International trends in esophageal cancer incidence rates by histological subtype (1990-2012) and prediction of the rates to 2030

BACKGROUND

We provide an up-to-date overview of recent international trends (1990-2012) and predicted trends (2013-2030) in the incidence rates of esophageal cancer.

METHODS

We used data from the Cancer Incidence in Five Continents (CI5plus) database that contains annual incidence data by cancer site, age, and sex as well as corresponding populations. The age-standardized esophageal cancer incidence rates of each country were calculated and plotted from 1990 through 2012 and were predicted to 2030 using a Bayesian age-period-cohort model.

RESULTS

Globally, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) showed opposing trends between 1990 and 2012; ESCC showed a decreasing trend, with an AAPC of - 1.5 (95% CI - 2.4, - 0.7), yet EAC showed an increasing trend, with an AAPC of 5.2 (95% CI 4.2, 6.2). The increasing trend in EAC was commonly observed in high-income countries. The predicted trend to 2030 indicated that most countries will continue to experience a decreasing trend or a stable trend in esophageal cancer incidence, except Denmark, the Netherlands, and the UK, where the overall esophageal cancer incidence rates, mainly driven by EAC, are predicted to increase.

CONCLUSIONS

Decreasing trends in ESCC have been observed worldwide in both low- and middle-income countries and high-income countries, which may have been offset by increasing trends in EAC in high-income countries. The changing patterns of these two main subtypes of esophageal cancer may call for interventions, especially innovative interventions, to address obesity, GERD, and Barrett's esophagus.

Exosome-mediated miR-25/miR-203 as a potential biomarker for esophageal squamous cell carcinoma: improving early diagnosis and revealing malignancy

Background

Esophageal squamous cell carcinoma (ESCC) is the leading cause of cancer death in men and women worldwide. The poor prognosis and rapid increase in ESCC incidence highlight the need to promote early detection and prediction. Identifying key molecular targets involved in ESCC monitoring and progression is critical for ESCC patients.

Methods

This study examined miR-25/miR-203 as a biomarker for ESCC patients. Real-time quantitative polymerase chain reaction (PCR) was used to detect miR-25/miR-203 expression levels in tissues and serum exosomes, and MiR-25/miR-203 upregulation was confirmed in ESCC.

Results

We found that the miR-25/miR-203 ratio in cancer tissues from 36 ESCC patients was significantly enhanced compared with that in adjacent tissues. Moreover, the serum level of miR-25/miR-203 in 57 ESCC patients was higher than that in 31 healthy volunteers. Intriguingly, in 38 ESCC patients, the level of miR-25/miR-203 decreased significantly after surgery. Using ROC curve statistical analysis, we found that each group of miR-25/miR-203 had obvious sensitivity and high specificity. The miR-25/miR-203 relationship with the clinicopathological features of ESCC patients was also analyzed. MiR-25/miR-203 was significantly associated with the ESCC TNM-stage and lymph node metastasis, which predicts the prognosis of ESCC and reflects tumor progression.

Conclusions

This study highlights the feasibility of using exosome-mediated miR-25/miR-203 as a vital noninvasive biomarker for the detection and treatment monitoring of ESCC.

Oestrogen receptors: A potential therapeutic target in oesophageal adenocarcinoma?

Oesophageal cancer is the seventh most common cancer in the world and adenocarcinoma is the dominant subtype in Western industrialised nations. The global 5-year relative survival rate for oesophageal adenocarcinoma is 12%. Chemotherapy is a standard treatment offered to patients with both resectable and unresectable disease. However, there are only a few established chemotherapeutic drug options and progress in this area is limited. Recent efforts have focused on targeted molecular therapies. Epidemiological evidence points towards hormonal influences on disease development, particularly sex hormones. Several research studies have demonstrated oestrogen receptor (ER) expression in oesophageal adenocarcinoma tissue, making them a possible option for targeting with ER modulating agents. ERs are also present in laboratory models of the disease and experiments in ER-positive cell lines suggest that ER modulator therapy may be effective. A deeper understanding of the roles of ERα and ERβ in this disease would be valuable for future translation into clinical practice. In this review, we discuss the association between oestrogens and the development of oesophageal adenocarcinoma and the potential to modulate ER signalling networks for therapeutic benefit.

Does age affect oesophagectomy survival: a cohort study

BACKGROUND

Curative oesophagectomy for oesophageal cancer is associated with considerable potential mortality. Surgeons are increasingly treating older patients presenting with oesophageal cancer as the population ages. The question remains as to the survival in an older population group, many of whom are not fit for combined multimodal therapy. This study aimed to assess the effect of age on overall survival and disease-free survival in patients undergoing curative oesophagectomy for cancer.

METHODS

Patient data were analysed from a prospectively maintained database. Demographic, surgical and survival outcomes were compared between groups according to age less than 75 years or 75 and older.

RESULTS

Oesophagectomy was performed in 351 patients between 1990 and 2019 (283 patients <75 years, 68 patients ≥75 years). There was a higher rate of neoadjuvant chemotherapy in the younger group (37.7% versus 7.4%; P < 0.001). The 30-day mortality between younger and older groups was similar (2.5% and 2.9%; P = 0.827). There was no statistical difference in 5-year survival rates (50.3% versus 38.6%; P = 0.082) or median survival (22.6 versus 19.3 months; P = 0.053) between groups. There was no statistical difference in 5-year disease-free survival (45.1% and 35.7%; P = 0.180).

CONCLUSION

Overall survival, disease-free survival and 30-day mortality rates in patients aged 75 years and older were not statistically different to their younger counterparts. On the basis of these results, older patients should not be precluded from consideration of potentially curative oesophagectomy on age alone, providing surgery may be performed at reasonable risk.

Preferences for Surveillance of Barrett's Oesophagus: a Discrete Choice Experiment

PURPOSE

Endoscopic surveillance for Barrett's oesophagus is undertaken to detect dysplasia and early cancer, and to facilitate early intervention. Evidence supporting current practice is of low quality and often influenced by opinion. This study investigated the preferences of patients for surveillance of Barrett's oesophagus in an Australian cohort.

METHODS

Four Barrett's oesophagus surveillance characteristics/attributes were evaluated within a discrete choice experiment based on literature and expert opinion: (1) surveillance method (endoscopy vs a blood test vs a novel breath test), (2) risk of missing a cancer over a 10-year period, (3) screening interval, and (4) out-of-pocket cost. The data from the discrete choice experiment was analysed within the framework of random utility theory using a mixed logit regression model.

RESULTS

The study sample comprised patients (n = 71) undergoing endoscopic surveillance for Barrett's oesophagus of whom n = 65 completed the discrete choice experiment. The sample was predominantly male (77%) with average age of 65 years. All attributes except surveillance method significantly influenced respondents' preference for Barrett's oesophagus surveillance. Policy analyses suggested that compared to the reference case (i.e. endoscopy provided annually at no upfront cost and with a 4% risk of missing cancer), increasing test sensitivity to 0.5% risk of missing cancer would increase participation by up to 50%; surveillance every 5 years would lead to 26% reduction, while every 3 to 3.5 years would result in 7% increase in participation. Respondents were highly averse to paying A$500 for the test, resulting in 48% reduction in participation. None of the other surveillance methods was preferred to endoscopy, both resulting in 11% reduction in participation.

CONCLUSION

Test sensitivity, test frequency and out-of-pocket cost were the key factors influencing surveillance uptake. Patients prefer a test with the highest sensitivity, offered frequently, that incurs no upfront costs.

Health-Related Quality of Life Associated with Barrett's Esophagus and Cancer

BACKGROUND

Research assessing health-related quality of life (HRQoL) which can be applied to economic evaluation in Barrett's esophagus (BE) and esophageal cancer is limited. This study derived health state utilities for various 'stages' of BE and Cancer.

METHODS

A cross-sectional survey was conducted, including patients with non-dysplastic BE, low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma. HRQoL was assessed using generic instruments-EQ-5D-5L and SF-36, and a cancer-specific instrument-EORTC QLQ-C30. Outcomes were compared for health states following different treatments. Correlations and agreements for the three instruments were investigated using Spearman's correlation coefficient (r) and intraclass correlation coefficient (ICC).

RESULTS

A total of 97 respondents (80% male, mean age 68 years) returned questionnaires. The mean (standard deviation) health state utilities for the total sample were 0.79 (0.24) for the EQ-5D-5L, 0.57 (0.29) for the SF-6D (derived from SF-36) and 0.73 (0.20) for the QLU-C10D (derived from EORTC QLQ-C30). There were strong correlations (r > 0.80) and absolute agreement (except EQ-5D-5L and SF-6D with an ICC of 0.69) among the three instruments. No significant differences were observed for different stages of BE or interventions. However, following surgery for cancer patients reported better psychological well-being than those under surveillance or following endoscopic treatments.

CONCLUSION

HRQoL for BE surveillance and following cancer treatment was similar. Esophagectomy was associated with better psychological functioning, and this might be attributed to a reduction in the perceived risk of cancer. The correlation between the EORTC QLU-C10D and the other health state utility instruments supports the validity of this new instrument.

Rural dwellers are less likely to survive cancer - An international review and meta-analysis

BACKGROUND

Existing research from several countries has suggested that rural-dwellers may have poorer cancer survival than urban-dwellers. However, to date, the global literature has not been systematically reviewed to determine whether a rural cancer survival disadvantage is a global phenomenon.

METHODS

Medline, CINAHL, and EMBASE were searched for studies comparing rural and urban cancer survival. At least two authors independently screened and selected studies. We included epidemiological studies comparing cancer survival between urban and rural residents (however defined) that also took socioeconomic status into account. A meta-analysis was conducted using 11 studies with binary rural:urban classifications to determine the magnitude and direction of the association between rurality and differences in cancer survival. The mechanisms for urban-rural cancer survival differences reported were narratively synthesised in all 39 studies.

FINDINGS

39 studies were included in this review. All were retrospective observational studies conducted in developed countries. Rural-dwellers were significantly more likely to die when they developed cancer compared to urban-dwellers (HR 1.05 (95% CI 1.02 - 1.07). Potential mechanisms were aggregated into an ecological model under the following themes: Patient Level Characteristics; Institutions; Community, Culture and Environment; Policy and Service Organization.

INTERPRETATION

Rural residents were 5% less likely to survive cancer. This effect was consistently observed across studies conducted in various geographical regions and using multiple definitions of rurality. High quality mixed-methods research is required to comprehensively evaluate the underlying factors. We have proposed an ecological model to provide a coherent framework for future explanatory research.

FUNDING

None.

Neoadjuvant chemotherapy or chemoradiotherapy for adenocarcinoma of the esophagus

BACKGROUND

The optimal treatment strategy for patients with esophageal adenocarcinoma (EAC) remains undetermined. This study compared outcomes in patients undergoing neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) for EAC.

METHODS

Patients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000-2017) and included. After propensity score matching, the impact of the treatments on postoperative complications, in-hospital mortality, pathological outcomes, and survival rates were compared.

RESULTS

Of the 396 eligible patients, 262 patients were analysed following matching with 131 patients in both groups. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P = 0.802) or in-hospital mortality (2% vs 0%, P = 0.156). Patients who had nCRT had more R0 resections (93% vs 83%, P = 0.013), and higher pathological complete response rates (15% vs 5%, P < 0.001). No differences in 5-year overall survival rates (nCT vs nCRT; 44% vs 33%, P = 0.645) were found.

CONCLUSION

In this study no differences between nCT and nCRT were seen in postoperative complications and in-hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities.

Social group disparities in the incidence and prognosis of oesophageal cancer

There are substantial disparities in the incidence and prognosis of oesophageal cancer across social population groups, including sex, race/ethnicity, geographical location and socio-economic status. Both squamous cell carcinoma and adenocarcinoma of the oesophagus are more common in men than in women, but the male predominance in adenocarcinoma is stronger and less well understood. The varying incidence and prognosis of oesophageal cancer across racial/ethnic groups show distinct patterns by histological type. Individuals residing in rural areas have a higher incidence and worse prognosis than those in urban areas in developing regions. Lower socio-economic status is associated with an increased incidence and reduced survival in oesophageal cancer. Sustained research identifying novel preventive and therapeutic strategies are needed to reduce the risk of oesophageal cancer and improve the prognosis in all social groups.

Validation of a risk prediction model for Barrett's esophagus in an Australian population

Background

Esophageal adenocarcinoma is a disease that has a high mortality rate, the only known precursor being Barrett's esophagus (BE). While screening for BE is not cost-effective at the population level, targeted screening might be beneficial. We have developed a risk prediction model to identify people with BE, and here we present the external validation of this model.

Materials and methods

A cohort study was undertaken to validate a risk prediction model for BE. Individuals with endoscopy and histopathology proven BE completed a questionnaire containing variables previously identified as risk factors for this condition. Their responses were combined with data from a population sample for analysis. Risk scores were derived for each participant. Overall performance of the risk prediction model in terms of calibration and discrimination was assessed.

Results

Scores from 95 individuals with BE and 636 individuals from the general population were analyzed. The Brier score was 0.118, suggesting reasonable overall performance. The area under the receiver operating characteristic was 0.83 (95% CI 0.78-0.87). The Hosmer-Lemeshow statistic was p=0.14. Minimizing false positives and false negatives, the model achieved a sensitivity of 74% and a specificity of 73%.

Conclusion

This study has validated a risk prediction model for BE that has a higher sensitivity than previous models.

Clinicopathological and functional implications of the inhibitor of apoptosis proteins survivin and XIAP in esophageal cancer

Based on their overexpression and important roles in progression and therapy-resistance in malignant diseases, the inhibitor of apoptosis protein family (IAP) members, survivin and X-linked inhibitor of apoptosis protein (XIAP), represent attractive candidates for targeted therapy. The present study investigated the prognostic and biological relevance of survivin and XIAP in esophageal squamous-cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC). Survivin and XIAP expression was analyzed by immunohistochemistry using tissue microarrays containing 120 ESCC and 90 EAC samples as well as the corresponding non-neoplastic esophageal mucosa samples. IAP expression levels were then correlated to clinicopathological parameters and overall survival to identify any associations. In addition, esophageal cancer cell lines were treated with the survivin inhibitor YM155, and the XIAP inhibitors Birinapant and GDC-0152 in vitro. Survivin and XIAP expression were significantly increased in EAC and ESCC when compared with tumor-adjacent mucosa. In patients with ESCC XIAP expression was associated with female gender and advanced tumor stages, and nuclear survivin expression was associated with poor grading. High XIAP expression was identified as an independent negative prognostic marker in ESCC. By contrast, XIAP inhibitors did not affect cancer cell viability in vitro, and the small molecule survivin inhibitor YM155 significantly reduced cell viability and proliferation in esophageal cancer cell lines. Western blot analysis revealed a dose dependent decrease of survivin accompanied by an increased poly (adenosine diphosphate-ribose) polymerase cleavage following YM155 treatment. These findings underline the potential role of survivin and XIAP in the oncogenesis of esophageal cancer and provide a rationale for future clinical studies investigating the therapeutic efficacy of IAP directed therapies in patients with esophageal cancer.

Optimizing the diagnosis and therapy of Barrett's esophagus

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

Association between selenium levels and oesophageal adenocarcinoma risk: evidence from a meta-analysis

Quantification of the association between selenium and risk of oesophageal adenocarcinoma (OAC) is still conflicting. The purpose of this meta-analysis is to explore the relationship between selenium levels and OAC risk. PubMed and Web of Knowledge were searched for the related articles. Pooled relative risks (RRs) with 95% confidence intervals (CIs) from random effects models were calculated. Sensitivity analysis and publication bias were conducted. Dose-response relationship was assessed by restricted cubic spline and variance-weighted least squares regression analysis. Five articles involving 748 OAC cases were included in this meta-analysis. Pooled results suggest that higher selenium level was not significantly associated with the risk of OAC (summary RRs=1.08, 95% CIs=0.84-1.39, I(2)=0%). Besides, no significant association was found in case-control studies (summary RRs=1.13, 95% CIs=0.84-1.52, I(2)=0%) or cohort studies (summary RRs=0.99, 95% CIs=0.55-1.78, I(2)=32.6%). A linear dose-response relationship was attested that an increase in dietary selenium intake of 10 μg/day is marginally associated with 1% increase in the risk of developing OAC (summary RRs=1.01, 95% CIs=0.99-1.03), but not statistically significant. No publication bias was found. In conclusion, our analysis indicated that a higher selenium level was not significantly associated with the risk of OAC. The relevant further studies are warranted.

A newly identified susceptibility locus near FOXP1 modifies the association of gastroesophageal reflux with Barrett's esophagus

BACKGROUND

Important risk factors for esophageal adenocarcinoma and its precursor, Barrett's esophagus, include gastroesophageal reflux disease, obesity, and cigarette smoking. Recently, genome-wide association studies have identified seven germline single-nucleotide polymorphisms (SNP) that are associated with risk of Barrett's esophagus and esophageal adenocarcinoma. Whether these genetic susceptibility loci modify previously identified exposure-disease associations is unclear.

METHODS

We analyzed exposure and genotype data from the BEACON Consortium discovery phase GWAS, which included 1,516 esophageal adenocarcinoma case patients, 2,416 Barrett's esophagus case patients, and 2,187 control participants. We examined the seven newly identified susceptibility SNPs for interactions with body mass index, smoking status, and report of weekly heartburn or reflux. Logistic regression models were used to estimate ORs for these risk factors stratified by SNP genotype, separately for Barrett's esophagus and esophageal adenocarcinoma.

RESULTS

The odds ratio for Barrett's esophagus associated with at least weekly heartburn or reflux varied significantly with the presence of at least one minor allele of rs2687201 (nominal P = 0.0005, FDR = 0.042). ORs (95% CIs) for weekly heartburn or reflux among participants with 0, 1, or 2 minor alleles of rs2687201 were 6.17 (4.91-7.56), 3.56 (2.85-4.44), and 3.97 (2.47-6.37), respectively. No statistically significant interactions were observed for smoking status and body mass index.

CONCLUSION

Reflux symptoms are more strongly associated with Barrett's esophagus risk among persons homozygous for the major allele of rs2687201, which lies approximately 75 kb downstream of the transcription factor gene FOXP1.

IMPACT

The novel gene-exposure interaction discovered in this study provides new insights into the etiology of esophageal adenocarcinoma.

Circulating Serum Exosomal miRNAs As Potential Biomarkers for Esophageal Adenocarcinoma

BACKGROUND

The poor prognosis and rising incidence of esophageal adenocarcinoma highlight the need for improved detection methods. The potential for circulating microRNAs (miRNAs) as biomarkers in other cancers has been shown, but circulating miRNAs have not been well characterized in esophageal adenocarcinoma. We investigated whether circulating exosomal miRNAs have potential to discriminate individuals with esophageal adenocarcinoma from healthy controls and non-dysplastic Barrett's esophagus.

METHODS

Seven hundred fifty-eight miRNAs were profiled in serum circulating exosomes from a cohort of 19 healthy controls, 10 individuals with Barrett's esophagus, and 18 individuals with locally advanced esophageal adenocarcinoma. MiRNA expression was assessed using all possible permutations of miRNA ratios per individual. Four hundred eight miRNA ratios were differentially expressed in individuals with cancer compared to controls and Barrett's esophagus (Mann-Whitney U test, P < 0.05). The 179/408 ratios discriminated esophageal adenocarcinoma from healthy controls and Barrett's esophagus (linear regression, P < 0.05; area under receiver operating characteristic (ROC) > 0.7, P < 0.05). A multi-biomarker panel (RNU6-1/miR-16-5p, miR-25-3p/miR-320a, let-7e-5p/miR-15b-5p, miR-30a-5p/miR-324-5p, miR-17-5p/miR-194-5p) demonstrated enhanced specificity and sensitivity (area under ROC = 0.99, 95% CI 0.96-1.0) over single miRNA ratios to distinguish esophageal adenocarcinoma from controls and Barrett's esophagus.

CONCLUSIONS

This study highlights the potential for serum exosomal miRNAs as biomarkers for the detection of esophageal adenocarcinoma.

Esophageal Adenocarcinoma and Its Rare Association with Barrett's Esophagus in Henan, China

Incidence of esophageal adenocarcinoma (EAC) has increased sharply in Western Europe and United States over the past three decades. Nearly all cases of EAC in the west are thought to be associated with Barrett's esophagus (BE) at the time of diagnosis. Regions in the Henan province of China have one of world's highest incidences of esophageal cancer, yet recent temporal trends in the relative rates of EAC with respect to esophageal squamous-cell carcinoma (ESCC), as well as its association with Barrett's esophagus (BE), have not been reported. In this report, we present large-scale longitudinal clinical and histological data on 5401 esophageal cancers (EC) patients diagnosed during the recent 10-year period (2002-2011) at Henan Cancer Hospital, China. All 217 esophageal adenocarcinoma (EAC) patients from these 5401 EC patients were examined to better understand the relationship between Barrett's esophagus (BE) and EAC. We found that EAC was relatively rare and accounted for approximately 5% of all esophageal cancers each year during 2002-2011. There is no evidence of significant temporal trends in the rate of EAC relative to ESCC. Only 10 out of 217 (4.6%) EAC cases were detected to have any evidence of Barrett's esophagus. This result raises the possibility of a different etiological basis for EAC in China motivating more detailed epidemiological, clinical and molecular characterization of EAC in China in order to better understand the neoplastic development of EAC.

Prognostic Value of Metabolic Tumor Volume Measured by 18F-FDG PET/CT in Esophageal Cancer Patients

Objective: In this study, we aimed to explore prognostic importance of definition of preoperative metabolic tumor volume in esophageal cancer patients.

Methods: 22 patients who have histologically proven stage IIA-III esophageal cancer and underwent ¹⁸F-FDG PET/CT for preoperative staging of disease were included to the study. After ¹⁸F-FDG PET/CT, all the patients underwent surgery within 4 weeks period. Patients have been followed up until death or Sept 15^th, 2012. Dates of death were recorded for survival analysis. During evaluation of ¹⁸F-FDG PET/CT images, metabolic tumor volumes were calculated by drawing the isocontour region of interests from all visually positive FGD uptake lesions.

Results: 22 patients (15M, 7F; mean age: 65.1±8.4, min-max:48-80) underwent ¹⁸F-FDG PET/CT for preoperative staging of esophageal cancer. Preoperative diagnosis was squamous cell and adeno cancer in 17 (%77) and 5 (%23) patients, respectively. Location of primary tumor is distal, proximal and mid-esophagus in 13 (%59), 6 (%27) and 3 (%13) patients, respectively. Primary tumor of all the patients were FDG avid (mean SUV_max: 18.85±7.0; range: 5.5-35.1). Additionally, ¹⁸F-FDG uptake was seen in mediastinal lymph nodes in 13 patients (5.45±8.15; range: 2.6-29.9). Mean metabolic tumor volumes of primary esophageal lesions were calculated as 8.77±8.46cm³ (range: 2.3-34.2). Mean MTV of lymph nodes was 2.44±1.01cm³ (range: 0.4-3.6). Mean total metabolic tumor volume was calculated as 9.99±8.58cm³ (range: 2.3-27.3). 10 patients died during 447±121 days follow-up period. Mean survival time was 11.9±1.5 months (95%CI: 8.99-14.74) for entire patient group. Total metabolic tumor volume had a significant effect on survival (p=0.045) according to Cox proportional hazards regression analysis. One unit increase in MTV caused 1.1 (95%CI:1.003-1.196) fold increase in hazard, at any time.

Conclusion: Definition of preoperative metabolic tumor volume has a prognostic value in the prediction of postoperative survival times. Patients who have higher preoperative metabolic tumor volumes could be good candidates for more aggressive chemo-radiation therapy regiments.

Conflict of interest:None declared.

Barrett esophagus: when to endoscope

Increasing interest in identifying an effective strategy for decreasing the burden of esophageal adenocarcinoma (EAC) has been fuelled by the rising EAC rates worldwide, the morbidity associated with esophagectomy, and the development of endoscopic methods for curing early-stage EAC. In the face of this enthusiasm, however, we should be cautious about continuing our current evidence-free approach to screening and one with unclear benefits and unclear costs to the community. The literature is increasingly recognizing that the value of traditional endoscopy for screening and surveillance of Barrett esophagus may be more limited than initially believed. A better understanding of the risk factors for Barrett esophagus and progression to dysplasia and a more individualized risk calculation will be useful in defining populations to consider for Barrett screening. The development of novel, nonendoscopic screening techniques and of less expensive endoscopic techniques holds promise for a cost-effective screening and surveillance method to curtail the increasing rates of EAC.

Epidemiology and risk factors for oesophageal adenocarcinoma

Oesophageal adenocarcinoma will soon cease to be a rare form of cancer for people born after 1940. In many Western countries, its incidence has increased more rapidly than other digestive cancers. Incidence started increasing in the Seventies in England and USA, 15 years later in Western Europe and Australia. The cumulative risk between the ages of 15 and 74 is particularly striking in the UK, with a tenfold increase in men and fivefold increase in women in little more than a single generation. Prognosis is poor with a 5-year relative survival rate of less than 10%. The main known risk factors are gastro-oesophageal reflux, obesity (predominantly mediated by intra-abdominal adipose tissues) and smoking. Barrett's oesophagus is a precancerous lesion, however, the risk of degeneration has been overestimated. In population-based studies the annual risk of adenocarcinoma varied between 0.12% and 0.14% and its incidence between 1.2 and 1.4 per 1000 person-years. Only 5% of subjects with Barrett's oesophagus die of oesophageal adenocarcinoma. On the basis of recent epidemiological data, new surveillance strategies should be developed. The purpose of this review is to focus on the epidemiology and risk factors of oesophageal adenocarcinoma.

Age at onset of GERD symptoms predicts risk of Barrett's esophagus

OBJECTIVES

Symptoms of gastroesophageal reflux disease (GERD) are the primary risk factor for Barrett's esophagus (BE). However, the significance of age at symptom onset is unknown. We examined the effects of multiple dimensions of GERD exposure on BE risk and whether these associations are modified by other risk factors for BE.

METHODS

Data were from a cross-sectional study of 683 Veterans Affairs patients undergoing an elective esophagogastroduodenoscopy (EGD) or a study EGD concurrently with colonoscopy from primary care clinics. We compared 236 patients with both endoscopically suspected and histologically confirmed BE to 447 primary-care patients ("primary-care controls") without endoscopically suspected BE on their study EGD. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariate logistic regression.

RESULTS

Age at onset <30 years of frequent (at least weekly) GERD symptoms was associated with highest risk of BE (OR=15.1, 95% CI 7.91-28.8), and risk increased linearly with earlier age at onset of symptoms (P-trend=0.001). This association was independent of cumulative GERD symptom duration. People with early onset GERD symptoms who reported ever using proton pump inhibitors were at especially high risk of BE (OR=31.1, 95% CI 13.9-69.7). In people with frequent GERD symptoms, BE risk was almost 80% lower among Helicobacter pylori-positive patients (OR=2.60, 95% CI 1.26-5.40) than those negative for H. pylori (OR=8.24, 95% CI 5.00-13.6).

CONCLUSIONS

Risk of BE increased linearly with earlier age at onset of frequent GERD symptoms. Age at symptom onset may help practitioners decide which patients with GERD symptoms to refer for endoscopic screening for BE.

Dietary antioxidants and risk of Barrett's esophagus and adenocarcinoma of the esophagus in an Australian population

While dietary antioxidants are emerging as potentially modifiable risk factors for esophageal adenocarcinoma (EAC), studies on dietary antioxidants and its precursor Barrett's esophagus (BE) are limited. The present study extends previous work on BE by investigating risks of nondysplastic BE, dysplastic BE and EAC associated with intake of antioxidants such as vitamin C, vitamin E, β-carotene, and selenium. Age and sex matched control subjects (n=577 for BE; n=1,507 for EAC) were sampled from an Australian population register. Information on demography, and well established EAC risk factors were obtained using self-administered questionnaires. Intake of antioxidants for patients newly diagnosed with nondysplastic BE (n=266), dysplastic BE (n=101), or EAC (n=299), aged 18-79 years, were obtained using a food frequency questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariable adjusted logistic regression models. High intake of β-carotene from food and supplement sources combined was inversely associated with risk of dysplastic BE (OR Q4 vs. Q1=0.45; 95%CI: 0.20-1.00). High intake of vitamin E from food sources (OR Q4 vs. Q1=0.43; 95%CI: 0.28-0.67), from food and supplements combined (OR Q4 vs. Q1=0.64; 95%CI: 0.43-0.96), and a high antioxidant index score were inversely associated with risk of EAC. We found no significant trends between intake of β-carotene, vitamin C, vitamin E, and selenium and risk of nondysplastic or dysplastic BE. However, our data suggest that a high intake of β-carotene may be associated with decreased risk of dysplastic BE.

Oesophageal carcinoma

Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.

The incidence of esophageal adenocarcinoma continues to rise: analysis of period and birth cohort effects on recent trends

BACKGROUND

During the past four decades, the incidence of esophageal adenocarcinoma (EAC) has increased markedly in Western populations. Recent reports have suggested that the rate of increase has slowed or plateaued.

PATIENTS AND METHODS

Using data from cancer registries in Australia, the United States and Sweden, we examined incidence trends for esophageal and gastric cardia tumors between 1984 and 2008 using joinpoint analyses and age-period-cohort models.

RESULTS

EAC incidence continues to undergo statistically significant annual increases in Australia and the United States, although the rate of increase has slowed. Among men, incidence increased annually by 2.2% [95% confidence interval (CI) 1.5% to 2.9%] between 1994 and 2008 in Australia and 1.5% (95% CI 0.2% to 2.8%) between 1998 and 2008 in the United States. EAC incidence among men remained unchanged in Sweden between 2001 and 2008 (P = 0.52). EAC incidence among women showed significant linear increases between 1984 and 2008. Age-period-cohort models suggested strong effects for both period and birth cohort on EAC incidence in Australia and the United States, and a strong period effect for Sweden.

CONCLUSIONS

EAC incidence continues to increase in Australia and the United States. The continued increases, even among more recent birth cohorts, suggest that EAC incidence will continue to rise during coming decades.

Oesophagectomy rates and post-resection outcomes in patients with cancer of the oesophagus and gastro-oesophageal junction: a population-based study using linked health administrative linked data

Background

Hospital performance is being benchmarked increasingly against surgical indicators such as 30-day mortality, length-of-stay, survival and post-surgery complication rates. The aim of this paper was to examine oesophagectomy rates and post-surgical outcomes in cancers of the oesophagus and gastro-oesophageal junction and to determine how the addition of gastro-oesophageal cancer to oesophageal cancer impacts on these outcomes.

Methods

Our study population consisted of patients with a primary invasive oesophageal or gastro-oesophageal cancer identified from the NSW Cancer Registry from July 2000-Dec 2007. Their records were linked to the hospital separation data for determination of resection rates and post-resection outcomes. We used multivariate logistic regression analyses to examine factors associated with oesophagectomy and post-resection outcomes. Cox-proportional hazard regression analysis was used to examine one-year cancer survival following oesophagectomy.

Results

We observed some changes in resection rates and surgical outcomes with the addition of gastro-oesophageal cancer patients to the oesophageal cancer cohort. 14.6% of oesophageal cancer patients and 26.4% of gastro-oesophageal cancer patients had an oesophagectomy; an overall oesophagectomy rate of 18.2% in the combined cohort. In the combined cohort, oesophagectomy was associated with younger age, being male and Australian-born, having non-metastatic disease or adenocarcinoma and being admitted in a co-located hospital. Rates of length-of-stay >28 days (20.9% vs 19.7%), 30-day mortality (3.8% vs 2.7%) and one-year survival post-surgery (24.5% vs 23.1%) were similar between oesophageal cancer alone and the combined cohort; whilst 30-day complication rates were 21.5% versus 17.0% respectively. Some factors statistically associated with post-resection complication in oesophageal cancer alone were not significant in the overall cohort. Poorer post-resection outcomes were associated with some patient (older age, birthplace) and hospital-related characteristics (fiscal sector, area health service).

Conclusion

Outcomes following oesophagectomy in oesophageal and gastro-oesophageal cancer patients in NSW are within world benchmarks. Our study demonstrates that the inclusion of gastro-oesophageal cancer did alter some outcomes compared to analysis based solely on oesophageal cancer. As such, care must be taken with analyses based on administrative health data to capture all populations eligible for treatment and to understand the contribution of these subpopulations to overall outcomes.

Molecular biomarkers and ablative therapies for Barrett's esophagus

Barrett's esophagus is the major risk factor for esophageal adenocarcinoma. Endoscopic interventions that ablate Barrett's esophagus mucosa lead to replacement with a new squamous (neosquamous) mucosa, but it can be difficult to achieve complete ablation. Knowing whether cancer is less likely to develop in neosquamous mucosa or residual Barrett's esophagus after ablation is critical for determining the efficacy of treatment. This issue can be informed by assessing biomarkers that are associated with an increased risk of progression to adenocarcinoma. Although there are few postablation biomarker studies, evidence suggests that neosquamous mucosa may have a reduced risk of adenocarcinoma in patients who have been treated for dysplasia or cancer, but some patients who do not have complete eradication of nondysplastic Barrett's esophagus may still be at risk. Biomarkers could be used to optimize endoscopic surveillance strategies following ablation, but this needs to be assessed by clinical studies and economic modeling.

The role of comorbidities on the uptake of systemic treatment and 3-year survival in older cancer patients

BACKGROUND

Older patients are notably absent from clinical trials. Thus, observational studies are the primary avenue for understanding the role of comorbidity in cancer care and survival. We examined the impact of comorbidity on systemic treatment initiation and 3-year survival in a cohort of older cancer patients.

PATIENTS AND METHODS

Our cohort comprised 2753 Australian veterans aged ≥65 years with full health coverage and a cancer registry notification for colorectal (CRC), breast, prostate or non-small-cell lung cancer (NSCLC). We established comorbidities based on drugs prescribed in the 6 months prior to cancer diagnosis.

RESULTS

Patients with higher comorbidity burden were more likely to receive systemic treatment for prostate cancer [adjusted odds ratio 1.21, 95% confidence interval (CI) 1.05-1.39] but less likely for NSCLC (0.63, 95% CI 0.45-0.86). After adjusting for receipt of treatment, increased comorbidity resulted in shorter survival for CRC [adjusted hazard ratio (aHR) 1.16, 95% CI 1.07-1.26] and breast cancer (aHR 1.23, 95% CI 1.02-1.48). However, we did not demonstrate significant improvements in 3-year survival for patients receiving systemic treatment.

CONCLUSION

Comorbidity influences systemic treatment uptake and adversely affects survival, with impact dependent upon comorbidity and cancer type. Clinical trials should be undertaken in older patients to better understand the risks and benefits of cancer treatments.

Meta-analysis: risk of esophageal adenocarcinoma with medications which relax the lower esophageal sphincter

Reasons for the rising annual incidence of esophageal adenocarcinoma (EAC) remain uncertain. Previous studies have given conflicting results, but some have suggested that drugs which relax the lower esophageal sphincter (LES) may increase the risk of EAC. This study is to determine systematically the risk of EAC associated with individual medications which relax the LES and compare risks with esophageal squamous cell carcinoma (ESCC) and gastric cardia adenocarcinoma (GCA). Relevant published studies were identified by systematic searching PubMed for case-control studies reporting on risk of EAC, ESCC or GCA with use of medications known to reduce LES pressure. Pooled odds ratios (ORs) were calculated for each malignancy. Data were analyzed from four case-control studies involving 9,412 participants. EAC was significantly associated with theophylline use (OR 1.55, 95% confidence interval [CI] 1.05-2.28; P= 0.03, I(2) = 0%) and anticholinergic medications (OR 1.66, 95% CI 1.13-2.44; P= 0.01, I(2) = 84%). This effect was not observed in cases of ESCC or GCA. Other drug groups including calcium channel modulators and nitrates did not increase the risk of EAC. An inverse relationship was observed between ESCC and nitrates and between GCA and benzodiazepines. The lack of increased EAC risk with many commonly used medications is reassuring. However, a significant correlation was found between EAC and the use of anticholinergics and theophyllines. This may reflect common causality between obstructive lung disease and EAC, and further studies to explore these relationships are warranted.

Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia

OBJECTIVE

This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios.

METHODS

A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken.

RESULTS

Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368).

CONCLUSION

These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.

A clinical risk prediction model for Barrett esophagus

Barrett esophagus is the only known precursor to esophageal adenocarcinoma. As definitive diagnosis requires costly endoscopic investigation, we sought to develop a risk prediction model to aid in deciding which patients with gastroesophageal reflux symptoms to refer for endoscopic screening for Barrett esophagus. The study included data from patients with incident nondysplastic Barrett esophagus (n = 285) and endoscopy control patients with esophageal inflammatory changes without Barrett esophagus ("inflammation controls", n = 313). We used two phases of stepwise backwards logistic regression to identify the important predictors for Barrett esophagus in men and women separately: first, including all significant covariates from univariate analyses and then fitting non-significant covariates from univariate analyses to identify those effects detectable only after adjusting for other factors. The final model pooled these predictors and was externally validated for discrimination and calibration using data from a Barrett esophagus study conducted in western Washington State. The final risk model included terms for age, sex, smoking status, body mass index, highest level of education, and frequency of use of acid suppressant medications (area under the ROC curve, 0.70; 95%CI, 0.66-0.74). The model had moderate discrimination in the external dataset (area under the ROC curve, 0.61; 95%CI, 0.56-0.66). The model was well calibrated (Hosmer-Lemeshow test, P = 0.75), with predicted probability and observed risk highly correlated. The prediction model performed reasonably well and has the potential to be an effective and useful clinical tool in selecting patients with gastroesophageal reflux symptoms to refer for endoscopic screening for Barrett esophagus.

Current status and future perspectives on the etiology of esophageal adenocarcinoma

Esophageal adenocarcinoma is the most common type of esophageal cancer in most Western countries and is an important contributor to overall cancer mortality. Most cases of esophageal adenocarcinoma are believed to arise from Barrett’s esophagus. Esophageal adenocarcinoma occurs more frequently in white men over 50 years old, as well as in people with frequent symptoms of gastroesophageal reflux, in smokers and in people who are obese. Higher consumption of fruit and vegetables, use of non-steroidal anti-inflammatory drugs, and infection with Helicobacter pylori have all been shown to reduce the risk of esophageal adenocarcinoma. Here, we review the epidemiological evidence for the major risk factors of esophageal adenocarcinoma and also discuss perspectives for future research.

Influence of socioeconomic environment on survival in patients diagnosed with esophageal cancer: a population-based study

The influence of social environment on survival in patients with cancer has been demonstrated in many studies, subjects living in the most deprived areas having a poorer prognosis. Geographic remoteness and limited access to specialized care centers are often associated with socioeconomic deprivation. The aim was to assess the influence of social environment and geographic remoteness on the relative survival of patients diagnosed with esophageal cancer between 1997 and 2004 in the department of Calvados in France. The study population, which was provided by the Calvados digestive cancer registry, included 629 patients. Relative survival was used to estimate the influence of social environment and geographic remoteness on patient survival. Five-year survival rates were 14.1%, 15.1%, 11.8%, 8.8%, and 11.4%, respectively, for patients living in the least to the most deprived areas (P= 0.39). The influence of social environment was significant after adjustment for clinical variables, patients living in the most deprived areas having the worst survival. These discrepancies cannot totally be explained by differences in access to care, cancer extension, or morphology at diagnosis. No association was observed between distance to the nearest cancer center and survival. Social environment appears to induce disparities among patients diagnosed with esophageal cancer, with a worse prognosis for patients living in the most deprived areas.

Healthcare resource use and medical costs for the management of oesophageal cancer

BACKGROUND

This study examined the interaction between natural history, current practice patterns in diagnosis, monitoring and treatment of oesophageal cancer, and associated health resource utilization and costs.

METHODS

A cost analysis of a prospective population-based cohort of 1100 patients with a primary diagnosis of oesophageal cancer was performed using chart review from the Australian Cancer Study Clinical Follow-Up Study. The analysis enabled estimation of healthcare resources and associated costs in 2009 euros by stage of disease and treatment pathway.

RESULTS

Most patients (88·5 per cent) presented with stage II, III or IV cancer; 61·1 per cent (672 of 1100) were treated surgically. Overall mean costs were €37,195 (median €29,114) for patients undergoing surgery and €17,281 (median €13,066) for those treated without surgery. Surgery contributed 66·4 per cent of the total costs (mean €24,697 per patient) in the surgical group. In the non-surgical group, use of chemotherapy was more prevalent (81·9 per cent of patients) and contributed 61·1 per cent of the total costs. Other important cost determinants were gastro-oesophageal junction tumours, treatment location and tumour stage. Mean costs of those monitored for Barrett's oesophagus (7·3 per cent of patients) were lower, although about one-third still presented with advanced-stage cancer.

CONCLUSION

Overall costs for managing oesophageal cancer were high and dominated by surgery costs in patients treated surgically and by chemotherapy costs in patients treated without surgery. Radiotherapy, treatment location and cancer subtype were also important. Monitoring for Barrett's oesophagus and earlier-stage detection were associated with lower management costs, but the potential net benefit from surveillance strategies needs further investigation.

The use of nonsteroidal anti-inflammatory drugs and the risk of Barrett's oesophagus

BACKGROUND

Epidemiological studies have consistently reported inverse associations between nonsteroidal anti-inflammatory drugs (NSAIDs) and oesophageal adenocarcinoma, but few have investigated associations with the precursor lesion, Barrett's oesophagus.

AIM

To investigate the relationship between NSAID use and risk of Barrett's oesophagus.

METHODS

We conducted a large population-based case-control study that collected information on patterns of intake for aspirin and non-aspirin NSAIDs during the past 5 years and other exposures from 285 patients with nondysplastic Barrett's oesophagus, 108 patients with dysplastic Barrett's oesophagus, and two separate control groups: 313 endoscopy patients with acute inflammatory changes ('inflammation controls') and 644 population controls. We calculated odds ratios (ORs) and 95% CIs using unconditional logistic regression.

RESULTS

Use of aspirin was not associated with nondysplastic Barrett's oesophagus when compared with population (OR=1.01, 95% CI 0.71-1.43) or inflammation controls (OR=1.16, 95% CI 0.80-1.68). Whereas we observed significant risk reductions for use of non-aspirin NSAIDs when nondysplastic Barrett's oesophagus cases were compared with population controls (OR=0.69, 95% CI 0.49-0.97), the effect was weaker and nonsignificant when cases were compared with inflammation controls (OR=0.82, 95% CI 0.57-1.18), and no dose-response effects were present in either analysis. We found no evidence that aspirin or non-aspirin NSAID use conferred risk reductions for dysplastic Barrett's oesophagus, regardless of the control series. We excluded effect modification by known risk factors as an explanation for these null findings.

CONCLUSIONS

We found little support for an inverse association between use of NSAIDs and Barrett's oesophagus. The question of whether or not these medications prevent the onset of Barrett's oesophagus remains open.

Validation and application of a death proxy in adult cancer patients

PURPOSE: Fact of death is not always available on data sets used for pharmacoepidemiological research. Proxies may be an appropriate substitute in the absence of death data. The purposes of this study were to validate a proxy for death in adult cancer patients and to assess its performance when estimating survival in two cohorts of cancer patients. METHODS: We evaluated 30-, 60-, 90- and 180-day proxies overall and by cancer type using data from 12 394 Australian veterans with lung, colorectal, breast or prostate cancer. The proxy indicated death if the difference between the last dispensing record and the end of the observational period exceeded the proxy cutoff. We then compared actual survival to 90-day proxy estimates in a subset of 4090 veterans with 'full entitlements' for pharmaceutical items and in 3704 Australian women receiving trastuzumab for HER2+ metastatic breast cancer. RESULTS: The 90-day proxy was optimal with an overall sensitivity of 99.3% (95%CI: 98.4-99.7) and a specificity of 97.6% (95%CI: 91.8-99.4). These measures remained high when evaluated by cancer type and spread of disease. The application of the proxy using the most conservative date of death estimate (date of last dispensing) generally underestimated survival, with estimates up to 3 months shorter than survival based on fact of death. CONCLUSIONS: A 90-day death proxy is a robust substitute to identify death in a chronic population when fact of death is not available. The proxy is likely to be valid across a range of chronic diseases as it relies on the presence of 'regular' dispensing records for individual patients. Copyright © 2011 John Wiley & Sons, Ltd.

Dietary patterns and risk of oesophageal cancers: a population-based case–control study

Epidemiological studies investigating the association between dietary intake and oesophageal cancer have mostly focused on nutrients and food groups instead of dietary patterns. We conducted a population-based case–control study, which included 365 oesophageal adenocarcinoma (OAC), 426 oesophagogastric junction adenocarcinoma (OGJAC) and 303 oesophageal squamous cell carcinoma (OSCC) cases, with frequency matched on age, sex and geographical location to 1580 controls. Data on demographic, lifestyle and dietary factors were collected using self-administered questionnaires. We used principal component analysis to derive three dietary patterns: ‘meat and fat’, ‘pasta and pizza’ and ‘fruit and vegetable’, and unconditional logistic regression models to estimate risks of OAC, OGJAC and OSCC associated with quartiles (Q) of dietary pattern scores. A high score on the meat-and-fat pattern was associated with increased risk of all three cancers: multivariable-adjusted OR 2·12 (95 % CI 1·30, 3·46) for OAC; 1·88 (95 % CI 1·21, 2·94) for OGJAC; 2·84 (95 % CI 1·67, 4·83) for OSCC (P-trend < 0·01 for all three cancers). A high score on the pasta-and-pizza pattern was inversely associated with OSCC risk (OR 0·58, 95 % CI 0·36, 0·96,Pfor trend = 0·009); and a high score on the fruit-and-vegetable pattern was associated with a borderline significant decreased risk of OGJAC (OR for Q4v.Q1 0·66, 95 % CI 0·42, 1·04,P = 0·07) and significantly decreased risk of OSCC (OR 0·41, 95 % CI 0·24, 0·70,Pfor trend = 0·002). High-fat dairy foods appeared to play a dominant role in the association between the meat-and-fat pattern and risk of OAC and OGJAC. Further investigation in prospective studies is needed to confirm these findings.

Whole genome expression array profiling highlights differences in mucosal defense genes in Barrett's esophagus and esophageal adenocarcinoma

Esophageal adenocarcinoma (EAC) has become a major concern in Western countries due to rapid rises in incidence coupled with very poor survival rates. One of the key risk factors for the development of this cancer is the presence of Barrett's esophagus (BE), which is believed to form in response to repeated gastro-esophageal reflux. In this study we performed comparative, genome-wide expression profiling (using Illumina whole-genome Beadarrays) on total RNA extracted from esophageal biopsy tissues from individuals with EAC, BE (in the absence of EAC) and those with normal squamous epithelium. We combined these data with publically accessible raw data from three similar studies to investigate key gene and ontology differences between these three tissue states. The results support the deduction that BE is a tissue with enhanced glycoprotein synthesis machinery (DPP4, ATP2A3, AGR2) designed to provide strong mucosal defenses aimed at resisting gastro-esophageal reflux. EAC exhibits the enhanced extracellular matrix remodeling (collagens, IGFBP7, PLAU) effects expected in an aggressive form of cancer, as well as evidence of reduced expression of genes associated with mucosal (MUC6, CA2, TFF1) and xenobiotic (AKR1C2, AKR1B10) defenses. When our results are compared to previous whole-genome expression profiling studies keratin, mucin, annexin and trefoil factor gene groups are the most frequently represented differentially expressed gene families. Eleven genes identified here are also represented in at least 3 other profiling studies. We used these genes to discriminate between squamous epithelium, BE and EAC within the two largest cohorts using a support vector machine leave one out cross validation (LOOCV) analysis. While this method was satisfactory for discriminating squamous epithelium and BE, it demonstrates the need for more detailed investigations into profiling changes between BE and EAC.

The validity of self-reported cancer diagnoses and factors associated with accurate reporting in a cohort of older Australian women

Epidemiological research often ascertains cancer history via self-reported questionnaires. We assessed the validity of self-reported cancer diagnoses in women born 1921-1926 recruited to the Australian Longitudinal Study in Women's Health (ALSWH) and determined the factors associated with false positive (FP) and false negative (FN) reporting. 4234 ALSWH cohort members were asked at baseline (1996) and in subsequent three-yearly surveys whether they had been diagnosed with specific cancers, including breast, cervical, lung and colorectal. We linked the cohort to the population-based New South Wales Central Cancer Registry (CCR) from 1972 to 2005 to identify registered invasive cancers. We calculated sensitivity, specificity and positive predictive value (PPV) of self-reported cancer diagnoses overall, at baseline (prevalent cancers) and follow-up (incident cancers) using the CCR diagnosis as the 'gold standard'. We used adjusted logistic regression to examine the determinants of FP and FN reports. Overall sensitivity was 89.2% (95% CI 86.0-91.7%) and exceeded 90% for breast, lung and colorectal cancer at baseline. Overall specificity was 96.9% (95% CI 96.3-97.5%), however, PPV was lower at 66.5% (95% CI 62.7-70.1%). FN reporting of any cancer at baseline was associated with being born overseas. Sensitivity and specificity of self-reported cancer diagnoses in this cohort of older women (aged 70-75 years at baseline) is high but PPV is comparatively lower. Hence, the use of linked data from population-based cancer registries is recommended for studies of cancer epidemiology. Particular attention must also be paid to country of birth in self-reported cancer data, as these findings suggest cancer will be under-reported by this group of women.

Obesity, metabolic syndrome and esophageal adenocarcinoma: epidemiology, etiology and new targets

BACKGROUND

Rates of distal and junctional adenocarcinomas are increasing in Western countries.

METHODS

Systematic review of epidemiological evidence linking obesity to esophageal adenocarcinoma (EA) was performed for studies published from 2005 to 2010. The current understanding of obesity's role in the etiology and potential dysplastic progression of Barrett's esophagus (BE) to EA is reviewed.

RESULTS

Accumulating epidemiological studies provide evidence of obesity's role as a driving force behind the increasing rates of EA. The simplest construct is that obesity promotes reflux, causing chronic inflammation and BE, predisposing to adenocarcinoma. However, as obesity is positively associated with the prevalence of many cancers, other mechanisms are important. A link may exist between fat distribution patterns and the risk of BE and EA. Altered metabolic profiles in the metabolic syndrome (MetS) may be a key factor in cell cycle/genetic abnormalities that mark the progression of BE towards cancer. Research highlighting a unique role of MetS in the length of BE, and its association with systemic inflammation and insulin resistance is discussed, as well as adipokine receptor expression in both BE and esophageal epithelium, and how MetS and the systemic response impacts on key regulators of inflammation and tumorigenesis. CONCLUSIONS/IMPACT: Obesity is positively associated with EA. The systemic inflammatory state consequent on the altered metabolism of obese patients, and the associated impact of adipocytokines and pro-coagulant factors released by adipocytes in central fat, may underlie obesity's relationship to this cancer. Novel therapeutic agents that may antagonize adipo-cytokines and potentially offer a promising role in cancer therapy are discussed.

Barrett's esophagus

Barrett's esophagus is an acquired metaplastic abnormality in which the normal stratified squamous epithelium lining of the esophagus is replaced by an intestinal-like columnar epithelium. While in itself a benign and asymptomatic disorder, the clinical importance of this relatively common condition relates to its role as a precursor lesion to esophageal adenocarcinoma, the incidence of which has dramatically increased in Western populations in recent years. Although known to arise as a consequence of chronic gastroesophageal reflux, the cellular and molecular mechanisms underlying development Barrett's esophagus and its progression to cancer remain unclear.

Is endoscopic surveillance for non-dysplastic Barrett's esophagus cost-effective? Review of economic evaluations

BACKGROUND AND AIM

  Several health economic evaluations have explored the cost-effectiveness of endoscopic surveillance for patients with non-dysplastic Barrett's esophagus, with conflicting results. By comparing results across studies and highlighting key methodological and data limitations a platform for future, more rigorous analyses, can be developed.

METHODS

  A systematic literature review was undertaken of studies evaluating cost-effectiveness of surveillance for non-dysplastic Barrett's esophagus. Articles were included if they assessed both cost and health outcomes for surveillance versus no surveillance. A descriptive review was undertaken and the quality of the studies appraised against best-practice recommendations for economic evaluations and modeling studies.

RESULTS

  Seven publications met the inclusion criteria. All used decision-analytic Markov models. Half of the evaluations found surveillance was not cost-effective. At best, surveillance produced improved outcomes at a cost of US$16 640 per quality-adjusted life-year, and at worst it did more harm than good and at a greater cost. The quality of the evaluations and generalizability to the Asia-Pacific region was diminished as a result of inadequate or inconsistent evidence supporting parameter estimates, such as quality of life, endoscopic sensitivity and specificity and cancer recurrence rates.

CONCLUSIONS

  Unless newly emerging technologies improve the quality-adjusted survival benefit conferred by endoscopic surveillance, this strategy is unlikely to be cost-effective. Obsolete assumptions and incomplete analyses reduce the quality of published evaluations. For these reasons new evaluations are required that encompass the growing evidence base for new technologies, such as new endoscopic therapies for high-grade dysplasia and intramucosal cancer.

High intake of folate from food sources is associated with reduced risk of esophageal cancer in an Australian population

Folate plays a key role in DNA synthesis and methylation. Limited evidence suggests high intake may reduce risks of esophageal cancer overall; however, associations with esophageal cancer subtypes and Barrett's esophagus (BE), a precancerous lesion, remain unexplored. We evaluated the relation between intake of folate, B vitamins, and methyl-group donors (methionine, choline, betaine) from foods and supplements, polymorphisms in key folate-metabolizing genes, and risk of BE, esophageal adenocarcinoma (EAC), and esophageal squamous cell carcinoma (ESCC) in 2 population-based case-control studies in Australia. BE patients without (n = 266) or with (n = 101) dysplasia were compared with population controls (n = 577); similarly, EAC (n = 636) or ESCC (n = 245) patients were compared with population controls (n = 1507) using multivariable adjusted logistic regression. Increasing intake of folate from foods was associated with reduced EAC risk (P-trend = 0.01) and mitigated the increased risks of ESCC associated with smoking and alcohol consumption. In contrast, high intake of folic acid from supplements was associated with a significantly elevated risk of BE with dysplasia. High intakes of riboflavin and methionine from food were associated with increased EAC risk, whereas increasing betaine intake was associated with reduced risks of BE without (P-trend = 0.004) or with dysplasia (P-trend = 0.02). Supplemental thiamin, riboflavin, niacin, and vitamin B-12 were associated with increased EAC risk. There were no consistent associations between genetic polymorphisms studied and BE or EAC risk. High intake of folate-containing foods may reduce risk of EAC, but our data raise the possibility that folic acid supplementation may increase risks of BE with dysplasia and EAC.

Surgical outcomes associated with oesophagectomy in New South Wales: an investigation of hospital volume

INTRODUCTION

Resection remains the standard treatment for curable oesophageal cancer. By linking the NSW Central Cancer Registry (CCR) and the NSW Admitted Patient Data Collection (APDC) databases, mortality, post-resection complication and survival associated with oesophagectomy were investigated.

METHODS

All patients diagnosed with oesophageal cancer from 2000 to 2005 as recorded in the CCR (n = 2,082) were linked with records in the APDC, giving a total of 17,205 episodes of care. Over 15% (n = 321) of all patients underwent an oesophagectomy.

RESULTS AND DISCUSSION

The overall 30-day mortality rate following resection was 3.7%, ranging from 2.6% in high volume hospitals to 6.4% in low volume hospitals. Three-year absolute survival for localised-regional disease following oesophagectomy was 64% (95%CI 54-73%) in high-volume hospitals, 58% (95%CI 46-68%) in mid-volume and 45% (95%CI 23-65%) in low-volume hospitals. The post-resection complication rate was 19% (95%CI 13-26%) for high-volume hospital, 24% (95%CI 13-40%) in low-volume and 31% (95%CI 22-41%) in mid-volume hospitals.

CONCLUSION

Oesophagectomy in NSW is performed with satisfactory results. However, there is a suggestion that higher- rather than lower-volume hospitals have better post-resection outcomes.

Eating habits and risk of esophageal cancers: a population-based case-control study

OBJECTIVE

Eating behaviors, such as the timing, speed of eating, and frequently consuming hot drinks, fried, spicy, or barbecued foods may be associated with increased risks of esophageal cancer. We analyzed data from a population-based case-control study to examine whether eating behaviors are associated with risk of esophageal cancer.

METHODS

Self-administered questionnaire was used to collect data on demographic, socioeconomic, and lifestyle characteristics, and a food frequency questionnaire was used to collect data on dietary behaviors from 1,472 control subjects, 286 cases with adenocarcinoma of the esophagus, 320 cases with esophagogastric junction adenocarcinoma (EGJAC), and 238 cases with esophageal squamous cell carcinoma (ESCC). We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional multivariable adjusted logistic regression, adjusting for confounders.

RESULTS

Frequency of hot drinks, home-fried foods, barbecued meats, spicy foods, and the timing of eating an evening meal were not associated with esophageal cancer risk. Those who frequently consumed fried 'take-away' food had increased risks of EGJAC (OR = 1.44, 95% CI = 1.01-2.05; p value = 0.04). Eating speed was inversely associated with ESCC risk (p for trend = 0.001).

CONCLUSION

We found no evidence that consumption of hot drinks, barbecued meats, spicy foods, or the timing of the evening meal are associated with increased risk of esophageal cancer in this Australian population. Associations with consumption of fried 'take-away' foods and eating speed await confirmation in future studies.