Analysis Shows Incidence of Advanced Stage Esophageal Adenocarcinoma Increasing in Younger Adults

A study published in Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research seems to suggest that the incidence of Esophageal Adenocarcinoma is increasing in younger adults. [1]

According to the authors of the study, which was funded by the National Cancer Institute and the National Center for Advancing Translational Sciences, an analysis of the available data demonstrates further that patients under age 50 are also more likely to be diagnosed at advanced stages.

Esophageal cancer is a relatively rare cancer, with 18,440 cases expected to be diagnosed in the United States this year, according to the Surveillance, Epidemiology, and End Results (SEER) database. While those cases account for only about 1% of U.S. cancer diagnoses, esophageal cancer has poor survival outcomes, with a five-year survival rate of only 19.9%.

Esophageal adenocarcinoma (EAC) is one of the most common types of esophageal cancer.

“Patients who present with late-stage esophageal cancer typically have poorer outcomes than those with early-stage disease. As such, it is important to understand the epidemiology of esophageal cancer to target our screening strategies,” Prasad G. Iyer, MD, MSc, professor of medicine in the Barrett’s Esophagus Unit, Division of Gastroenterology and Hepatology; and Don C. Codipilly, MD, a gastroenterology fellow, both at the Mayo Clinic in Rochester, Minnesota.

Iyer’s research is focused on identifying the most acceptable noninvasive and accurate techniques for the early detection of esophageal neoplasia arising in Barrett’s esophagus, which is a complication of gastroesophageal reflux, in the population. As part of his research, Iyer and his team are studying biomarkers that can help in the early detection and risk assessment of subjects with Barrett’s esophagus. In addition, Iyer is also studying the role of obesity in the development and progression of neoplasia in subjects with Barrett’s esophagus.

Study design
In the study, Iyer and his colleagues sought to assess trends in incidence, stage, and survival outcomes in patients diagnosed with EAC before age 50 compared with those diagnosed at later ages.

The researchers used the Surveillance, Epidemiology, and End Results database to identify 34,443 cases of EAC diagnosed between 1975 and 2015. They calculated age-standardized incidence across three age groups: under 50; 50-69; and 70 and over.

Results
Incidence of EAC increased across all age groups, with the rate of incidence for patients under age 50 increasing an average of 2.9% per year between 1975 and 2015.

Younger patients were more likely to be diagnosed at advanced stages of the disease, with 84.9% of those under 50 diagnosed at regional or distant stages, compared with 67.3% of those 50 or older.

As a result, the younger age group also had poorer survival outcomes: In the most recent time period, 2000-2011, those under 50 had a five-year EAC-free survival rate of 22.9%, compared with 29.6% for both the 50-69 and the 70-and-over age groups.

Rare disease
The authors cautioned that while EAC remains a rare cancer, especially in those under 50, clinicians and patients should be aware of the increasing incidence and the poor survival outcomes in younger patients.

“The magnitude of late-stage disease and poor cancer-related survival in this age group were surprising findings for us,” Iyer noted.

“We are also concerned by the trend of increase over the past four decades,” he added.

The authors pointed out that the rising incidence of EAC in younger adults mirrors the trend in colon cancer.

“In both cases, physicians may attribute symptoms to other causes, delaying diagnosis and potentially leading to worse outcomes,” Don Codipilly, MD, one of the co-authors of the study said.

The authors further added that patients should be aware of risk factors and symptoms of esophageal cancer. Symptoms typically include dysphagia (difficulty swallowing), chest discomfort, or unintended weight loss. They added that certain high-risk groups, such as those with long-term reflux and those with a family history of esophageal cancer, should discuss screening with their health care providers.

“Physicians must keep in mind that EAC is not a disease of the elderly, and that outcomes for young people with EAC are dismal,” Codipilly explained.

“Our findings suggest that physicians should have a low threshold of suspicion for patients who present with dysphagia. While younger patients would typically not be at high risk for EAC, they may benefit from an upper endoscopy,” he added.

Both Iyer and Codipilly said that that a procedure, in which doctors examine the upper lining of the digestive tract, could rule out EAC or could help diagnose the disease at an earlier stage when it is much easier to treat.

They also said that based on the study result, current diagnostic and management strategies for young-onset esophageal adenocarcinoma may need to be reevaluated.

Study Limitations
The authors noted that a limitation of the study is that researchers could not examine individual-level data. Also, comorbidity information was not available in the SEER database.

Research
[1] Codipilly DC, Sawas T, Dhaliwal L, Johnson ML, Lansing R, Wang KK, Leggett CL, Katzka DA, Iyer PG. Epidemiology and Outcomes of Young-Onset Esophageal Adenocarcinoma: An Analysis from a Population-Based Database. Cancer Epidemiol Biomarkers Prev. 2020 Dec 11. doi: 10.1158/1055-9965.EPI-20-0944. Epub ahead of print. PMID: 33328255. [Pubmed][Article]

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