Precision prevention of oesophageal adenocarcinoma

Abstract

The incidence of oesophageal adenocarcinoma has risen rapidly over the past four decades. Unfortunately, treatments have not kept pace; unless their cancer is identified at a very early stage, most patients will not survive a year after diagnosis. The beginnings of this widespread problem were first recognized over 25 years ago, yet rates have continued to rise against a backdrop of much improved understanding and management of oesophageal adenocarcinoma. We estimate that only ∼7% of the 10,000 cases of oesophageal adenocarcinoma diagnosed annually in the USA are identified through current approaches to cancer control, and trace pathways by which the remaining 93% are 'lost'. On the basis of emerging data on aetiology and predictive factors, together with new diagnostic tools, we suggest a five-tier strategy for prevention and control that begins with a wide population base and triages individuals into progressively higher risk strata, each with risk-appropriate prevention, screening and treatment options.

Figure 1

Esophageal adenocarcinoma incidence in white males, United States, 1973–2011. [Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 9 Regs Research Data, (with SEER Delay Factors) Nov 2013 Sub (1973–2011) <Katrina/Rita Population Adjustment> National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2014, based on the November 2013 submission.]

Figure 2

The size of Napoleon’s army, represented by the width of the line, dwindled from almost 500,000 to about 10,000 during his invasion of Russia (gray), and return to France (black) during the extremely cold winter of 1812–1813. (Charles Minard, 1869; public domain)

Figure 3

The current approach to control of esophageal adenocarcinoma identifies only about 7% of the cases via screening and surveillance, with most of the remainder diagnosed because of alarm symptoms, usually indicative of later stage disease. Approximately half (52%) of the cases arise in persons with reflux symptoms who are not investigated through endoscopy or other means. Numbers in red indicate the estimated annual incidence rate in each population subgroup. See text for details.