Outcome of oesophagogastric carcinoma in young patients

Outcomes assessment of the surgical management of esophageal cancer in younger and older patients

BACKGROUND

The aim of this study was to assess the influence of age on disease presentation, clinical and pathologic staging, postoperative outcomes, costs, and long-term survival after esophagectomy for esophageal malignancy.

METHODS

All patients undergoing esophagectomy for cancer between 1991 and 2011 were prospectively enrolled in an Institutional Review Board approved database.

RESULTS

A total of 493 patients underwent surgical resection during the study period; 58 (11.76%) of these patients were 50 years or less (44 ± 4.7) and 435 patients were greater than 50 years (67 ± 8.44). There was no difference in clinical stage; however, patients 50 years or less were more likely to have adenocarcinoma and reduced Charlson comorbidity index and younger patients tended to have a more delayed presentation as manifested by an increased period of dysphagia and a greater degree of weight loss. In the 50 or less age group there was a significantly greater use of neoadjuvant therapy in stage II patients and the use of neoadjuvant chemotherapy significantly decreased with increasing age. Surgery in the 50 or less age group was associated with significantly reduced intensive care unit stay, incidence of postoperative complications, and overall costs. Multivariate analysis also confirmed associations between increasing age and increased incidence of postoperative complications and cost. There were no significant differences in pathologic stage, positive resection margins, incidence of complete response to neoadjuvant therapy, or in overall survival.

CONCLUSIONS

This study demonstrates younger patients have fewer complications and lower overall treatment costs after esophagectomy. In spite of having a more delayed presentation, younger patients presented with a similar stage and demonstrated similar overall survival.

Prevalence and clinicopathologic characteristics of gastric cardia cancer in South Korea

BACKGROUND AND AIM

Western reports have suggested that the prevalence of gastric cardia cancer (GCC) has been increasing, and indicated some differences between GCC and gastric noncardia cancer (GNCC). However, few studies have been conducted in Asia. The aims of this study were to estimate the prevalence of GCC and to evaluate differences of clinicopathologic characteristics between GCC and GNCC in South Korea.

METHODS

This study was single-center case-control study. A total of 829 patients with gastric cancer and 270 controls were enrolled between 2003 and 2011. Baseline characteristics, Helicobacter pylori (H. pylori) infection status, and histologic characteristics were compared among three groups (GCC, GNCC, and control).

RESULTS

Sixty cases (7.2%) of gastric cancer were located in cardia. Multivariate analysis showed that male odds ratio (OR, 5.72; 95% CI, 1.72-19.07; p = .005) and cigarette smoking (OR, 5.38; 95% CI, 1.39-20.90; p = .015) were risk factors of GCC in comparison with control group, but H. pylori infection rate was not significant. In the case of GNCC, cigarette smoking (OR, 3.87; 95% CI, 1.81-8.29; p < .001), past alcohol intake (OR, 2.82; 95% CI, 1.28-6.20; p = .010), intestinal metaplasia (OR, 3.22; 95% CI, 2.00-5.17; p < .001), and H. pylori infection (OR, 3.06; 95% CI, 1.90-4.93; p < .001) were risk factors of GNCC. Gastroesophageal reflux disease symptoms were higher in the GNCC (21.2%) than control group (13.5%) (p = .008). However, in the case of GCC, they were similar between the GCC (12.7%) and control group (p = .872). According to multivariate analysis, history of H. pylori eradication (OR, 0.34; 95% CI, 0.19-0.61; p < .001) was associated with a protective effect on GNCC. GCC showed higher depth of invasion (p = .038) and frequent distant metastasis (p = .012) than GNCC.

CONCLUSION

In this referral center based study, the prevalence of GCC was 7.2% in South Korea. Risk factors and clinicopathologic characteristics for GCC and GNCC were different, supporting that the pathophysiology is different in the development of GCC and GNCC.

The impact of young age on outcomes in esophageal and junctional cancer

It is not known whether patients diagnosed with esophageal and junctional cancer aged younger than 50 years have a more aggressive disease phenotype and thus poorer outcomes following treatment. Prospectively maintained database records of all patients diagnosed with esophageal carcinoma (n= 2129) over a 20-year period (1990-2009) in a single institution were analyzed. Patients aged less than 50 years at diagnosis (n= 170) were compared with those over 50 years with respect to clinicopathological stage and oncological outcomes. There was a significantly greater proportion of male patients (77.4 vs. 64.7%) among the younger group (P= 0.001). Patients were more likely to be diagnosed with an esophagogastric junction tumor (P= 0.002) and to have symptoms for a longer period prior to diagnosis (24.0 vs. 17.8 weeks, P= 0.03) if they were aged less than 50 years old. There was no significant difference in clinicopathological staging including Tumor-Nodal-Metastasis (TNM) stage, differentiation, and lymphatic and perineural invasion other than a greater likelihood of venous invasion in the older group (P= 0.002). Younger patients were more likely to be treated with curative rather than palliative intent (66.9 vs. 51.1%, P < 0.001). The disease-specific survival of patients younger than 50 years treated with curative intent was significantly greater than older patients (median 35 vs. 21 months, P= 0.04), except for the subgroup of patients aged less than 35 years (n= 18) who have reduced survival. Multivariate analysis revealed independent factors related to the difference in survival included sex, age, advanced T stage, and nodal metastases (P < 0.05). A consistent proportion of esophageal cancer patients are diagnosed aged less than 50 years old over time (1990-2009). Few phenotypic tumor differences were noted between the groups. With an aggressive approach to management, survival is significantly greater than in the older cohort, although outcomes are poorer in those aged below 35 years.

Endoscopic, clinicopathological features and prognosis of very young patients with gastric cancer

BACKGROUND AND AIM

The number of clinical reports of very young (<35 years) patients with gastric cancer are limited. We aimed to investigate the endoscopic and clinicopathological features and long-term prognosis of this unique group of patients.

METHODS

A prospective endoscopy database review of all consecutive very young patients with gastric cancer was performed. The gender, age, clinical features, endoscopic and pathologic findings, and long-term survival of these very young patients were analyzed and compared with those of elderly patients.

RESULTS

A total of 210 patients were included with a median age of 31 year, 60.0% was female, and 34.3% presented with alarm features, 19.0% reported family history of gastric cancer. 58.1% of these cancers were located in gastric body, 33.8% were located in the antrum. 63.8% of these cancers were found to be diffuse type; 18.1% of patients underwent curative surgical treatment, and the 5-year survival rate was 42.1%.

CONCLUSIONS

The study describes that very young patients with gastric cancer were mainly females, who were less likely to present with alarm features, but had a high frequency of family history of gastric cancer; and the majority of these cancers were located in gastric body, and they had similar long-term prognosis compared with elderly counterparts if curative surgical resection was performed.

Presentation and survival of operable esophageal cancer in patients 55 years of age and below

BACKGROUND

The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer.

METHODS

This study was conducted from 2000 to 2007 in a specialized esophagogastric center. All patients who had esophageal cancer operations were included. Variables collected included ages, duration of symptoms, presenting symptoms, tumor characteristics, and follow-up data.

RESULTS

In total, 365 esophagectomies were performed for cancer, of which 76 patients were younger than aged 55 years (20.8%) and 289 were older than aged 55 years. In patients younger than aged 55 years, 15 patients had symptoms for 6 months or more, 54 had dysphagia, 35 had weight loss compared with 220 and 175 respectively of patients older than aged 55 years. On histopathology, 48 had T3 tumors (63.2%), 17 had T2 (22.4%), and 10 had T1 (13.2%) for patients younger than aged 55 years compared with 141 had T3 (48.7%), 85 had T2 (29.4%), and 55 had T1 (19%) for patients older than aged 55 years. These differences in tumor stage at presentation between groups were significant (p < 0.05 with 3DF). In-hospital mortality was 0 for the group younger than aged 55 years and 5 for those older than aged 55 years. Average follow-up was 35 (minimum, 15) months. Thirty patients had locoregional recurrence in the first group and 110 in the latter group. Survival at 1 year after surgery was 79.6%, at 2 years 65.1%, and at 5 years 42.3% compared with 78.4, 60.6, and 45.9%, respectively, for the group older than aged 55 years, but this was not significant using log-rank (p = 0.99).

CONCLUSIONS

A significant proportion (20.8%) of patients presenting with operable esophageal cancer was younger than aged 55 years. Almost two-thirds of those presenting younger than aged 55 years had T3 stage tumors, which was significantly different than those older than aged 55 years. Despite more advanced tumor stage at presentation, the prognosis of esophageal cancer for patients younger than aged 55 years is similar to those older than aged 55 years (log-rank = 0.99).

Presentation and prognosis of esophageal adenocarcinoma in patients below age 50

Esophageal adenocarcinoma (EAC), one of the fastest growing cancers in the United States, is increasingly recognized in younger patients in whom the clinicopathologic features have been poorly described. We aim to compare clinical presentation between early (i.e., <or=50 years of age) and later onset EAC, and to evaluate factors associated with survival. All patients diagnosed with EAC at our hospital between 1994 and 2004 were evaluated. Demographics, social history, family history of cancer, clinical presentation, diagnosis during Barrett's surveillance, endoscopic and histologic findings, treatment, and survival were compared between patients older than 50 and <or=50 years of age. Thirty-one of 242 (12.8%) patients were <or=50 years at diagnosis. Patients <or=50 were more likely to present with dysphagia (80% vs. 60%, P = 0.003) and have lymphatic spread at diagnosis (48% vs. 31%, P = 0.015). Median survival was 21.1 months (range 13.1-31.4) for younger patients and 22.0 months (range 20.0-28.1) for older patients (P = NS). Factors associated with shortened survival were dysphagia at presentation, advanced histologic grade, lymphatic spread, and esophagectomy. By multivariable analysis, shortened survival was associated with histologic grade (P = 0.03) and lymphatic spread (P = 0.01). Younger patients comprise a considerable proportion of newly diagnosed EAC. Diagnosis is delayed in younger patients presenting with dysphagia which contributes to adverse outcomes and advanced stage at time of diagnosis. Early endoscopy should be performed in the evaluation of gastroesophageal reflux disease (GERD) and dysphagia, particularly for patients younger than 50 years.

Role of symptoms in diagnosis and outcome of gastric cancer

Gastric cancer is one of the most common cancers and the second most common cause of cancer deaths worldwide. Apart from Japan, where screening programmes have resulted in early diagnosis in asymptomatic patients, in most countries the diagnosis of gastric cancers is invariably made on account on dyspeptic and alarm symptoms, which may also be of prognostic significance when reported by the patient at diagnosis. However, their use as selection criteria for endoscopy seems to be inconsistent since alarm symptoms are not sufficiently sensitive to detect malignancies. In fact, the overall prevalence of these symptoms in dyspeptic patients is high, while the prevalence of gastro-intestinal cancer is very low. Moreover, symptoms of early stage cancer may be indistinguishable from those of benign dyspepsia, while the presence of alarm symptoms may imply an advanced and often inoperable disease. The features of dyspeptic and alarm symptoms may reflect the pathology of the tumour and be of prognostic value in suggesting site, stage and aggressiveness of cancer. Alarm symptoms in gastric cancer are independently related to survival and an increased number, as well as specific alarm symptoms, are closely correlated to the risk of death.Dysphagia, weight loss and a palpable abdominal mass appear to be major independent prognostic factors in gastric cancer, while gastro-intestinal bleeding, vomiting and also duration of symptoms, do not seem to have a relevant prognostic impact on survival in gastric cancer.

Palliative care treatment patterns and associated costs of healthcare resource use for specific advanced cancer patients in the UK

The purpose of this paper is to identify the treatment patterns and corresponding costs of healthcare resource use associated with palliative care for different types of advanced cancer patients, from the time they started strong opioid treatment until death. This was a modelling study performed from the perspective of the UK's National Health Service (NHS). A data set was created comprising 547 patients in the DIN-Link database who had a Read code for malignant neoplasms with a specific tumour-type diagnosis and who received their first strong opioid between 1 January 1998 and 30 September 2000 and died during that period. Palliative care-related resource utilization data were obtained from the DIN-Link database. Unit costs at 2000/2001 prices were applied to the resource use estimates to determine the mean cost of palliative care from the start of treatment until death. There were significant differences in age between patients with different cancer types and in patients' survival from diagnosis, time to the start of palliative care and duration of palliative care. The mean duration from cancer diagnosis to the start of strong opioid treatment ranged from 0.7 to 5.4 years in patients with lung and breast cancer respectively. Moreover, the length of palliative care ranged from 180 to 372 days in patients with these cancer types respectively. There were also statistically significant differences in resource use between patients with different cancer types, but this reflected, in part, the varying durations of palliative care. Nevertheless, there were also differences in the monthly number of primary care visits reflecting the different number of monthly prescriptions. There was no apparent relationship between the length and corresponding cost of palliative care which ranged from 1816 pounds sterling for colon cancer to 4789 pounds sterling for ovarian cancer. Additionally, on average, only a third of all patients also received 4-hourly morphine as part of their initial strong opioid treatment. The total cost of palliative care varied between cancer type and reflects, at least in part, the distinct clinical features associated with different tumours and the varying lengths of survival following the start of strong opioid treatment. Nevertheless, no apparent relationship was found between length of palliative care and corresponding costs. This analysis provides data on palliative care resource use for a variety of cancers and could provide useful input when planning local healthcare strategies and building service commissioning models.

Family members' experiences, information needs and information seeking in relation to living with a patient with oesophageal cancer

A qualitative study was conducted with the aim to describe family members' experiences, information needs and information seeking in relation to living with a patient suffering from oesophageal cancer. Data were collected by means of semi-structured interviews with nine family members. A content analysis was used in order to organize data. It was found that family members were not aware of the severe diagnosis and the illness caused intrusions on the family. The time following diagnosis family members' information seeking was low. They used interpersonal as well as mass media sources to obtain knowledge about and handle the uncertainty related to the illness. Some family members did not actively seek information. In conclusion, healthcare professionals are expected to improve quality of cancer care. These improvements are unlikely to occur without an understanding of family members' needs. This study shows that the family members were unprepared of receiving a diagnosis of oesophageal cancer. They emphasized the importance of including the children in the care given. Moreover, the whole family was faced with uncertainty, which led to intrusion on everyday life. Therefore, family members used different strategies for managing the uncertainty, whereof one was searching for information. The primary source of information was the physician.

Development of an adenocarcinoma of the esophagus 22 years after primary repair of a congenital atresia

Esophageal cancer development after previous atresia repair is extremely rare in young patients. We present the clinical course of a patient who developed an adenocarcinoma of the esophagus at the age of 22 years, after repair of a tracheoesophageal fistula with esophageal atresia in the neonatal period. She developed a stricture of the esophageal anastomosis requiring frequent dilatations. Six years after an antireflux procedure because of a difficult treatable severe gastroesophageal reflux, an advanced adenocarcinoma was detected at the site of the end-to-end anastomosis of the previous atresia.

The risk of missed gastroesophageal cancer diagnoses in users and nonusers of antisecretory medication

BACKGROUND & AIMS

Some patients with early gastroesophageal cancer may appear to "heal" because of antisecretory medication, but the risk of a missed diagnosis is unknown. The aim of the study was to estimate the incidence of gastroesophageal cancer with or without pre-endoscopic treatment with antisecretory medication.

METHODS

We extracted data on use of endoscopies, gastroesophageal cancer diagnoses, death, migration, and use of antisecretory medication (H(2) blockers and proton pump inhibitors) from 5 population-based registries covering 1974-2002. We included all citizens in Funen County (population, 470,000) who between 1993 and 2002 were investigated by endoscopy for the first time. The patients were followed up until death, emigration, or the end of the study period.

RESULTS

Among 27,829 patients with a first endoscopy (mean age, 56 years; 48% male, 115,804 person-years of follow-up), 461 had gastroesophageal cancer diagnosed at the first endoscopy and 52 were diagnosed during a median follow-up of 2.7 years after the first endoscopy. The incidence during follow-up was similar to the background population (standardized incidence ratio, 1.24; 95% confidence interval, 0.81-1.91), increased with age, and was higher in male patients. The incidence of gastroesophageal cancer during follow-up was 46 per 100,000 person-years in users of antisecretory medication the last 180 days before the first endoscopy compared with 44 per 100,000 person-years in nonusers (age and sex standardized difference, 4 per 100,000 person-years; 95% confidence interval, -14 to 22).

CONCLUSIONS

Very few cancers are missed at endoscopy. The risk seems similar in users and nonusers of antisecretory medication before endoscopy.

Esophageal Adenocarcinoma in Patients ≤50 Years Old: Delayed Diagnosis and Advanced Disease at Presentation

During the past decade, we encountered an increasing number of young patients with esophageal adenocarcinoma. It is not clear whether young patients have more aggressive course and worse prognosis. Our aim was to compare clinicopathological characteristics/treatment results of patients with esophageal adenocarcinoma who were ≤50 and >50 years of age. We studied 263 consecutive patients with resectable esophageal adenocarcinoma: 32 (12.1%) were ≤50 years old. Dysphagia was present in 69 per cent of patients ≤50 years old and in 48 per cent of older patients ( P = 0.019). The median duration of dysphagia was 3.5 months in younger patients compared to 2 months in patients >50 years ( P < 0.0001). Seven of 22 (31.8%) young and three of 108 (2.8%) older patients with dysphagia reported dysphagia for ≥6 months ( P < 0.0001). Fifty per cent of younger patients were stage HI/IV and >70 per cent were node positive ( P = 0.04 and P = 0.02 vs patients >50 years, respectively). Five-year survival was 32.6 per cent for <50 years and 45.5 per cent for >50 years. More than 10 per cent of esophageal adenocarcinoma patients undergoing surgery are now ≤50 years of age. They usually present with dysphagia, are symptomatic for a longer time before diagnosis, and have more advanced disease compared to older patients. With appropriate aggressive treatment, survival is similar. Liberal use of endoscopy and aggressive diagnostic approach are paramount in young patients with dysphagia/symptoms of gastroesophageal reflux disease (GERD).

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

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