Indicators of prognosis among patients with esophageal adecnocarcinoma
Dr. Matt Buas and colleagues at Roswell Park analyzed clinical and lifestyle factors among 371 persons with esophageal adenocarcinoma diagnosed over a 17 year period. They observed a number of factors (e.g., diet, physical activity, statin or NSAID use) correlated with improved survival, depending on stage of diagnosis. Among those with localized or regional tumors, current smoking was associated with a 2.5-fold increased mortality risk.
Best practice guidelines for reducing use of PPIs
Proton pump inhibitors (PPIs) are very commonly used to treat upper GI symptoms including gastroesophageal reflux, which is a key risk factor for Barrett's and esophageal adenocarcinoma. Although they are usually quite effective in relieving symptoms, they are not without the potential for side effects and adverse events. This expert review provides "best practice advice" for de-prescribing PPIs.
Prioritising BE surveillance using Cytsponge biomarker panel and clinical and epidemiologic risk factors
In addition to serving as a minimally invasive screening tool to help identify persons with Barrett's (BE), dysplasia and early stage esophageal adenocarcinoma, the Cytosponge (and similar devices) also have a potentially important role in long term surveillance of persons with BE. In this report, Dr. Fitgerald and colleagues are among the first to evaluate how this device might be used, in tandem with clinical and epidemiologic risk factors, to triage BE patients into risk groups, each with a unique follow up regimen. As the authors note, "Further investigation could validate their use in clinical practice and lead to a substantial reduction in endoscopy procedures compared with current surveillance pathway."
Opportunities for esophageal cancer screening
In a case-control study using the Veterans Health Administration (VHA) Central Cancer Registry, the authors investigated opportunites to undergo screening for esophageal adenocarcinoma (EAC). They found that more than 80% of individuals diagnosed with EAC or EGJAC had not undergone prior upper endoscopy, and the vast majority of those individuals had potential opportunities at which screening could have been offered prior to their cancer diagnosis. They also observed that cancer cases with prior BE who were overdue for surveillance made up only 3.3% of EAC cases.
Evolution of esosphageal adenocarcinoma and implications for screening and surveillance
This nice review updates the molecular/genomic changes leading to esophageal adenocarcinoma and makes the link to more effective screening and treatment approaches. As the authors conclude: "Ultimately, the long evolutionary history and repeated patient surveillance can be used to help improve personalized risk prediction in the management of patients with BE. By understanding the evolutionary dynamics across a BE segment through a global view of the genomic structural instability and the resulting clonal cell populations, we can also begin to improve our understanding of EAC with the aim to detect cancers earlier."
Asbestos exposure and increased risk of ESCC
A meta-analysis of 34 studies of occupational exposure to asbestos reveals a 28% increased risk of esophageal squamous cell carcinoma, which increased to 84% among those most highly exposed. The authors conducted a quite thorough analysis, while lack of available information on the major risk factors (smoking and alcohol) remains a limitation.
Limitations of current Barrett's screening criteria
The urgent need to include additional predictors (risk and protective factors) in identifying high-risk persons for BE and EAC screening is becoming more and more clear. Here, using two cohorts from the US and UK, the authors again observe that 39% of EAC cases did not report heartburn - a required component of screening eligibility. Several risk prediction algorithms have already been proposed to address this problem; they need to be evaluated in prospective studies.
Hormone therapy and esophageal adenocarcinoma
Drs. Xie and colleagues observed a decreased risk of esophageal adenocarcinoma among women taking post-menopausal hormones in this population-based cohort study in Sweden with 693 EAC cases. This supports the concept that female sex hormones contribute to the lower incidence of EAC in women.
Importance of family history in Barrett's and esophageal adenocarcinoma
Family history of Barrett's and/or EAC was determined in 480 BE patients and 420 controls and validated using the Dutch nationwide histopathology database. A positive family history was found in 6.5% of BE patients, which is consistent with other studies, yielding a five-fold increased risk. The authors emphasize the importance of a detailed family history in patients with BE or EAC to identify individuals at increased risk who may benefit from early detection strategies to prevent EAC-related mortality
Markov model indicates cost-effectiveness of Cytosponge-TFF3 screening
The Cytosponge-TFF3 tandem for non-endoscopic screening is one of several being developed or newly available to expand screening for Barrett's or early stage adenocarcinoma at lower cost and with less invasiveness and patient inconvenience. In this report from the BEST3 Consortium, Markov modeling was used to investigate cost effectiveness and quality-adjusted life-years in a randomized clinical trial. They found an ICER of £5,500 (a relatively low amount), which might be even lower in a younger population.
Esophageal cancer mortality trends in US
This report focuses on esophageal cancer mortality trends in the US from 1992-2016. Importantly, the dramatic decrease in esophageal squamous cell carcinoma among black males over the past several decades is highlighted and observed to be continuing. The authors attribute this decrease in part to reduced prevalence of heavy smoking. In addition, the recent leveling off of mortality for esophageal adenocarcinoma in white males was observed to continue.
Esophageal squamous cell risk predictor developed
Dr. Wang and colleagues developed and validated a risk prediction model and web-based calculator for ESCC, based on age, sex, smoking, alcohol and BMI. The AUC was 0.70 with a sensitivity and specificity of 56.8% and of 74.0%, respectively. Significantly Increased accuracy would likely be achieved by incorporating a more finely-grained assessment of age, smoking and alcohol.
When to stop Barrett's surveillance?
Gastroenterology societies recommend surveillance for non-dysplastic Barrett's but do not give guidance on when surveillance should stop. In this modeling study Dr. Omidvari and colleagues report that the optimal age for last surveillance of NDBE patients depends on the sex and the comorbidity level of patients. For men with NDBE without comorbidity, the optimal age for last surveillance is 81 years, while it may be up to 8 years earlier for those with comorbidity. For women, they found that without comorbidity, the optimal age for last surveillance of NDBE patients is 75 years, but can be up to 6 years earlier if patients have comorbidities.
Indoor wood combustion and esophageal squamous dysplasia Kenya
In this cross-sectional study of non-smokers from a rural area of Kenya, where indoor cooking with wood is common, metabolites of carcinogenic PAHs were substantially elevated compared to non-smokers in other countries. Prevalence of esophageal squamous dysplasia in this high-risk areea was positively correlated with levels of various PAH metabolites in urine. The authors point out that: "High PAH exposure is a consistent finding in high-risk areas for ESCC, and we expected similar findings in this understudied high-risk population from East Africa. But the urinary PAH metabolite concentrations in the current study were dramatically higher than those reported in previous urine metabolite studies of other populations."
Prediction tools evaluated in large retrospective cohort study
Using a Northern California Kaiser Permanente cohort linked with local cancer registries to determine incidence of EAC, Dr. Rubenstein and colleagues evaluated the accuracy of four published prediction tools for EAC. The Kunzmann algorithm was found to be most effective (AUC = 0.73) and substantially better than using GERD symptoms alone to identify high-risk persons. Some of the limitations include the relatively small number of EAC outcomes (168), the need to impute multiple variables and records, and the lack of information on changes to participants' risk profiles (e.g., obesity, GERD symptoms, etc.) over the very long follow up time. Many of these limitations are conservative in nature, i.e., resulting in an underestimate of predictive ability. Also lacking, due to the source of the data, is information on other potential risk and preventive factors which have been shown to predict subsequent EAC. For example, a risk calculator (IC-RISC) that also includes race, family history and use of NSAIDs exhibits an AUC of 0.81 (although it has not been independently validated.) Nevertheless, the authors make the important point that any of the tested tools are vastly superior to using only GERD in defining "high-risk" persons for screening, and should be implemented in clinical practice.
Visceral obesity and esophageal cancer
In this remarkably thorough review, Drs. Elliott and Reynolds summarize the evidence for and potential mechanisms underlying the association between visceral (abdominal or central) obesity and risk of esophageal adenocarcinoma, as well as potential roles for associated dietary, lifestyle, pharmacologic and surgical interventions on risk of EAC.
Three-tiered screening program proposed
Drs. Yusuf and Fitzgerald review recent technological advancements in screening for Barrett's esophagus and propose a three-tier approach using risk prediction algorithms and minimally invasive approaches to improving detection rate for Barrett's and EAC
Review of Barrett's and Esophageal Adenocarcinoma
The authors review the incidence of BE and EAC and associated risk factors, evidence for improved outcomes among patients with a prior diagnosis of BE compared to those without, discuss the challenges of developing sufficiently accurate prediction models in the context of high population prevalence of risk factors (e.g., obesity, reflux, smoking), and emphasize the need for larger biomarker studies.
Good news in treatment of esophageal cancer
Dr. Ilson's editorial in the New England Journal of Medicine puts new findings regarding the monoclonal antibody, nivolumab, in treatment of esophagal cancer in perspective. [Figure from original research article by Kelly, et al in same issue]