Prateek Sharma, Richard Sampliner, David Ilson, Prateek Sharma, Richard Sampliner, David Ilson
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Esophageal Cancer and Barrett's Esophagus
Prateek Sharma, Richard Sampliner, David Ilson, Prateek Sharma, Richard Sampliner, David Ilson
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About This Book
Esophageal Cancer and Barrett's Esophagus, 3E, focuses on these two common and key conditions that affect the esophagus, providing expert guidance to their pathogenesis, cause, prevention, diagnosis and clinical management.
Top international names in the field examine each of the many issues involved, using the very latest evidence-based research, and clear, didactic adviceallows the reader to understand the best methods of diagnosis and clinical management of each condition – whether early or late stage.
Well-illustrated and fully revised to include the latest in ACG/ASG/UEGW guidelines, itis the perfect consultation tool for gastroenterologists and oncologists managing patients with cancer of the esophagus. It is also ideal for teaching residents and fellows optimum patient management, and for identifying areas requiring future research.
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Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Houston VA HSR&D Center of Excellence, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
1.1 The incidence and mortality related to esophageal cancer
Esophageal cancer is the sixth most common cancer among men and the ninth among women, affecting more than 450,000 people globally each year. Approximately 90% of cases of esophageal cancer are squamous cell carcinoma (ESCC) [1], and the rest are adenocarcinoma (EA). The highest reported incidence and mortality rates for ESCC occur in Jiashan, China, with an age-adjusted incidence rate of 14.6 cases per 100,000 (Figure 1.1). The highest age-adjusted incidence rates of EA occur in Scotland (6.6 per 100,000) and in other parts of the United Kingdom [2]. In the United States, the age-adjusted rate of esophageal cancer in 2009 was 4.1 per 100,000; EA alone had 2.7 cancers per 100,000, a sharp increase from the 1973 rate of 0.4 cancers per 100,000 [3] (Figure 1.2)
Although EA is the fastest-rising malignancy among white men in the United States, its increase may be slowing [4]. The US average annual percentage change in incidence was 8.4 (95% CI 7.7–9.1) before 1997, but it decreased to 1.6 (95% CI 0.0–3.3) from 1998 to 2009 [5]. In Scandinavia, the average annual percentage change has continued to increase [6].
In addition to geographic differences in the distribution of EA, there are remarkable variations in the demographics of persons affected by this cancer. The incidence of EA increases with age and peaks in the eighth decade of life. Independent of age, however, people born in more recent years have a higher incidence of EA [7]. EA incidence is five-fold higher among non-Hispanic whites than among blacks, while ESCC incidence rates among black men are four times higher than for white men [8]. Finally, most esophageal cancer cases (77.7%) affect men [6].
The incidence of EA is 7–10 times higher in men, while the incidence of ESCC is only 2–3 times higher in men than in women, according to numerous cancer registries around the world [9, 10]. This sex discrepancy varies among different races; for example, in the 50–59 age group, the highest male-to-female ratio was 20.5 in Hispanics, followed by 10.8 in whites and then 7.0 in blacks. With EA, male predominance is evident globally (Figure 1.1). Whether the difference in incidence rates among men and women or between whites and blacks is due to less gastroesophageal reflux disease (GERD) and/or Barrett's Esophagus (BE) prevalence, or to a less progressive form of these diseases, is unknown. Despite an equal distribution of GERD between men and women [11, 12], men seem to have a more severe form of the disease, with a higher complication rate [13].
With ESCC, some areas (e.g. South Karachi, Pakistan; West Midlands, UK; Oman; Penang, Malaysia; South Australia; Kuwait) have a higher age-adjusted incidence rate among women than among men [2] (Figure 1.1). The reason behind this is unknown. The main risk factors for ESCC, which show broad regional variation, include heavy alcohol consumption, tobacco smoking and human papilloma virus infection, as well as few rare disorders, such as achalasia of the cardia, and tylosis. These will not be discussed further in this review.
1.2 Mortality
Esophageal cancer is a highly fatal disease. The overall five-year relative survival for patients diagnosed with esophageal cancer in the United States was approximately 17.3% between 2003 and 2009 (Figure 1.2). The disease stage at time of diagnosis impacts survival greatly, as the age-adjusted five-year relative survival of 38.6% in localized disease declines to 3.5% in disease associated with distant spread. However, the overall survival over the past two decades has slightly, but significantly, improved. Despite the use of screening endoscopy in high-risk groups, about 35% of EA cases between 2004 and 2010 were diagnosed at an advanced stage [14]. A higher mortality rate for nonwhite Hispanics and blacks mostly has been attributed to the decreased receipt of cancer-directed surgery, indicating possible ethnic disparities in treatment application or availability [15].
1.2.1 Progression of BE to EA
A summary of published annual EA-risk data of nondysplastic BE ranges from 0.12–0.50% to 0.33–0.70% in population-based studies and meta-analyses, respectively [16]. Recent studies have indicated that the risk of progression from BE to EA is lower than previously reported [17]. The risk in a Dutch study of 42,207 patients was 0.4% [18]; in an Irish study of 8,522 patients, it was 0.22% per year (95% CI 0.19–0.26%) [19]; and in a Danish study of 11,028 patients, it was 0.12% (95% CI 0.09–0.15) [20].
1.3 Risk factors for EA
Risk factors for esophageal adenocarcinoma are outlined in Table 1.1.
Table 1.1 Summary of risk factors for the development of esophageal adenocarcinoma
Several population-based case control studies have established a strong association, including a dose-response relationship between GERD symptoms and EA (and adenocarcinoma of the gastric cardia), but not ESCC [21, 22]. In a meta-analysis of five population-based studies, the presence of at least weekly GERD symptoms was associated with an odds ratio (OR) for developing EA of 4.92 (95% CI 3.90–6.22), which increased to 7.4 (95% CI 4.94–11.10) when the symptoms occurred on a daily basis, compared with asymptomatic controls or those with less frequent symptoms [23]. However, up to 40% of the patients with EA may not report bothersome GERD symptoms.
1.3.2 Tobacco smoking
A pooled analysis of individual data from ten case-control and two cohort studies from Australia, Canada, Ireland, the United Kingdom and the United States, including 1242 EA cases, 1263 gastroesopheageal junction cancer (GEJ-CA) cases, 954 ESCC cases and 7053 controls without cancer [24], reported an increased risk of both types of esophageal cancer with history of tobacco smoking. The calculated OR of EA increased from 1.66 (95% CI 1.1–2.4) with 1–29 pack-...