Indeed, smoking reportedly accounts for a larger percentage of risk in developed regions or countries [ 26 ], whereas relatively lower attributable risk has been observed in less developed regions or countries [ 27 , 28 ]. Further, China showed significantly increased trends in tobacco-related DALYs and deaths over the year study period.
Many studies have revealed that alcohol use is a risk factor for EC in both developing and developed regions. Alcohol use increases the risk of EC 1. The association between alcohol use and EC appears to be stronger in regions with low burden of EC, such as Europe [ 32 , 33 ].
A systematic review reported that high intake of fruits can reduce the risk and morbidity of EC [ 35 ]. However, the trends in deaths and DALYs owing to these two risk factors were different. China has the largest number of obesity and overweight people, attributed to changes in food environment and systems [ 36 ]. In all, strategies for health promotion should take tobacco, alcohol use, and high BMI into consideration. Patients exposed to these risk factors should be provided with proper prevention and education.
In China, quitting smoking, reducing alcohol consumption, and reducing weight should be essential components of prevention strategies. Our study has some limitations.
First, the study lacked information on the histological subtypes of EC. However, owing to a lack of necessary data, we could not identify the burden and risk factors in these two histological subtypes. Second, data on the type of risk factors in this study were limited. More factors that might be attributable to EC, such as Helicobacter pylori infection, should be investigated in future studies. With an aging population, EC will create a heavier burden on public health care systems.
Risk factors, including smoking, alcohol use, high BMI, and low-fruit diet, are the main factors of death and DALYs and should thus be given importance. CA Cancer J Clin. Article Google Scholar. Global incidence of oesophageal cancer by histological subtype in Int J cancer. Esophageal carcinoma. N Engl J Med. Article PubMed Google Scholar. Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol. Population attributable risks of esophageal and gastric cancers.
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Please update your settings with a valid address before to continue using PracticeUpdate. Close Back. Sign in. Join now. Esophageal adenocarcinoma and esophageal squamous cell carcinoma ESCC are the two major histological sub-types of esophageal cancer. The striking geographical variation implies that environmental and genetic factors play important roles in the development of esophageal cancer.
Esophageal cancer is the fifth most frequently diagnosed cancer and the fourth leading cause of death from cancer in China, with estimated , new cases and , deaths in , according to the National Central Cancer Registry 5. In China, incidence is generally higher among males and in rural areas. Age-specific incidence and mortality increase with age.
The incidence of esophageal cancer before the age of 40 is relatively low but increases rapidly after the age of 40 Figure 1. The mortality of esophageal cancer before the age of 45 is also relatively low and increases rapidly after the age of 50 Figure 2 and peaks between the ages of 80 and The incidence of esophageal cancer has been steady in recent decades and in most countries. The incidence among males in Asia has generally declined, whereas the incidence slightly increased in Europe.
Data provided by National Central Cancer Registry show that age-adjusted incidence rate decreases from From to , age-adjusted mortality rate decreased from Age-adjusted mortality rate has dramatically decreased across the three National Retrospective Sampling Survey of Death Causes , and Primary prevention, such as lifestyle modification, secondary prevention, such as screening, and improved medical level, may be the main cause for the decline of esophageal cancer incidence in China.
The incidence and mortality of esophageal cancer are also affected by geography. The third national census of cancer shows evident regional differences in the incidence of esophageal cancer in China. Provinces with higher rates, where near the Taihang Mountains, and the highest incidence of esophageal and cardiac carcinoma were in Linxian, Henan Province, where esophageal and cardiac carcinoma accounted for In addition, reports pointed out that smoking and alcohol drinking exert a synergistic effect on ESCC risk.
A meta-analysis showed that the combined effect of drinking and smoking is almost double the sum of their effects individually However, another meta-analysis showed that the effect of smoking on ESCC is considerably higher in Asian populations than in Western populations.
In a prospective study of risk factors for ESCC in Linxian, China, smoking and alcohol drinking were not significantly associated with the more significant risk factors of long-term ESCC risk, which is not consistent with results of previous studies in other areas in the world In several observational studies, non-frequent consumption of fresh fruits and vegetables is closely associated with a higher risk of ESCC 17 - However, in that report, no distinction was made between ESCC and esophageal adenocarcinoma.
A meta-analysis that included several prospective studies suggested that eating fruits and vegetables is significantly associated with reduction in ESCC risk There are no prospective studies and the relationship between dysplasia and squamous carcinoma development in this population is still unknown[ 23 ]. The main dysplastic lesion associated with esophageal squamous cell carcinoma in prospective population studies in the Chinese region of Linxia is the high-grade dysplasia, which is associated with an RR of Endoscopy: Endoscopy is the gold standard for the diagnosis of pre-cancerous squamous lesions.
Squamous dysplasia may go undetected when using standard endoscopy and therefore chromoendoscopy techniques have been suggested to improve the performance of the test. The most simple and effective for the detection of squamous dysplasia is Lugol staining. Most of the studies, if not all, have been performed in Asia where the incidence of squamous carcinoma is high.
In this regard, a prospective population study was conducted in in Henan, one of the areas of Northern China with high incidence of esophageal carcinoma, in the context of a screening program with biopsies taken and guided by chromoendoscopy. A total of people between 40 and 69 years were examined. The study detected 7. The results of several cost-benefit studies about endoscopic screening of esophageal squamous carcinoma have shown that such strategy is only cost-effective in areas of high incidence of squamous cell carcinoma, such as in Northern and rural areas of China.
However, some variations may occur even in high-risk areas. The geographical and the economic status of the region have a great impact in the onset of esophageal carcinoma regarding the age of onset, the number needed to screen, the precursor lesions that have to be identified and the intervals for a proper surveillance in people with such lesions[ 26 , 27 ].
The two key strategies to be followed to ensure cost-effective programs taking into account the acceptance of the population and the distribution of wealth in different regions were: 1 screening once throughout life and starting at the age of 50, following up after 5 years of detecting low-grade dysplasia and 3 years after intermediate-grade dysplasia, for areas with limited access to healthcare, impoverished and with a difficult track the target population economy[ 26 ]; and 2 screening three times over life, starting at the age of 40, and monitoring low-grade dysplasia and intermediate-grade dysplasia as above, for areas with appropriate access to health care, and economies that are more advanced and good monitoring program by the target population[ 26 ].
One of the questions is whether these results can be applied to Western countries. There are no European studies suggesting that endoscopic screening for squamous esophageal carcinoma is either necessary or cost-effective. The low incidence of squamous esophageal carcinoma in the European population and the predominance of public health systems might be some of the main reasons why screening of this condition is not an option even in individuals with risk factors.
Other screening techniques: There are areas in the world with high incidence of squamous carcinoma, beyond those already mentioned, where screening program using the gold standard technique with Lugol chromoendoscopy have not been shown to be cost-effective. An Iranian review published in suggested that new screening strategies, cheaper and more effective, should be tracked. The low number of suitable samples and low sensitivity makes them unsuitable for effective screening[ 16 ]. Very few studies looking at blood biomarkers on people of countries with high incidence of squamous carcinoma have been performed, but most suggest that these should be used in the future in combination with other screening techniques to optimize the results[ 16 ].
Early esophageal carcinoma EEC is defined as those early stages in which the neoplastic involvement does not exceed the submucosa, and there are no nodes involved DAG, T1a, T1b, N0 [ 29 , 30 ] Table 2 , Figure 3. There are big differences among treatment for early esophageal cancer between Western and Asian countries.
In fact, the Asian attitude is more aggressive in managing these patients. Most Western studies convey the idea that the rate of lymph node metastasis in T1b tumors is too high to be considered a safe endoscopic therapy as a definitive treatment for this neoplastic disease. For stage T1a, esophagectomy is seen today as a second treatment option, with a success rate similar to endoscopic cancer but with a much larger treatment morbidity. However, in m3 T1a squamous carcinomas, lymph node involvement is higher than previously presumed and esophagectomy with lymphadenectomy should be considered[ 31 , 32 ].
A number of articles from Asia, mainly Japan and China, have a more aggressive approach from the point of view of endoscopic management of early esophageal cancer. T1a and T1b lesions, regardless of histological type, with confirmed no lymph node metastases, are managed by endoscopy resection, since it is considered that this technique has the same efficacy as esophagectomy. The main objective of this approach is to preserve the esophagus as a functional organ and avoid the morbidity of surgery at that level.
The EMR was the first endoscopic technique developed. However, it has its limitations. The authors conclude that it is a safe and effective technique[ 37 ].
Squamous cell carcinoma is still the most common histologic type in the world. The areas with the highest incidence are found in Africa and the Middle East. The risk factors most frequently involved, are the abuse of tobacco and alcohol, as well as mutations in metabolizing pathways of these substances, and nutritional deficits.
In areas of high incidence, defined as 30 or more cases per person-years, justified the mass screening of squamous carcinoma, a fact that improves detection rates of early squamous cell carcinoma and its management without surgery, with a high proportion of patients treated with endoscopic resection strategy. There has been a shift from squamous carcinoma to adenocarcinoma as the most frequent histological type of esophageal carcinoma in fundamental areas of Europe such as Norway, United Kingdom, in the United States and in Australia.
Differentiating risk factors are fundamentally obesity, GERD and BE as well as the influence of toxics such as tobacco. BE is a precursor of adenocarcinoma, but the rate of cancer transformation in European and United States populations is low, which questions surveillance programs and the search for an early diagnosis of adenocarcinoma in BE, which is common clinical practice today.
In any case, the rate of detection of early stage adenocarcinoma is lower in Western countries and treatment, therefore, is less conservative, with high proportion of patients treated with surgical techniques to achieve eradication of the disease. Advanced Search. This Article. Academic Rules and Norms of This Article. Copyright Assignment PDF. Citation of this article. Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries.
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