Pathophysiological mechanisms linking obesity and esophageal adenocarcinoma

Abstract

In recent decades there has been a dramatic rise in the incidence of esophageal adenocarcinoma (EAC) in the developed world. Over approximately the same period there has also been an increase in the prevalence of obesity. Obesity, especially visceral obesity, is an important independent risk factor for the development of gastro-esophageal reflux disease, Barrett's esophagus and EAC. Although the simplest explanation is that this mediated by the mechanical effects of abdominal obesity promoting gastro-esophageal reflux, the epidemiological data suggest that the EAC-promoting effects are independent of reflux. Several, not mutually exclusive, mechanisms have been implicated, which may have different effects at various points along the reflux-Barrett's-cancer pathway. These mechanisms include a reduction in the prevalence of Helicobacter pylori infection enhancing gastric acidity and possibly appetite by increasing gastric ghrelin secretion, induction of both low-grade systemic inflammation by factors secreted by adipose tissue and the metabolic syndrome with insulin-resistance. Obesity is associated with enhanced secretion of leptin and decreased secretion of adiponectin from adipose tissue and both increased leptin and decreased adiponectin have been shown to be independent risk factors for progression to EAC. Leptin and adiponectin have a set of mutually antagonistic actions on Barrett's cells which appear to influence the progression of malignant behaviour. At present no drugs are of proven benefit to prevent obesity associated EAC. Roux-en-Y reconstruction is the preferred bariatric surgical option for weight loss in patients with reflux. Statins and aspirin may have chemopreventative effects and are indicated for their circulatory benefits.

Keywords: Adipose; Barrett’s esophagus; Body mass index; Reflux.

Figure 1

Possible mechanisms linking obesity with the development of esophageal adenocarcinoma. There are several potential and not mutually exclusive mechanisms that could link obesity and esophageal adenocarcinoma. Adipose tissue can exert both mechanical and endocrine effects that could enhance gastro-esophageal reflux and progression to adenocarcinoma. Decreased H. pylori could promote both gastro-esophageal reflux by increasing gastric acidity and increase body mass by enhancing production of the gastric appetite-stimulating peptide ghrelin.

Figure 2

Effects of the adipokines leptin and adiponectin on Barrett’s esophagus and esophageal adenocarcinoma. Obesity, more specifically visceral obesity, is associated with increased serum leptin and decreased serum adiponectin levels. Leptin and adiponectin have a set of antagonistic pathophysiological actions on Barrett’s esophageal and adenocarcinoma cells.