively (P_trend  < .001). Comparable associations were also observed for ESCC, GCC and GNCC mortality. Results remained similar across different age groups (P_interaction  > .05). All HRs observed in the second half follow-up period were stronger than that observed in the first half follow-up period. Our study indicated that higher CRS was associated with increased risk of UGI cancer mortality. Appropriate measures should be taken to reduce unhealthy lifestyles.

Mortality after multivitamin supplementation: Nearly 35-year follow-up of the randomized Linxian Dysplasia Nutrition Intervention Trial

BACKGROUND

The objective of this study was to update the association between multivitamin supplementation and total or cause-specific mortality in a population with a high prevalence of undernutrition in China.

METHODS

The Linxian Dysplasia Nutrition Intervention Trial was a randomized, double-blind, placebo-controlled trial in which 3318 persons aged 40-69 years with esophageal squamous dysplasia were assigned to receive daily multivitamin supplementation or a placebo for 6 years and were followed for 29 years. The primary outcome was esophageal/gastric cardia cancer mortality. The data were analyzed with Cox proportional hazards regression models. Subgroup analyses were performed by common characteristics such as age and gender.

RESULTS

The cumulative total mortality was 83.5%. Multivitamin supplementation did not affect total or cause-specific mortality in the participants as a whole (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89-1.03). Subgroup analyses showed that no association between multivitamin supplementation and all-cause mortality was observed in men (HR, 0.90; 95% CI, 0.81-1.01), women (HR, 1.01; 95% CI, 0.91-1.12), younger participants (HR, 0.97; 95% CI, 0.87-1.08), or older participants (HR, 0.94; 95% CI, 0.85-1.04). Significant reductions in heart disease mortality (HR, 0.64; 95% CI, 0.47-0.87) and cerebrovascular disease mortality (HR, 0.74; 95% CI, 0.56-1.00) were seen in older men. In a subgroup of younger men and a subgroup of moderate or severe dysplasia, subjects receiving multivitamin supplementation had a lower risk of esophageal/cardia cancer mortality (HR for younger men, 0.76; 95% CI, 0.58-0.99; HR for moderate or severe dysplasia, 0.76; 95% CI, 0.58-1.00). No association between multivitamin supplementation and any cause-specific mortality was observed in a mild dysplasia population.

CONCLUSIONS

Multivitamin supplementation in a population with esophageal squamous dysplasia was not associated with the risk of total mortality in the 35-year follow-up of this randomized controlled trial. In light of this and previous trials, multivitamin supplements should be used thoughtfully to improve health status of populations with esophageal squamous dysplasia.

LAY SUMMARY

Multivitamin supplementation is common, yet its effect on mortality is unclear. The aim of this study was to update the long-term effects of multivitamin supplementation on total and cause-specific mortality during nearly 35 years of follow-up in the Linxian Dysplasia Nutrition Intervention Trial in China. Multivitamin supplementation in a population with esophageal squamous dysplasia was not associated with the risk of total mortality in the 35-year follow-up of this randomized controlled trial, and this indicates that multivitamin supplements should be used thoughtfully to improve health status.

Gastric and esophageal cancer in China 2000 to 2030: Recent trends and short-term predictions of the future burden

BACKGROUND

Gastric and esophageal cancer (GEC) have made a great contribution to the cancer burden in China. This study aims to report GEC incidence and mortality trends in 2000-2015 and their predictions to 2030.

METHODS

We collected GEC data from 22 cancer registries for Joinpoint temporal trend analysis between 2000 and 2015 and average annual percent change was calculated. Based on the historical changes, combined with the 2015 GEC national incidence and mortality rate, the rate from 2016 to 2030 was predicted grouped by sex and age. The crude rate, standardized rate, and cumulative rate were calculated. The number of cases were obtained by multiplying the United Nations' World Population Prospects and the predicted rate of corresponding years. Attribution changes between 2015 and 2030 were apportioned into demographics and risk factors.

RESULTS

There were decreasing trends of age-standardized incidence rate world (ASIRW) and age-standardized mortality rate world (ASMRW) during 2000-2015 in China (p < 0.05), the decline was more significant for the age group of 40-49 years in men and the age group of 50-59 years in women. It was predicted that in 2030, about 549,724 new cases and 394,576 deaths of GEC would occur in China. Compared with 2015, the numbers of new GEC cases and deaths in 2030 decreased by 15.24% and 17.62%, respectively. From 2020 to 2030, GEC ASIRW and ASMRW were predicted to decline from 24.98 to 17.47 and from 17.41 to 11.82 per 100,000, respectively. The number of new cases decreased by about 15.24% with changing demographic (44.48%) and risk (-59.72%) and the number of deaths decreased by about 17.62% with changing demographic (47.18%) and risk (-64.80%).

CONCLUSIONS

Although GEC incidence and mortality rates showed downward trends, the disease burden remains heavy in China. The current prevention and control strategy are effective which need to be carried on.

Associations between cancer family history and esophageal cancer and precancerous lesions in high-risk areas of China

Background:

Family clustering of esophageal cancer (EC) has been found in high-risk areas of China. However, the relationships between cancer family history and esophageal cancer and precancerous lesions (ECPL) have not been comprehensively reported in recent years. This study aimed to provide evidence for identification of high-risk populations.

Methods:

This study was conducted in five high-risk areas in China from 2017 to 2019, based on the National Cohort of Esophageal Cancer. The permanent residents aged 40 to 69 years were examined by endoscopy, and pathological examination was performed for suspicious lesions. Information on demographic characteristics, environmental factors, and cancer family history was collected. Unconditional logistic regression was applied to evaluate odds ratios between family history related factors and ECPL.

Results:

Among 33,008 participants, 6143 (18.61%) reported positive family history of EC. The proportion of positive family history varied significantly among high-risk areas. After adjusting for risk factors, participants with a family history of positive cancer, gastric and esophageal cancer or EC had 1.49-fold (95% confidence interval [CI]: 1.36–1.62), 1.52-fold (95% CI: 1.38–1.67), or 1.66-fold (95% CI: 1.50–1.84) higher risks of ECPL, respectively. Participants with single or multiple first-degree relatives (FDR) of positive EC history had 1.65-fold (95% CI: 1.47–1.84) or 1.93-fold (95% CI: 1.46–2.54) higher risks of ECPL. Participants with FDRs who developed EC before 35, 45, and 50 years of age had 4.05-fold (95% CI: 1.30–12.65), 2.11-fold (95% CI: 1.37–3.25), and 1.91-fold (95% CI: 1.44–2.54) higher risks of ECPL, respectively.

Conclusions:

Participants with positive family history of EC had significantly higher risk of ECPL. This risk increased with the number of EC positive FDRs and EC family history of early onset. Distinctive genetic risk factors of the population in high-risk areas of China require further investigation.

Trial registration:

ChiCTR-EOC-17010553.

The predictive value of the prognostic nutritional index to postoperative prognosis and nursing intervention measures for colorectal cancer

OBJECTIVES

This study discussed and analyzed the predictive value of the prognostic nutritional index (PNI) to postoperative prognosis and nursing intervention measures for colorectal cancer.

METHODS

196 patients with colorectal cancer who underwent radical resection in gastrointestinal surgery were retrospectively analyzed. The patients' data and follow-up results were collected and classified into two groups based on the PNI, i.e., the high PNI group (≥45.61, 107 cases) and the low PNI group (<45.61, 89 cases) by reregarding PNI 45.61 as the threshold value. The differences in clinical materials and prognosis between the two groups were compared, and the multivariate analysis of 5-year survival after radical resection of colorectal cancer was conducted by Cox proportional hazard model.

RESULTS

The incidence of postoperative complications and severe complications in low PNI group was critically higher than those in high PNI group (P<0.05). Besides, the postoperative disease-free survival and overall survival of the high PNI patients were obviously superior to those of the counterpart (P<0.05). In addition, the results of univariate and multivariate analysis showed that age, TNM staging and PNI were independent risk factors that affected the postoperative survival of patients with colorectal cancer (P<0.05).

CONCLUSION

The preoperative PNI is an independent risk factor that affects the survival of colorectal cancer patients after radical resection. PNI assessment of patients with colorectal cancer helps predict the clinical prognosis of patients. At the same time, the corresponding nursing countermeasures were provided according to the PNI score to improve patients' nutritional status and immune function, which may eventually improve the clinical prognosis.

Microbiome and Cancers of the Esophagus: A Review

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

Research on esophageal cancer: With personal perspectives from studies in China and Kenya

The most common form of esophageal cancer (EC), esophageal squamous cell carcinoma (ESCC), is prevalent in many unindustrialized societies, among people with lower socioeconomic status and those who frequently use tobacco and alcohol. In some areas, ESCC mortality ranked top among all cancer. In this review, we begin with discussions of the extensive research on EC in Linxian in northern China that started 60 years ago and the recent studies in Kenya from our personal perspectives. Based on the results obtained from these studies and information from the literature, we summarize our current understanding about the risk factors for ESCC including lifestyle factors (smoking, alcohol, consumption of food and beverages at high temperature and other unhealthy habits), poor diet and nutritional insufficiencies and genetic susceptibility. Elimination or minimization of these environmental risk factors, as well as early detection and treatment of precancerous lesions, would be effective means for the prevention of ESCC. Current knowledge of molecular alterations in ESCC (gene mutations, hypermethylation and amplification or overexpression), as well as treatment of ESCC and the potential of targeted therapy, are also discussed. Finally, we propose effective approaches for the prevention of ESCC by adapting a healthy lifestyle, including a healthy diet that would also prevent other diseases. Community outreach, public education and international collaboration are important for achieving this public health goal.

Serum Levels of Androgens, Estrogens, and Sex Hormone Binding Globulin and Risk of Primary Gastric Cancer in Chinese Men: A Nested Case-Control Study

Gastric cancer shows a strong male predominance, and sex steroid hormones have been hypothesized to explain this sex disparity. Previous studies examining the associations between sex hormones and sex hormone binding globulin (SHBG) and risk of gastric cancer come primarily from western populations and additional studies in diverse populations will help us better understand the association. We performed a nested case-control study in Linxian Nutrition Intervention Trials cohorts to evaluate the associations among Chinese men, where we had sufficient cases to perform a well-powered study. Using radioimmunoassays and immunoassays, we quantitated androgens, estrogens, and SHBG in baseline serum from 328 men that developed noncardia gastric cancer and matched controls. We used multivariable unconditional logistic regression to calculate ORs and 95% confidence intervals (CI) and explored interactions with body mass index (BMI), age, alcohol drinking, smoking, and follow-up time. Subjects with SHBG in the highest quartile, as compared with those in the lowest quartile, had a significantly increased risk of gastric cancer (OR = 1.87; 95% CI, 1.01-3.44). We found some evidence for associations of sex steroid hormones in men with lower BMI. Our study found a novel association suggesting that higher serum concentrations of SHBG may be associated with risk of gastric cancer in men. We found no overall associations with sex hormones themselves, but future studies should expand the scope of these studies to include women and further explore whether BMI modifies a potential association. PREVENTION RELEVANCE: It was the first study to investigate the association of gastric cancer with prediagnostic sex steroid hormones and SHBG in an Asian male population. Although there were no overall associations for sex steroid hormone concentrations, higher concentrations of SHBG was associated with increased risk of noncardia gastric cancer.

Family History and Risk of Upper Gastrointestinal Cancer in the Linxian General Population

OBJECTIVE

The objective of this study was to investigate family history (FH) of upper gastrointestinal (UGI) cancer and risk of esophageal squamous cell carcinoma (ESCC), gastric cardia carcinoma (GCC), and gastric non-cardia carcinoma (GNCC) in the Linxian General Population Nutrition Intervention Trial (NIT) cohort. Methods: This prospective analysis was conducted using the Linxian NIT cohort data. Subjects with FH of UGI cancer was treated as an exposed group while the remainders were considered as a comparison group. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between FH of UGI cancer and risk of UGI cancer incidence and mortality were estimated using Cox proportional hazards models.

RESULTS

There were 5,680 newly diagnosed UGI cancer cases during the follow-up period, with a total of 4,573 UGI cancer deaths occurred, including 2,603 ESCC, 1,410 GCC, and 560 GNCC deaths. A positive FH of UGI cancer was associated with a significantly increased risk of ESCC and GCC (Incidence: HRESCC = 1.45, 95%CI: 1.35-1.56; HRGCC = 1.27, 95%CI: 1.15-1.40; Mortality: HRESCC = 1.40, 95%CI: 1.30-1.52; HRGCC = 1.27, 95%CI: 1.14-1.42) after adjusting for age at baseline, gender, smoking status, alcohol drinking, education level, and frequency of fresh fruit and vegetable consumption. Subjects with FH in both parents had the highest risk of ESCC and GCC incidence (HRESCC = 1.65, 95%CI: 1.40-1.95; HRGCC = 1.42, 95%CI: 1.12-1.81) and deaths (HRESCC = 1.65, 95%CI: 1.38-1.97; HRGCC = 1.42, 95%CI: 1.09-1.85). Spouse diagnosed with UGI cancer did not increase the risk of any UGI cancers of the subjects. In subgroup analysis, FH of UGI cancer was shown to significantly increase the risk of GCC in non-drinkers (Incidence: HR = 1.31, 95%CI: 1.17-1.47; Mortality: HR = 1.33, 95%CI: 1.17-1.50). No associations were observed for risk of GNCC. Sensitivity analysis by excluding subjects who were followed up less than three years did not materially alter our results.

CONCLUSION

Our data point to the role of the FH of UGI cancer to the risk of ESCC and GCC incidence and mortality. The influence of family history on the risk of UGI cancer varies from different types of family members.

Trends in conditional overall survival of esophageal cancer: a population-based study

Background

This study aims to investigate the causes of death in patients with esophageal cancer (EC) and report reliable and accurate estimates of adjusted conditional overall survival (COS).

Methods

We retrieved data on patients aged 18 years or older who were diagnosed with EC between 1975 and 2016 from the Surveillance Epidemiology End Results (SEER) registry. We estimated COS by using an inverse probability weighting method to adjust for the available covariates. Linear trends were analyzed via a weighted linear regression.

Results

A total of 40,142 confirmed patients were included in the final analysis. Of these, 20,971 were diagnosed with esophageal squamous cell carcinoma, and 19,171 were diagnosed with esophageal adenocarcinoma. EC was the leading cause of death, followed by heart disease (5.2%), stomach cancer (3.2%), and other diseases (2.9%). Five-year adjusted COS, given that patients had already survived 36 months was improved from 0.50 to 0.87 (P_Difference<0.001) in comparison with the 5-year conventional overall survival. As the survival time increased from 0 to 48 months, the 5-year adjusted COS improved significantly. The adjusted conditional EC-specific survival also showed similar trends.

Conclusions

For patients with EC who had survived over time, the 5-year adjusted COS and the conditional EC-specific survival improved dramatically. Other causes of death in EC patients should also be considered.

NOX2-Derived Reactive Oxygen Species in Cancer

The formation of reactive oxygen species (ROS) by the myeloid cell NADPH oxidase NOX2 is critical for the destruction of engulfed microorganisms. However, recent studies imply that ROS, formed by NOX2⁺ myeloid cells in the malignant microenvironment, exert multiple actions of relevance to the growth and spread of neoplastic cells. By generating ROS, tumor-infiltrating myeloid cells and NOX2⁺ leukemic myeloid cells may thus (i) compromise the function and viability of adjacent cytotoxic lymphocytes, including natural killer (NK) cells and T cells, (ii) oxidize DNA to trigger cancer-promoting somatic mutations, and (iii) affect the redox balance in cancer cells to control their proliferation and survival. Here, we discuss the impact of NOX2-derived ROS for tumorigenesis, tumor progression, regulation of antitumor immunity, and metastasis. We propose that NOX2 may be a targetable immune checkpoint in cancer.

Functional variation of SLC52A3 rs13042395 predicts survival of Chinese gastric cancer patients

The solute carrier family 52 member 3 (SLC52A3) gene encodes riboflavin transporter protein which is essential to maintain mitochondrial function in cells. In our research, we found that SLC52A3 rs13042395 C > T variation was significantly associated with poor survival in a 926 Chinese gastric cancer (GCa) patients cohort (CC/CT genotype versus TT genotype, HR = 0.57, 95%CI (0.40-0.82), log-rank P = 0.015). The SLC52A3 rs13042395 C > T change led to its increased mRNA expression according to expression quantitative trait loci analysis (P = 0.0029). In vitro, it was revealed that rs13042395 C allele had higher binding affinity to inhibitory transcription factor Meis homeobox 1 (MEIS1) compared with T allele, knock-down of MEIS1 could up-regulate SLC52A3, and overexpression of SLC52A3 contributed to the increased ability of proliferation, colony formation, migration and invasion in GCa cells. Subsequently, the bioinformatics analysis combined with experiments in vitro suggested that Gap junction protein alpha 1 (GJA1) was the downstream effector of SLC52A3, SLC52A3 may promote the GCa cells aggressiveness by down-regulating the GJA1 expression. Overall, SLC52A3 genetic variant rs13042395 C > T change was associated with poorer survival in Chinese GCa patients and increased SLC52A3 expression by interaction with MEIS1. SLC52A3 promoted the GCa cells aggressiveness by down-regulating the GJA1 expression.

Oral leukoplakia and the long-term risk of upper gastrointestinal cancer deaths in the Linxian dysplasia population

BACKGROUND

To investigate oral leukoplakia (OL) and risk of upper gastrointestinal (UGI) cancer deaths in the Linxian Dysplasia Nutrition Intervention Trial (NIT) cohort.

METHODS

A total of 3318 subjects with esophageal squamous dysplasia enrolled on 1 May 1985, and were followed up until 30 September 2015. Participants with OL at baseline were treated as an exposed group, while the remainder was selected as a control group. All subjects were followed monthly and reviewed quarterly by the Linxian Cancer Registry. Cox proportional hazard model was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

During the 30-year follow-up, a total of 902 UGI cancer deaths occurred, including 541 esophageal squamous cell carcinoma (ESCC) related, 284 gastric cardia carcinoma (GCC) related, and 77 gastric noncardia carcinoma (GNCC) related deaths. Relative to subjects without OL, the long-term risk of ESCC mortality in participants with OL increased by 26.1% (HR = 1.26, 95% CI: 1.05-1.52). In the subgroup analyses, adverse effects of OL on ESCC mortality were observed especially in younger subjects (HR = 1.48, 95% CI: 1.11-1.97), females (HR = 1.44, 95% CI: 1.11-1.89), non-smokers (HR = 1.44, 95% CI: 1.15-1.81), nondrinkers (HR = 1.28, 95% CI: 1.04-1.57), and individuals with a family history of cancer (HR = 1.37, 95% CI: 1.05-1.79). No associations were observed between OL and risk of GCC and GNCC mortality.

CONCLUSIONS

OL may increase the long-term risk of ESCC mortality, especially in younger subjects, females, nondrinkers, non-smokers, and subjects with a family cancer history. Future studies are needed to explore the potentially etiological mechanism.

On the effect of vitamin C intake on human health: How to (mis)interprete the clinical evidence

For decades, the potential beneficial effect of vitamin C on human health-beyond that of preventing scurvy-has been subject of much controversy. Hundreds of articles have appeared either in support of increased vitamin C intake through diet or supplements or rejecting the hypothesis that increased intake of vitamin C or supplementation may influence morbidity and mortality. The chemistry and pharmacology of vitamin C is complex and has unfortunately rarely been taken into account when designing clinical studies testing its effect on human health. However, ignoring its chemical lability, dose-dependent absorption and elimination kinetics, distribution via active transport, or complex dose-concentration-response relationships inevitably leads to poor study designs, inadequate inclusion and exclusion criteria and misinterpretation of results. The present review outlines the differences in vitamin C pharmacokinetics compared to normal low molecular weight drugs, focusses on potential pitfalls in study design and data interpretation, and re-examines major clinical studies of vitamin C in light of these.

Vitamin E and cancer prevention: Studies with different forms of tocopherols and tocotrienols

α-Tocopherol (α-T) is the major form of vitamin E (VE) in animals and has the highest activity in carrying out the essential antioxidant functions of VE. Because of the involvement of oxidative stress in carcinogenesis, the cancer prevention activity of α-T has been studied extensively. Lower VE intake or nutritional status has been shown to be associated with increased cancer risk, and supplementation of α-T to populations with VE insufficiency has shown beneficial effects in lowering the cancer risk in some intervention studies. However, several large intervention studies with α-T conducted in North America have not demonstrated a cancer prevention effect. More recent studies have centered on the γ- and δ-forms of tocopherols and tocotrienols (T3). In comparison with α-T, these forms have much lower systemic bioavailability but have shown stronger cancer-preventive activities in many studies in animal models and cell lines. γ-T3 and δ-T3 generally have even higher activities than γ-T and δ-T. In this article, we review recent results from human and laboratory studies on the cancer-preventive activities of different forms of tocopherols and tocotrienols, at nutritional and pharmacological levels. We aim to elucidate the possible mechanisms of the preventive actions and discuss the possible application of the available information for human cancer prevention by different VE forms.

Plant Foods, Antioxidant Biomarkers, and the Risk of Cardiovascular Disease, Cancer, and Mortality: A Review of the Evidence

Although a high intake of plant foods such as fruits, vegetables, whole grains, nuts, and legumes has been recommended for chronic disease prevention, it has been unclear what is the optimal amount of intake of these foods and whether specific subtypes are particularly beneficial. The evidence from several recently published meta-analyses on plant foods and antioxidants and various health outcomes is reviewed as well as more recently published studies. In meta-analyses of prospective studies, inverse associations were observed between intake of fruits, vegetables, whole grains, and nuts and the risk of coronary artery disease, stroke, cardiovascular disease overall, total cancer, and all-cause mortality. The strongest reductions in risk were observed at an intake of 800 g/d for fruits and vegetables, 225 g/d for whole grains, and 15-20 g/d for nuts, respectively. Whole-grain and nut consumption was also inversely associated with mortality from respiratory disease, infections, and diabetes. Stronger and more linear inverse associations were observed between blood concentrations of antioxidants (vitamin C, carotenoids, vitamin E) and cardiovascular disease, cancer, and all-cause mortality than for dietary intake. Most studies that have since been published have been consistent with these results; however, further studies are needed on subtypes of plant foods and less common causes of death. These results strongly support dietary recommendations to increase intake of plant foods, and suggest optimal intakes for chronic disease prevention may be ∼800 g/d for intakes of fruits and vegetables, 225 g/d for whole grains, and 15-20 g/d for nuts. Diets high in plant foods could potentially prevent several million premature deaths each year if adopted globally.

Serologic Profile of Antiparietal Cell Antibodies, Pepsinogens, and H. pylori and Risk of Upper Gastrointestinal Cancer: A Nested Case-Control Study in China

BACKGROUND

Autoimmune gastritis is understudied and possibly associated with gastric noncardia adenocarcinoma (GNCA) and esophageal squamous cell carcinoma (ESCC) in Western populations when it presents as pernicious anemia.

METHODS

A nested case-control study within a Chinese cohort included 100 ESCC, 200 gastric cardia adenocarcinoma (GCA), and 200 GNCA cases diagnosed between 1986 and 2001 and 400 controls. Serostatus of antiparietal cell antibodies (APCA), Helicobacter pylori antibodies, and pepsinogens were measured using commercial kits and serum collected at baseline. We used logistic regression to calculate odds ratios (OR) and 95% confidence interval (CI) for associations between serologic biomarkers and cancer risk adjusted for numerous potential confounders.

RESULTS

There was an average interval of 8 years between baseline blood draw and cancer diagnosis. The baseline prevalence of APCA seropositivity was 10.0% and 14.5% in subjects who developed GCA and GNCA, respectively. APCA seropositivity was inversely associated with later development of GCA (OR = 0.42; 95% CI, 0.24-0.75), but not significantly associated with later development of GNCA (OR = 0.82; 95% CI, 0.50-1.36) or ESCC (OR = 1.05; 95% CI, 0.58-1.88). APCA seropositivity was significantly associated with low pepsinogen I/II ratios (OR = 3.69; 95% CI, 1.66-8.21), and individuals with low pepsinogen I/II ratios who were seronegative for APCA had the highest risk of both GCA and GNCA.

CONCLUSIONS

APCA seropositivity measured years prior to diagnosis was associated with prevalent atrophic gastritis but inversely associated with incident GCA in this Chinese population.

IMPACT

APCA may contribute to a growing list of serologic markers that can improve risk stratification for gastric cancer.

Effects of Helicobacter pylori treatment and vitamin and garlic supplementation on gastric cancer incidence and mortality: follow-up of a randomized intervention trial

OBJECTIVE

To assess the effects of Helicobacter pylori treatment, vitamin supplementation, and garlic supplementation in the prevention of gastric cancer.

DESIGN

Blinded randomized placebo controlled trial.

SETTING

Linqu County, Shandong province, China.

PARTICIPANTS

3365 residents of a high risk region for gastric cancer. 2258 participants seropositive for antibodies to H pylori were randomly assigned to H pylori treatment, vitamin supplementation, garlic supplementation, or their placebos in a 2×2×2 factorial design, and 1107 H pylori seronegative participants were randomly assigned to vitamin supplementation, garlic supplementation, or their placebos in a 2×2 factorial design.

INTERVENTIONS

H pylori treatment with amoxicillin and omeprazole for two weeks; vitamin (C, E, and selenium) and garlic (extract and oil) supplementation for 7.3 years (1995-2003).

MAIN OUTCOME MEASURES

Primary outcomes were cumulative incidence of gastric cancer identified through scheduled gastroscopies and active clinical follow-up through 2017, and deaths due to gastric cancer ascertained from death certificates and hospital records. Secondary outcomes were associations with other cause specific deaths, including cancers or cardiovascular disease.

RESULTS

151 incident cases of gastric cancer and 94 deaths from gastric cancer were identified during 1995-2017. A protective effect of H pylori treatment on gastric cancer incidence persisted 22 years post-intervention (odds ratio 0.48, 95% confidence interval 0.32 to 0.71). Incidence decreased significantly with vitamin supplementation but not with garlic supplementation (0.64, 0.46 to 0.91 and 0.81, 0.57 to 1.13, respectively). All three interventions showed significant reductions in gastric cancer mortality: fully adjusted hazard ratio for H pylori treatment was 0.62 (95% confidence interval 0.39 to 0.99), for vitamin supplementation was 0.48 (0.31 to 0.75), and for garlic supplementation was 0.66 (0.43 to 1.00). Effects of H pylori treatment on both gastric cancer incidence and mortality and of vitamin supplementation on gastric cancer mortality appeared early, but the effects of vitamin supplementation on gastric cancer incidence and of garlic supplementation only appeared later. No statistically significant associations were found between interventions and other cancers or cardiovascular disease.

CONCLUSIONS

H pylori treatment for two weeks and vitamin or garlic supplementation for seven years were associated with a statistically significant reduced risk of death due to gastric cancer for more than 22 years. H pylori treatment and vitamin supplementation were also associated with a statistically significantly reduced incidence of gastric cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00339768.

What have we learned from Linxian esophageal cancer etiological studies?

Esophageal cancer is the sixth leading cause of cancer death in the world. Esophageal squamous cell carcinoma (ESCC) accounts for 90% of esophageal cancer cases, over half of which occur in China. Linxian, a county located in the North Central Taihang Mountain range, has the highest ESCC mortality rate, which may be the leading cause of death in this area. In a decades-long research program in Linxian, Chinese and international scientists have exerted great efforts to describe the epidemiological characteristics and elucidate the etiology of ESCC. A systematic review and summary of the current knowledge gained from previous research is informative for future ESCC prevention and control in similar populations, and may be translated to other high-incidence countries, such as Brazil, Iran, Malawi, and South Africa. As ESCC is a major cause of cancer death, more research is required in China and in other high-incidence countries to deepen our understanding of the etiology of ESCC and develop preventative strategies.

Association between tooth loss and upper gastrointestinal cancer: A 30-year follow-up of the Linxian Dysplasia Nutrition Intervention Trial Cohort

Background

This prospective study investigated the association between tooth loss and upper gastrointestinal (UGI) cancer mortality in the Linxian Dysplasia Nutrition Intervention Trial Cohort.

Methods

Subjects were categorized into three groups according to age at baseline. No missing teeth and less or greater than median tooth loss in each group was defined as none, moderate, and severe, respectively. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using the Cox proportional hazard model.

Results

Through 30 September 2015, 541 esophageal squamous cell carcinoma (ESCC), 284 gastric cardia carcinoma (GCC), and 77 gastric non‐cardia carcinoma (GNCC) deaths occurred. In the six‐year follow‐up, severe tooth loss was associated with an increased risk of GCC mortality (HR 1.55, 95% CI 1.06–2.18). In the 15‐year follow‐up, moderate tooth loss increased the ESCC mortality risk by 58% (HR 1.58, 95% CI 1.06–2.35), while severe loss increased the GCC mortality risk by 30% (HR 1.30, 95% CI 1.03–1.64). In the 30‐year follow‐up, moderate tooth loss increased the risk of ESCC mortality (HR 1.34, 95% CI 1.01–1.76). In subjects aged < 55 at baseline and men, moderate tooth loss had 53% and 52% higher risks of ESCC mortality (HR_{<55 years} 1.53, 95% CI 1.06–2.05; HRmen 1.52, 95% CI 1.01–2.28). No significant association was observed for GNCC in any subjects or subgroups.

Conclusion

Moderate tooth loss increased the risk of ESCC mortality, particularly in younger subjects and men. Severe tooth loss increased the risk of GCC mortality. Future studies are needed to confirm these findings.

Paradoxical Roles of Oxidative Stress Response in the Digestive System before and after Carcinogenesis

Oxidative stress is recognized as a cancer-initiating stress response in the digestive system. It is produced through mitochondrial respiration and induces DNA damage, resulting in cancer cell transformation. However, recent findings indicate that oxidative stress is also a necessary anticancer response for destroying cancer cells. The oxidative stress response has also been reported to be an important step in increasing the anticancer response of newly developed molecular targeted agents. Oxidative stress might therefore be a cancer-initiating response that should be downregulated in the precancerous stage in patients at risk of cancer but an anticancer cell response that should not be downregulated in the postcancerous stage when cancer cells are still present. Many commercial antioxidant agents are marketed as “cancer-eliminating agents” or as products to improve one’s health, so cancer patients often take these antioxidant agents. However, care should be taken to avoid harming the anticancerous oxidative stress response. In this review, we will highlight the paradoxical effects of oxidative stress and antioxidant agents in the digestive system before and after carcinogenesis.

Association of plasma vitamin C concentration to total and cause-specific mortality: a 16-year prospective study in China

BACKGROUND

Vitamin C insufficiency occurs across many countries and has been hypothesised to increase risk of various diseases. Few prospective studies with measured circulating vitamin C have related deficiency to disease mortality, particularly in low-income and middle-income countries.

METHODS

We randomly selected 948 subjects (473 males and 475 females) aged 53-84 years from a Chinese cohort and measured meta-phosphoric acid-preserved vitamin C concentrations in plasma samples collected in 1999-2000. A total of 551 deaths were accrued from sample collection through 2016, including 141 from cancer, 170 from stroke and 174 from heart diseases. Vitamin C was analysed using season-specific quartiles, as a continuous variable and as a dichotomous variable based on sufficiency status (normal >28 µmol/L vs low ≤28 µmol/L). HRs and 95% CIs were estimated using Cox proportional hazards models.

RESULTS

We found significant inverse associations between higher plasma vitamin C concentrations and total mortality in quartile (HR_{Q4 vs Q1}0.75, 95% CI 0.59 to 0.95), continuous (HR_q20umol/L0.90, 95% CI 0.82 to 0.99) and dichotomous analyses (HR_{normal-vs-low}0.77, 95% CI 0.63 to 0.95). We observed significant lower risks of heart disease (p_{trend-by-quantile}=0.03) and cancer deaths (p_{global-across-quantile}=0.04) for higher vitamin C, whereas the association was attenuated for stroke in adjusted models. Similar inverse associations were found when comparing normal versus low vitamin C for heart disease (HR_{normal-vs-low}0.62, 95% CI 0.42 to 0.89).

CONCLUSION

In this long-term prospective Chinese cohort study, higher plasma vitamin C concentration was associated with lower total mortality, heart disease mortality and cancer mortality. Our results corroborate the importance of adequate vitamin C to human health.