Recent incidence trends and sociodemographic features of oesophageal and gastric cancer types in an English region

Perforated Peptic Ulcer: A Case Report of a Dreaded Complication of an Insidious Disease

Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not only in their acute presentation but also in the diagnostic challenges they pose, particularly in patients with complex medical histories. Here we present a case of a 71-year-old female with a complex medical history, including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain, who initially were unresponsive and cyanotic. Despite challenges in diagnosis due to her medical complexity and opioid use, she was ultimately diagnosed with a perforated duodenal ulcer. Tragically, despite immediate surgical intervention, she succumbed to her illness, highlighting the complexities involved in managing perforated peptic ulcers, especially in patients with multiple chronic medical conditions. Peptic ulcer disease (PUD) can often remain asymptomatic, leading to delayed diagnosis and potentially life-threatening complications like perforation. Mortality rates associated with perforated peptic ulcers vary widely, ranging from 1.3% to 20%, with risk factors including nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, smoking, and corticosteroid use. Diagnosis necessitates a high index of suspicion, thorough clinical examination, and imaging modalities such as computed tomography (CT) scans with oral contrast. Treatment strategies range from nonoperative management with intravenous (IV) histamine H2-receptor blockers or proton pump inhibitors (PPIs) to surgical intervention, depending on the patient's hemodynamic stability. However, the case presented underscores the challenges in timely diagnosis and intervention, particularly in patients with complex medical histories, where symptoms may be masked or attributed to other comorbidities. Recent studies indicate a demographic shift toward older age and a higher prevalence among females, emphasizing the importance of increased awareness and vigilance among healthcare providers. Early recognition of symptoms, prompt investigation, and interdisciplinary collaboration are crucial in optimizing outcomes for patients presenting with perforated peptic ulcers, especially in the context of their underlying medical conditions.

Effect of Helicobacter pylori Eradication Therapy on the Incidence of Noncardia Gastric Adenocarcinoma in a Large Diverse Population in the United States

BACKGROUND & AIMS

High-quality data regarding the effect of Helicobacter pylori eradication on the risk of noncardia gastric adenocarcinoma (NCGA) remain limited in the United States. We investigated the incidence of NCGA after H pylori eradication therapy in a large, community-based US population.

METHODS

We performed a retrospective cohort study of Kaiser Permanente Northern California members who underwent testing and/or treatment for H pylori between 1997 and 2015 and were followed through December 31, 2018. The risk of NCGA was evaluated using the Fine-Gray subdistribution hazard model and standardized incidence ratios.

RESULTS

Among 716,567 individuals with a history of H pylori testing and/or treatment, the adjusted subdistribution hazard ratios and 95% confidence intervals of NCGA for H pylori-positive/untreated and H pylori-positive/treated individuals were 6.07 (4.20-8.76) and 2.68 (1.86-3.86), respectively, compared with H pylori-negative individuals. When compared directly with H pylori-positive/untreated individuals, subdistribution hazard ratios for NCGA in H pylori-positive/treated were 0.95 (0.47-1.92) at <8 years and 0.37 (0.14-0.97) ≥8 years of follow-up. Compared with the Kaiser Permanente Northern California general population, standardized incidence ratios (95% confidence interval) of NCGA steadily decreased after H pylori treatment: 2.00 (1.79-2.24) ≥1 year, 1.01 (0.85-1.19) ≥4 years, 0.68 (0.54-0.85) ≥7 years, and 0.51 (0.38-0.68) ≥10 years.

CONCLUSION

In a large, diverse, community-based population, H pylori eradication therapy was associated with a significantly reduced incidence of NCGA after 8 years compared with no treatment. The risk among treated individuals became lower than the general population after 7 to 10 years of follow-up. The findings support the potential for substantial gastric cancer prevention in the United States through H pylori eradication.

Epidemiological Review of Gastroesophageal Junction Adenocarcinoma in Asian Countries

BACKGROUND

Similar trends in the prevalence of gastroesophageal reflux disease (GERD), obesity, and Helicobacter pylori infection have been observed in Asian and Western countries despite their time differences. However, it is unclear whether the prevalence of gastroesophageal junction adenocarcinomas in Asian countries is increasing. In this review, we discuss the epidemiological trends of gastroesophageal junction adenocarcinoma in Asian countries.

SUMMARY

The prevalence of GERD is increasing in Asian countries, but most cases are considered mild. Obesity is a serious problem worldwide, but it is considered less serious in Asia than in Western countries. In Asian countries where gastric cancer is common, both cardiac and noncardiac cancers are associated with high rates of H. pylori infection, which is considered a carcinogenic risk factor for both sites of cancer. The widespread use of H. pylori eradication therapy for chronic gastritis in several Asian countries has not directly led to an increased prevalence of esophageal adenocarcinoma. One of the originating sites of junctional adenocarcinoma in most Asian countries is Barrett's esophagus, with short-segment Barrett's esophagus having much lower carcinogenicity than long-segment Barrett's esophagus. Key Messages: Considering the future trends of several risk factors for gastroesophageal junction adenocarcinoma in Asian countries, it is likely that the incidence of gastroesophageal junction adenocarcinoma will gradually increase, but not at a rate that exceeds that of squamous cell carcinoma, as in Western countries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risks and Predictors of Gastric Adenocarcinoma in Patients with Gastric Intestinal Metaplasia and Dysplasia: A Population-Based Study

OBJECTIVES

Gastric intestinal metaplasia and dysplasia are precursor lesions for adenocarcinoma. The risks of progression to malignancy from these lesions are not well characterized, particularly in the US populations.

METHODS

We identified 4,331 Kaiser Permanente Northern California members who were diagnosed with gastric intestinal metaplasia or dysplasia between 1997 and 2006 and followed them through December 2013. The incident rates of gastric adenocarcinoma, relative risks in comparison with the Kaiser Permanente general population, and predictors of progression to malignancy were investigated.

RESULTS

Among 4,146 individuals with gastric intestinal metaplasia and 141 with low-grade dysplasia with 24,440 person-years follow-up, 17 and 6 cases of gastric adenocarcinoma were diagnosed, respectively, after 1 year from the index endoscopy. The incidence rate of gastric adenocarcinoma was 0.72/1,000 person-years in patients with intestinal metaplasia, with a relative risk of 2.56 (95% confidence interval (CI) 1.49-4.10) compared with the Kaiser Permanente member population, and 7.7/1,000 person-years for low-grade dysplasia, with a relative risk of 25.6 (95% CI, 9.4-55.7). The median time for gastric intestinal metaplasia to progress to adenocarcinoma was 6.1 years, and for low-grade dysplasia, 2.6 years. Hispanic race/ethnicity and history of dysplasia were associated with significantly higher risk of progression to gastric adenocarcinoma.

CONCLUSIONS

Gastric intestinal metaplasia and dysplasia are significant predictors for gastric adenocarcinoma. The low risk for malignancy associated with intestinal metaplasia does not support routine endoscopic surveillance. However, surveillance should be considered in patients at higher risks, including those with suspicious endoscopic features, presence of dysplasia, and Hispanic race/ethnicity.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The socioeconomic profile of a Barrett's oesophagus cohort assessed by the 2010 Index of Multiple Deprivation

BACKGROUND

Several reports have described the relationship between socioeconomic status and oesophageal adenocarcinoma but only one with its precursor condition, Barrett's oesophagus. We therefore investigated such an association.

PATIENTS

The majority (88%) of patients diagnosed with Barrett's at Rotherham District General Hospital between 28 April 1978 and 31 August 2012 consented to inclusion in the UK Barrett's Oesophagus Registry. Those residing within Rotherham form the basis of this study.

METHODS

We assessed socioeconomic status using the Index of Multiple Deprivation 2010 scores which can be assigned to every English postcode. The scores for the whole of England were divided into five equal groups; those of the 6257 postcodes within Rotherham (including those of Barrett's patients) were compared against the national quintile relevant to their score. We examined the ratio of observed against expected numbers of Barrett's in each quintile before and since 2001, the median year of diagnosis.

RESULTS

The study group comprised 1076 patients with Barrett's oesophagus. Before 2001 their distribution across the deprivation quintiles was similar to that expected. Since then it has changed significantly, with 37% more Barrett's patients than expected among the two least deprived quintiles, but 11% fewer than expected in the larger population comprising the two most deprived quintiles (P=0.0001). There was no significant difference in the distribution of sex (P=0.27), nor the mean age at diagnosis between the two time periods (P=0.92).

CONCLUSION

Since 2001, there has been a major change in the distribution of Barrett's in relation to socioeconomic status, measured by the Index of Multiple Deprivation.

Significant Racial Disparities Exist in Noncardia Gastric Cancer Outcomes Among Kaiser Permanente's Patient Population

INTRODUCTION

Racial and ethnic differences in gastric cancer are not well understood. This study sought to compare the clinicopathological features and survival of noncardia gastric adenocarcinoma (NCGA) patients with different racial/ethnic backgrounds in Kaiser Permanente Northern California (KPNC), a large integrated health care system.

METHODS

This was a retrospective cohort study of 1,366 patients with newly diagnosed NCGA between 2000 and 2010. The subjects were categorized into four racial/ethnic groups: non-Hispanic Whites, Blacks, Asians, and Hispanics. Clinicopathological information and survival data were obtained from the KPNC electronic databases and compared among the four racial/ethnic groups.

RESULTS

The incidence of NCGA declined in Blacks and Whites, but remained stable in Asians and Hispanics. Whites had a lower incidence of NCGA compared with non-Whites. Asians and Hispanics were diagnosed at a younger age compared with Whites (mean age at diagnosis: 66, 63, and 72 years, respectively; P < 0.0001). Diffuse/mixed histological type (Lauren classification) was more prevalent in Asians and Hispanics than in Whites and Blacks (46 and 45 vs. 36 and 29 %, respectively, P = 0.001). History of Helicobacter pylori testing was associated with better survival. Asians had the highest survival rates at 1, 2, and 5 years, while Whites had the lowest (P < 0.0001).

CONCLUSIONS

Significant racial/ethnic differences exist in patients with noncardia gastric cancer. Asians and Hispanics were younger at diagnosis and had more diffuse/mixed histological type. Asians had the highest survival, while Whites had the lowest. Such differences may be related to biological, environmental, and treatment-related factors.

Changing trends in the proportions of small (≤ 2 cm) proximal and non-proximal gastric carcinomas treated at a high-volume tertiary medical center in China

OBJECTIVE

Guided by the recently established histological criteria of the gastroesophageal junction (GEJ), we aimed to investigate and compare trends in the proportions of small (≤ 2 cm) proximal gastric carcinoma (PGC) vs non-PGC (NPGC) in Chinese patients over an 8-year period.

METHODS

The study was conducted with consecutive surgical resected specimens of small PGC that was located within 3 cm below the GEJ and NPGC (located at all other gastric regions) treated at a single medical center in China. Differences in proportions between the two groups were compared.

RESULTS

Among all 313 cases, 111 (35.5%) were classified as PGC and the remaining 202 (64.5%) as NPGC. Patients with PGC were significantly elder than those with NPGC, and none aged younger than 40 years. The proportions of PGC significantly and progressively increased from 16% in 2004 to 45% in 2011, in contrast to a steady decreasing trend for NPGC from 84% to 55% over the same period. The difference in trends between the two groups approached, but was not at a statistically significant level (P = 0.08). Proportions of small cancers in the gastric corpus and in female patients remained low and stable, in contrast to a significantly higher proportion in male patients (P < 0.05).

CONCLUSIONS

Our data showed a significantly upward-shifting trend in the proportions of small PGC, primarily in elderly male patients, in contrast to a downward shifting trend in NPGC over the most recent 8-year period in Chinese patients.

Description and predictors of hospital costs of oesophageal cancer during the first year following diagnosis in Northern Ireland

The cost-effectiveness of novel interventions in the treatment of cancer is well researched; however, relatively little attention is paid to the cost of many aspects of routine care. Oesophageal cancer is the ninth most common cancer in the UK and sixth most common cause of cancer death. It usually presents late and has a poor prognosis. The hospital costs incurred by oesophageal cancer patients diagnosed in Northern Ireland in 2005 (n = 198) were determined by review of medical records. The average cost of hospital care per patient in the 12 months from presentation was £7847. Variations in total hospital costs by age at diagnosis, gender, cancer stage, histological type, mortality at 1 year, co-morbidity count and socio-economic status were analysed using multiple regression analyses. Higher costs were associated with earlier stages of cancer and cancer stage remained a significant predictor of costs after controlling for cancer type, patient age and mortality at 1 year. Thus, although early detection of cancer usually improves survival, this would mean increased costs in the first year. Deprivation achieved borderline significance with those from more deprived areas having lower resource consumption relative to the more affluent.

Health benefits and cost effectiveness of endoscopic and nonendoscopic cytosponge screening for Barrett's esophagus

BACKGROUND & AIMS

We developed a model to compare the health benefits and cost effectiveness of screening for Barrett's esophagus by either Cytosponge™ or by conventional endoscopy vs no screening, and to estimate their abilities to reduce mortality from esophageal adenocarcinoma.

METHODS

We used microsimulation modeling of a hypothetical cohort of 50-year-old men in the United Kingdom with histories of gastroesophageal reflux disease symptoms, assuming the prevalence of Barrett's esophagus to be 8%. Participants were invited to undergo screening by endoscopy or Cytosponge (invitation acceptance rates of 23% and 45%, respectively), and outcomes were compared with those from men who underwent no screening. We estimated the number of incident esophageal adenocarcinoma cases prevented and the incremental cost-effectiveness ratio of quality-adjusted life years (QALYs) of the different strategies. Patients found to have high-grade dysplasia or intramucosal cancer received endotherapy. Model inputs included data on disease progression, test accuracy, post-treatment status, and surveillance protocols. Costs and benefits were discounted at 3.5% per year. Supplementary and sensitivity analyses comprised esophagectomy management of high-grade dysplasia or intramucosal cancer, screening by ultrathin nasal endoscopy, and different assumptions of uptake of screening invitations for either strategy.

RESULTS

We estimated that compared with no screening, Cytosponge screening followed by treatment of patients with dysplasia or intramucosal cancer costs an additional $240 (95% credible interval, $196-$320) per screening participant and results in a mean gain of 0.015 (95% credible interval, -0.001 to 0.029) QALYs and an incremental cost-effectiveness ratio of $15.7 thousand (K) per QALY. The respective values for endoscopy were $299 ($261-$367), 0.013 (0.003-0.023) QALYs, and $22.2K. Screening by the Cytosponge followed by treatment of patients with dysplasia or intramucosal cancer would reduce the number of cases of incident symptomatic esophageal adenocarcinoma by 19%, compared with 17% for screening by endoscopy, although this greater benefit for Cytosponge depends on more patients accepting screening by Cytosponge compared with screening by endoscopy.

CONCLUSIONS

In a microsimulation model, screening 50-year-old men with symptoms of gastroesophageal reflux disease by Cytosponge is cost effective and would reduce mortality from esophageal adenocarcinoma compared with no screening.

Coffee consumption and risk of gastric and pancreatic cancer--a prospective cohort study

Only few prospective studies have examined the association between coffee consumption and risk of gastric and pancreatic cancer. This study is designed to evaluate this relationship among Finns, whose coffee consumption is the highest in the world. A total of 60,041 Finnish men and women who were 26-74 years of age and without history of any cancer at baseline were included in the present analyses. Coffee consumption and other study parameters were determined at baseline using standardized measurements. Participants were prospectively followed up for onset of gastric and/or pancreatic cancer, emigration, death or until June 30, 2006. During a mean follow-up period of 18 years, 299 cases of gastric cancer and 235 cases of pancreatic cancer were found. There was a nonsignificant inverse association between coffee consumption and risk of gastric cancer among men but not in the women. The multivariate-adjusted hazard ratio of stomach and pancreatic cancer incidence for ≥ 10 cups of coffee per day compared with nondrinkers were 0.75 (95% CI, 0.40-1.41) (P for trend = 0.19) and 0.82 (95% CI, 0.38-1.76) (P for trend = 0.95) for the combined population of men and women, respectively. We did not find a significant association between coffee consumption and the risk of gastric and/or pancreatic cancers.

Epidemiology of noncardia gastric adenocarcinoma in the United States

OBJECTIVES

Adenocarcinomas of the cardia (International Classification of Diseases (ICD)-9 code 151.0) and stomach (ICD-9 codes 151.1-151.9) are frequently grouped together in epidemiologic statistics, but are clearly distinct diseases. The objective of this study was to describe the current epidemiology of noncardia gastric cancer (noncardia gastric adenocarcinoma (NCGA)) in the United States.

METHODS

Rates of NCGA in the United States from 1997 to 2008 were analyzed in three national databases: the Surveillance, Epidemiology, and End Results registry was used for incidence, the Healthcare Costs and Utilization Project for hospitalizations, and the Compressed Mortality File for mortality. Population-based rates were calculated and age-adjusted to the US 2000 population using direct standardization. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated and adjusted for confounders with the Mantel-Haenszel method.

RESULTS

Annually, NCGA was associated with 18,873 incident cases, 17,284 hospitalizations for principal discharge diagnoses, 31,354 hospitalizations for all-listed diagnoses, and 11,562 deaths. Incidence was greater in men (OR=1.56, CI=1.53-1.59) and non-White races (OR=2.38, 2.33-2.43). Hospitalization was more common in men (1.82, 1.81-1.83) and non-White races (2.13, 2.10-2.15). Mortality was more common in men (1.83, 1.81-1.86) and non-White races (2.23, 2.20-2.26). NCGA rates showed a marked age-dependent rise (P<0.001). Hospitalization and mortality were greatest in the Northeast region of the United States (P<0.001).

CONCLUSIONS

Epidemiologic patterns of NCGA were congruent in three national databases. Older age, male gender, non-White race, and residence in the Northeast region were associated with increased risk. These patterns may reflect the underlying variations in Helicobacter pylori, lifestyle, and environmental exposures.

The changing face of esophageal cancer

The two main histological esophageal cancer types, adenocarcinoma and squamous cell carcinoma, differ in incidence, geographic distribution, ethnic pattern and etiology. This article focuses on epidemiology with particular reference to geographic and temporal variations in incidence, along with a review of the evidence supporting environmental and genetic factors involved in esophageal carcinogenesis. Squamous cell carcinoma of the esophagus remains predominantly a disease of the developing world. In contrast, esophageal adenocarcinoma is mainly a disease of western developed societies, associated with obesity and gastro-esophageal reflux disease. There has been a dramatic increase in the incidence of adenocarcinoma in developed countries in parallel with migration of both esophageal and gastric adenocarcinomas towards the gastro-esophageal junction.

Trends and variation in the management of oesophagogastric cancer patients: a population-based survey

Background

Previous evidence indicates potential variation in the quality of care of cancer patients. We aimed to examine whether recent changes in the treatment of oesophagogastric cancers have been distributed equally among different patient subgroups.

Methods

We analysed population-based cancer registry data about the treatment patterning of oesophagogastric cancer (other than oesophageal squamous cell carcinoma) during 1995-2006.

Results

There were 14,077 patients aged ≥40 years (69% men). There was only limited information on stage, and no information on co-morbidity status. During successive triennia, curative surgery use decreased from 28% to 20% (p < 0.001) whilst chemotherapy use increased from 9% to 30% (p < 0.001). Use of palliative surgery and of radiotherapy increased significantly but modestly (7% to 10%, and 9% to 11%, respectively). In multivariable logistic regression adjusting for age group, gender, diagnosis period and tumour type, curative surgery and chemotherapy were used less frequently in more deprived patients [per increasing deprivation group Odds Ratio (OR) = 0.96, 95% Confidence Interval (CI) 0.93-0.99, and OR = 0.90, 95%CI 0.87-0.93, respectively, p < 0.001 for both)]. Chemotherapy was also used less frequently in women (OR = 0.76, p < 0.001).

Conclusions

During the study period, curative surgery decreased by a third and chemotherapy use increased by more than three-fold, reflecting improvements in the appropriateness and quality of management, but chemotherapy use, in particular, was unequal, both by socioeconomic status and gender.