Endoscopy screening effect on stage distributions of esophageal cancer: A cluster randomized cohort study in China

Efficacy of endoscopic screening for esophageal cancer is not sufficiently definitive and lacks randomized controlled trial evidence. The present study proved short‐term screening efficacy through describing and comparing disease stage distributions of intervention and control populations. Villages from Linzhou and Cixian were cluster randomly allocated to the intervention or to the control group and the target population of 52 729 and 43 068 individuals was 40‐69 years old, respectively, and the actual enrolled numbers were 18 316 and 21 178, respectively. TNM stage information and study‐defined stage information of esophageal cases from 2012 to 2016 were collected. Stage distributions were compared between the intervention and control groups in the total target population, as well as in the subgroup populations in terms of enrolment and before or after intervention. There were a total of 199 and 141 esophageal cancer cases in the intervention and control groups, respectively. For the target population, distributions of TNM stage were borderline significant between the two groups after intervention (P = .093). However, subgroup analysis of the enrolled population during the after‐intervention period had statistical significance for both TNM and study‐defined stage. Natural TNM stage distributions were approximately 32%, 41%, 24% and 3% for stages I to IV vs 71%, 19%, 7% and 3% in the intervention population. The natural study‐defined stage distributions from early, middle to advanced stages were approximately 18%, 49% and 33% vs 59%, 33% and 8%. Early‐stage esophageal cancer cases accounted for a higher proportion after endoscopy screening, and the efficacy in the target population depends on the intervention compliance.     

Potential capacity of endoscopic screening for gastric cancer in Japan

In 2016, the Japanese government decided to introduce endoscopic screening for gastric cancer as a national program. To provide endoscopic screening nationwide, we estimated the proportion of increase in the number of endoscopic examinations with the introduction of endoscopic screening, based on a national survey. The total number of endoscopic examinations has increased, particularly in clinics. Based on the national survey, the total number of participants in gastric cancer screening was 3 784 967. If 30% of the participants are switched from radiographic screening to endoscopic screening, approximately 1 million additional endoscopic examinations are needed. In Japan, the participation rates in gastric cancer screening and the number of hospitals and clinics offering upper gastrointestinal endoscopy vary among the 47 prefectures. If the participation rates are high and the numbers of hospitals and clinics are small, the proportion of increase becomes larger. Based on the same assumption, 50% of big cities can provide endoscopic screening with a 5% increase in the total number of endoscopic examinations. However, 16.7% of the medical districts are available for endoscopic screening within a 5% increase in the total number of endoscopic examinations. Despite the Japanese government's decision to introduce endoscopic screening for gastric cancer nationwide, its immediate introduction remains difficult because of insufficient medical resources in rural areas. This implies that endoscopic screening will be initially introduced to big cities. To promote endoscopic screening for gastric cancer nationwide, the disparity of medical resources must first be resolved.     

Serum ghrelin and esophageal and gastric cancer in two cohorts in China

Ghrelin is a hormone produced in the oxyntic glands of the stomach. Previous work by our group has suggested that serum ghrelin concentrations are inversely associated with gastric and esophageal cancer risk. We measured ghrelin concentrations in the Linxian General Population Nutrition Intervention Trial (NIT), and the Shanghai Women's Health Study (SWHS). In NIT, we analyzed serum samples from 298 esophageal squamous cell carcinoma (ESCC) cases, 518 gastric cardia adenocarcinoma (GCA) cases, 258 gastric noncardia adenocarcinoma (GNCA) cases and 770 subcohort controls (case–cohort). In SWHS, we measured ghrelin in plasma samples from 249 GNCA cases and 498 matched controls (nested case–control). Ghrelin was measured using radioimmunoassay. In NIT and SWHS, low ghrelin concentrations were associated with an increased risk of developing GNCA and GCA. The hazard ratio (HR _Q1:Q4) for GNCA in NIT was 1.35 (95% CI: 0.89–2.05; p-trend = 0.02); the odds ratio in SWHS was 1.66 (95% CI: 1.02–2.70; p-trend = 0.06). Low ghrelin was associated with a twofold increase of GCA (HR _Q1:Q4 = 2.00, 95% CI: 1.45–2.77; p-trend<0.001). In contrast, a lower risk of ESCC (NIT ESCC HR _Q1:Q4 = 0.65, 95% CI: 0.45–0.92; p-trend = 0.02) was found in NIT. Low baseline ghrelin concentrations were associated with an increased risk for GNCA and GCA in the NIT and the SWHS. In contrast, low ghrelin concentrations at baseline were associated with a reduced risk of developing ESCC in the NIT. Ghrelin may be an early marker of future cancer risk for developing upper gastrointestinal cancer in regions of high incidence.     

食管支架在食管癌治疗中的应用进展

食管支架置入广泛用于临床解决进食困难的病人,本文就食管支架在食管癌治疗中的应用作一综述。     

NATURAL HISTORY OBSERVATION FOR ESOPHAGEAL AND CARDIA PRECURSORS BY REPETITIVE ENDOSCOPIC SCREENING OF 301 SUBJECTS IN SHEXIAN

OBJECTIVE To investigate the natural history of fast developing esophageal and cardia precursors. METHODS Repetitive endoscopic screenings were performed among 40-69-year-olds in the high-incidence areas for esophageal cancer in Shexian. RESULTS The initial diagnosis and the lag-time for 7 subsequently identified severe dysplasia （SD） subjects were as follows： in one subject 13 months after a baseline diagnosis of normal epithelium, in another subject 7 months after a baseline diagnosis of base cell hyperplasia （BCH）, in four subjects 3, 4, 4, and 10.5 months after baseline diagnosis of mild dysplasia （mD）, and in one subject 12.5 months after a baseline diagnosis of moderate dysplasia （MD）. The initial diagnosis and the lag-time for 6 subsequently identified carcinomas in situ or intramucosal carcinoma cases were： in one case 48 months after a baseline diagnosis of mD, in 2 cases 4 and 13 months after baseline diagnoses of MD, and in the other 3 cases 3.5, 9, and 17.5 months after baseline diagnoses of SD. The initial diagnosis and lag-time for 3 subsequently identified invasive cancer cases, were： in one case 50 months after a baseline diagnosis of MD, in 2 cases 14 and 19 months after baseline diagnoses of SD. In addition, during a 4-year-follow-up of 18 subjects after endoscopic mucosa resection, 9 of them were found to have developed precursors again at other sites, and also additional findings were obtained for 11 of the 16 dysplasia cases by repetitive biopsy in less than 2 months after the initial endoscopy. CONCLUSION A 5-year screening interval for BCH and mD, and a 3-year interval for MD may be too long for the fast developing precursors. Periodic screenings with shorter intervals should be considered to control the number of interval cases due to fast development, multifocal carcinogenesis, and false negative results inherent in one-time endoscopic biopsy sampling.     

内镜下射频治疗晚期食管癌37例疗效总结

目的：探讨内镜下射频治疗食管癌狭窄梗阻的疗效。方法：对37例3、4级狭窄梗阻的食管癌采用内镜下射频治疗。结果：显效22例、有效13例,总有效率达94.6%,不良反应是持续恶心、剧烈会厌反射、胸前区灼热痛、上腹部胀痛。结论：内镜下射频治疗3、4级食管癌在缓解梗阻和解决进食方面近期疗效显著,操作简单,安全可靠。     

山东省2013-2016年农村居民食管癌社会性筛查结果分析

目的 山东省自2006年开始承担国家食管癌早诊早治项目,取得了良好的社会效益.本研究旨在分析山东省2013-2016年食管癌早诊早治项目筛查结果,探讨食管癌筛查的改进策略.方法 采用整群随机抽样法选取2013-2016年山东省内9个项目点的目标人群,年龄40～69岁,对符合条件的受检者采用内镜下碘染色观察和指示性活检技术进行筛查;对筛查结果进行分析,计算检出率、早诊率等,并进行统计检验.结果 9个项目点共完成筛查107 431人次,检出重度异型增生及以上病例1 093例,检出率为1.02％,其中早期病例941例,早诊率为86.09％;食管各级病变例数大致呈“金字塔”型分布,筛查可发现大量癌前病变和早期食管癌患者;社会性筛查带动了项目点食管癌诊治水平的提高,但不同地区间的检出率差异较大(P＜0.05),食管癌检出率与当地发病率密切相关;与机会性筛查相比,食管癌社会性筛查具有“检出率低、早诊率高”的特点.结论 食管癌社会性筛查具有良好的社会效益,应继续推广;推动“社会性筛查”和“机会性筛查”融合发展以及“补需方”和“补供方”的有机结合,有利于提高检出率和早诊率,促进筛查工作的可持续发展.     

Cost-effectiveness of breast cancer screening programme for women in rural China

In low and middle-income countries mammographic breast cancer screening is prohibitively expensive and a cheaper alternative option is to use ultrasound as the primary screening test. In 2009, China launched a breast cancer screening programme for rural women aged 35–64 years with clinical breast examination coupled with ultrasound as the primary tool. Our study aimed to analyse the cost-effectiveness of breast screening compared to no screening among Chinese rural women. We developed a Markov model to estimate the lifetime costs and effects for rural women aged 35 years from a societal perspective. Asymptomatic women in the intervention arm were screened every 3 years before age 64 years. Breast cancer in the non-screening arm can only be diagnosed on presentation of symptoms. Parameter uncertainty was explored using one-way and probabilistic sensitivity analyses. Compared to no screening, breast cancer screening cost $186.7 more and led to a loss of 0.20 quality-adjusted life years (QALYs). Breast screening was more expensive and did harm to health among rural women with an incremental cost-effectiveness ratio (ICER) of $-916/QALY. The sensitivity analysis identified utility loss from false positives as the factor that most influenced the results, but this did not affect the conclusions. In a rural setting with such low breast cancer incidence, screening for asymptomatic disease is not cost-effective with current screening tools. Priority should be given to ensure that symptomatic women have proper access to diagnosis and treatment at an early stage as this will lead to mortality reductions without the usual screening harms.     

Systematic esophageal endoscopy screening in patients previously treated for?head and neck squamous-cell carcinoma

Background:An attempt was made to improve metachronous oesophageal cancer prognosis through bi-annual systematic esophageal endoscopy screening in patients treated for head and neck cancer. Patients and methods:Bi-annual esophageal endoscopy, without a staining procedure, was performed in 1560 patients from 1987 to 1997. The distribution of previous head and neck cancer was oral cavity (20%), oropharynx (30%), hypopharynx (34%), and larynx (16%). All patients had initial panendoscopic inspection before HNSCC treatment. Esophageal tumors were considered to be second synchronous primaries when discovered within the first six months of initial tumor diagnosis. Results:Fifty metachronous esophageal asymptomatic cancers (42 T₁ and 7 in situcarcinomas) were diagnosed by endoscopy. The median time between the HNC and the esophageal carcinoma was 43 months (7–137 months). Metachronous esophageal carcinoma was discovered in 2.6% of patients with oral cavity tumor, 5.7% of patients with oropharynx tumor, 2.3% of patients with hypopharynx tumor, and 1.7% of patients with larynx tumor. Causes of death were: 41.1% related to esophageal tumor with tumor progression, metastatic evolution, or treatment toxicity; 28.9% related to non malignant causes; 26.6% related to a cancer that was not of esophageal origin. Conclusions:Over a 10-year period, systematic bi-annual esophageal endoscopy uncovered metachronous esophageal tumors in 3.2% of 1560 patients originally treated for head and neck carcinoma, developing in a median time of 47 months. Patients with initial oropharyngeal tumors had a significantly higher risk of metachronous esophageal SCC, compared to the other tumor sites (P < 0.02 with Fisher exact test). Given the elevated death rate not related to the esophageal cancer and the median survival of 16 months, any potential benefit from this time-consuming procedure is debatable.     

Retrospective cohort study of risk-factors for esophageal cancer in Linxian,People's Republic of China

A retrospective cohort study of esophageal (including gastric cardia) cancer was conducted to examine dietary and other potential risk factors in Linxian, a high-risk area in P.R. China. Study subjects were identified based on participation in a cytology examination conducted in 1974. They were interviewed in 1989 to obtain information on esophageal cancer risk-factors and identify new cases and deaths. A total of 1,162 subjects from the analytic cohort of 12,693 were determined to have developed esophageal cancer over the 15-year follow-up period. Results indicate that increased age, male gender, a positive family history, low education level, surface-water use, and pork consumption were the strongest risk factors for esophageal cancer identified in this cohort, while use of corn as a primary staple and infrequent consumption of fresh vegetables also were possible risk factors. Traditional or suspected risk factors for esophageal cancer in this and other populations—smoking and alcohol use, and pickled vegetable and moldy food consumption—were not risk factors in this study. Some variation in risk was seen based on the subject's cytology result from 1974. We conclude that dietary factors appear to play a role in the etiology of esophageal cancer in this high-risk population, but are less important than other constitutional factors such as age, gender, and family history.Drs Yu, Li, Wang, Guo, Wang, Liu, and Li are with the Cancer Institute of the Chinese Academy of Medicinal Sciences in Beijing, PRC. Drs Taylor, Dawsey, and Blot are with the National Cancer Institute in Bethesda, MD, USA. Dr Shen is with Henan Medical University in Zhengzhou, PRC. This project was funded partially by contract # NO1-CP-41019 from the US National Cancer Institute.     

Sensitivity of endoscopic screening for gastric cancer by the incidence method

Although radiographic screening for gastric cancer has been conducted in Japan, it is anticipated that endoscopy will become a new screening method because of its high detection rate. The sensitivities of endoscopic and radiographic screening were calculated by the detection method and the incidence method based on the results of community‐based screening in Japan. There were 56,676 screenings for gastric cancer using endoscopy and radiography from April 2002 to March 2007 in Yonago, Japan. The target age group was from 40 to 79 years. Screen‐detected and interval cancers were investigated based on a screening database linked to the Tottori Cancer Registry. All gastric cancers diagnosed within 1 year after a negative screen were considered interval cancers. Based on the screening history, these were divided into prevalence screening and incidence screening. Prevalence screenings included 7,388 for endoscopic screening and 5,410 for radiographic screening, whereas incidence screenings included 18,021 for endoscopic screening and 11,417 for radiographic screening. The sensitivity of prevalence screening calculated by the incidence method was 0.886 (95% confidence interval [CI] = 0.698–0.976) for endoscopic screening and 0.831 (95% CI = 0.586–0.964) for radiographic screening; however, the difference was not significant (p = 0.626). The sensitivity of incidence screening calculated by the incidence method was 0.954 (95% CI = 0.842–0.994) for endoscopic screening and 0.855 (95% CI = 0.637–0.970) for radiographic screening (p = 0.177). Endoscopic screening for gastric cancer had a higher sensitivity than radiographic screening by the incidence method in both screening rounds. However, further study is needed to evaluate mortality reduction and to estimate overdiagnosis with endoscopic screening for gastric cancer.     

内镜下射频治疗晚期食管癌37例疗效总结

目的:探讨内镜下射频治疗食管癌狭窄梗阻的疗效。方法:对37例3、4级狭窄梗阻的食管癌采用内镜下射频治疗。结果:显效22例、有效13例,总有效率达94.6%,不良反应是持续恶心、剧烈会厌反射、胸前区灼热痛、上腹部胀痛。结论:内镜下射频治疗3、4级食管癌在缓解梗阻和解决进食方面近期疗效显著,操作简单,安全可靠。     

Effect of annual endoscopic screening on clinicopathologic characteristics and treatment modality of gastric cancer in a high-incidence region of Korea

We investigated risk factors for gastric cancer (GC) and effect of annual endoscopic screening on detection and treatment modality of GC. Asymptomatic adults who underwent upper endoscopy during health checkups at Seoul National University Hospital Healthcare System Gangnam Center were enrolled. We compared clinicopathologic characteristics of GC according to screening interval (repeated vs. infrequent, annual vs. biennial). After age- and sex-matching, relative risk was computed by hazard ratio (HR) using Cox proportional regression with multivariate adjustment. Of the 58,849 subjects who received screening endoscopy, 277 (0.47%) were found to have GC. Intestinal type comprised 55.4% (102/184) followed by diffuse type (n = 65, 35.3%). Age ≥50 years, family history and smoking independently increased the risk of GC for both types, whereas male gender [HR = 4.81, 95% confidence interval (CI): 2.72-8.03] and intestinal metaplasia (IM) (HR = 10.87, 95% CI: 3.36-22.30) were significant predictors for intestinal type only. Proportion of early gastric cancer (EGC) was 98.6% (71/72) in annual screening group and 80.7% (46/57) in biennial screening group (p < 0.01). In the former, tumor size was smaller (1.7 ± 1.3 vs. 2.3 ± 1.8 cm; p < 0.01] and proportion of intramucosal cancer was larger (75.0 vs. 56.1%; p = 0.04). Endoscopic resection was performed more frequently in annual screening group (56.9 vs. 33.3%; p = 0.02). IM along with male gender and older age was a strong risk factor for intestinal type GC. Annual screening group improved detection of early-stage and endoscopically treatable GC suggesting that intensive screening and surveillance may be useful for high-risk subpopulations with epidemiologic risk factors or premalignant lesions such as IM.     

Precision screening for esophageal squamous cell carcinoma in China

Esophageal squamous cell carcinoma(ESCC) is the predominant subtype of esophageal cancer in China, and this neoplasm is associated with high morbidity and mortality as well as clear geographical heterogeneity. Since primary prevention for ESCC lacks a clear intervention target, secondary prevention, also known as screening and early diagnosis and early treatment, has become the mainstay of ESCC prevention and control in China. ESCC screening in China has been subject to decades of evaluation and...     

The relationship between a cohort endoscopic screening of 15,000 subjects and the death of patients with esophageal and gastric cancers in high-risk areas

OBJECTIVE Ci-xian County is located in the north of China and is a high-risk area for esophageal cancer （EC）. In 2004, the incidence rate of EC in the county was 127/100,000 and 93/100,000 in the male and female population, respectively, and that of gastric cancer （GC） was 72/100,000 and 36/100,000. Since 2001 a cohort screening, supported by a special national fund, utilizing endoscopic examination with iodine staining for the target population at the age ranging from 40 to 69 years was carried out, so as to reduce the incidence and mortality rates in the high-risk areas of EC. METHODS In October 2001, 4 townships in the Ci-xian County, Hebei, China were selected, with 22,016 cases in the intervention group （IVG） and 33,410 in the control group （CG）. The total population coverage reached 55,000. There were 3257 males and 3339 females in the IVG with the age ranging from 40 to 69 years, and 4299 males and 4430 females in the CG with the same range of the age. Endoscopic screening with iodine staining was used in the IVG, with a screening rate of 53.2%. During the screening by endoscopic examination, 97 cases were found to have esophageal squamous epithelium, carcinoma-in-situ at the cardiac glandular epithelium or intra-mucosal carcinoma. Additionally, 102 cases were identified to have severe atypical hyperplasia in the esophagus and gastric cardia. The natural incidence rate of cancer and the mortality were observed in the CG. The ICD-0 version was used in the tumor incidence and death registration coding. During a period from June to September 2008, based on the information of the tumor registration database of the incidence and mortality in the Ci-xian County, the cohort groups were studied and followed. RESULTS There were 133 patients with untreatable EC and 48 with GC in the IVG, while there were 259 and 37 patients in the CG who died of esophageal and gastric cancer, respectively. The relative risk （RR） of death was 0.76 in the male patients with EC, 95%CI （0.59-0.98）, P = 0.038, and in the female patients the RR was 0.51, 95%CI （0.35-0.75）, P = 0.000. The RR of death in the GC patients was 2.45, （1.40-4.29） in the male, P = 0.01, and 0.99, （0.47-1.99）, in the female cases, P = 0.906. CONCLUSION Six years after a cohort screening of a large population by endoscopic examination with iodine staining in areas at high risk for EC, the death risk in the male and female patients with EC has decreased compared with that in the control group. The difference between the 2 groups was statistically significant. However, no protective method used to decrease the death risk in GC patients has been found during this period of endoscopic screening.     

Impact of the introduction of organised screening for cervical cancer in Turin, Italy: cancer incidence by screening history 1992-98

After an organised cervical screening programme was introduced in Turin in 1992, the age-adjusted cervical cancer incidence ratio in 1992-98 was 0.81 (95% confidence interval (CI) 0.59-1.09) for invited vs not invited women and 0.25 (95% CI 0.13-0.50) for attenders vs non attenders. An organised screening programme can further reduce cervical cancer incidence in an area where substantial spontaneous activity was previously present.     

CT仿真食管内窥镜在食管癌诊断中的应用

目的　采用CT仿真食管内窥镜技术探索诊断食管癌的无创新方法。方法　对 16例食管癌病人均行CT仿真食管内窥镜及上消化道造影检查。其中 14例行电子纤维食管镜检查 ,2例行锁骨上淋巴结针吸活检。手术切除 2例。最后进行对比分析。结果　全组CT仿真食管内窥镜均可显示食管粘膜、病变部位及长度。 12例可见食管腔阶段性狭窄 ,4例可见突向食管腔的肿块影。与上消化道造影及电子纤维食管镜检查结果比较基本一致。 2例施行手术切除 ,与术中、术后标本比较基本符合。本组对食管癌的诊断符合率 10 0 %。结论　CT仿真食管内窥镜可做为诊断食管癌的辅助方法之一。