Esophageal cancer has a strikingly uneven geographical distribution, resulting in focal endemic areas in several countries. One such endemic area is in western Kenya. We conducted a retrospective review of all pathology-confirmed malignancies diagnosed at Tenwek Hospital, Bomet District, between January 1999 and September 2007. Tumor site, histology, sex, age, ethnicity, and location of residence were recorded. Cases were analyzed within and outside a traditional catchment area defined as ≤ 50 km from the hospital. Since 1999, the five most common cancer sites were esophagus, stomach, prostate, colorectum, and cervix. Esophageal cancer accounted for 914 (34.6%) of the 2643 newly diagnosed cancers, and showed increasing trends within and outside the catchment area. Fifty-eight (6.3%) patients were ≤ 30 years old and 9 (1%) were ≤ 20 years old; the youngest patient was 14 at diagnosis. Young cases (≤30) were more common among patients of Kalenjin ethnicity (9.2%) than among other ethnicities (1.7%) (odds ratio (95%CI) 5.7 (2.1–15.1)). This area of western Kenya is a high-risk region for esophageal cancer, and appears unique in its large proportion of young patients. Our findings support the need for further study of both environmental and genetic risk factors for esophageal cancer in this area.
Esophageal cancer; Kenya; age of onset; ethnicity
Surgery is still the best way for treatment of esophageal cancer. The increase in life expectancy and the rising incidence of esophageal tumors have led to a great number of elderly candidates for complex surgery. The purpose of this study was to evaluate the effects of advanced age (70 years or more) on the surgical outcome of esophagectomy for esophageal cancer at a single high-volume center.
MATERIALS AND METHODS:
Between January 2000 and April 2006, 480 cases with esophageal cancer underwent esophagectomy in the referral cancer institute. One hundred sixty-five patients in the elderly group (70 years old or more) were compared with 315 patients in the younger group (< 70 years). All in-hospital morbidity and mortality were studied.
The range of age was 38–84 years, with a mean of 58.7. The mean age of the elderly and younger groups was 74 and 53.2, respectively. In the younger group, 70 patients (22.2%) and in the elderly group, 39 patients (23.6%) were complicated (P 0.72).The most common complications in the two groups were pulmonary complications (9.8% in younger and 10.3% in elderly) (P 0.87). Rates of anastomotic leakage and cardiac complications were also similar between the two groups. Hospital mortality rates in younger and elderly patients were 2.8% and 3%, respectively. There was no significant difference between the two groups in morbidities and mortality (P-value > 0.05).
With increased experience and care, the outcomes of esophagectomy in elderly patients are comparable to young patients. Advanced age alone is not a contraindication for esophagectomy.
Elderly; esophageal cancer; esophagectomy; morbidity; mortality
Maize kernel samples were collected in 1996 from smallholder farm storages in the districts of Bomet, Bungoma, Kakamega, Kericho, Kisii, Nandi, Siaya, Trans Nzoia, and Vihiga in the tropical highlands of western Kenya. Two-thirds of the samples were good-quality maize, and one-third were poor-quality maize with a high incidence of visibly diseased kernels. One hundred fifty-three maize samples were assessed for Fusarium infection by culturing kernels on a selective medium. The isolates obtained were identified to the species level based on morphology and on formation of the sexual stage in Gibberella fujikuroi mating population tests. Fusarium moniliforme (G. fujikuroi mating population A) was isolated most frequently, but F. subglutinans (G. fujikuroi mating population E), F. graminearum, F. oxysporum, F. solani, and other Fusarium species were also isolated. The high incidence of kernel infection with the fumonisin-producing species F. moniliforme indicated a potential for fumonisin contamination of Kenyan maize. However, analysis of 197 maize kernel samples by high-performance liquid chromatography found little fumonisin B1 in most of the samples. Forty-seven percent of the samples contained fumonisin B1 at levels above the detection limit (100 ng/g), but only 5% were above 1,000 ng/g, a proposed level of concern for human consumption. The four most-contaminated samples, with fumonisin B1 levels ranging from 3,600 to 11,600 ng/g, were from poor-quality maize collected in the Kisii district. Many samples with a high incidence of visibly diseased kernels contained little or no fumonisin B1, despite the presence of F. moniliforme. This result may be attributable to the inability of F. moniliforme isolates present in Kenyan maize to produce fumonisins, to the presence of other ear rot fungi, and/or to environmental conditions unfavorable for fumonisin production.
The incidence of esophageal carcinoma in the United States in white males is 6 per 100,000, compared with 20 per 100,000 in black males. The average 5-year survival for both groups is 5 percent. This study is a comprehensive analysis of esophageal carcinoma in blacks in the Pittsburgh area from 1957 to 1982. Family history, sex, age, ethnic background, social history, occupation, educational level, symptoms and signs, diagnosis, histopathology, cancer staging, treatment, and survival are reviewed. This information may expand our knowledge of esophageal cancers in blacks as well as all patients afflicted with this dreadful disease.
Background and Aim
The incidence of esophageal adenocarcinoma has increased over the last 30 years, especially in non-Hispanic whites (nHw). Recent work indicates an increase in Hispanic Americans (HA). It is important to understand the effect of ethnicity on cancer occurrence over a prolonged interval.
We searched the New Mexico Tumor Registry for all cases of esophageal cancer from 1 January 1973 to 31 December 2002. Inclusion criteria were histologic diagnosis of adenocarcinoma or squamous cell carcinoma, ethnicity and gender. Incidence rates for both were compared among ethnic groups in 5-year intervals.
Nine hundred eighty-eight patients met the criteria. Esophageal adenocarcinoma incidence rates/100,000 population increased significantly over 30 years; 1973–1977, 0.4 cases; 1978–1982, 0.4 cases; 1983–1987, 0.6 cases; 1988–1992, 1.2 cases, 1993–1997, 1.6 cases and 1998–2002, 2.2 cases; P < 0.001. Squamous cell carcinoma incidence rates remained unchanged during the interval. In nHw and HA, adenocarcinoma incidence rates increased significantly during the study period. In all minority groups, squamous cell carcinoma remained the major type.
Esophageal adenocarcinoma incidence among nHw and HA increased from 1973 to 2002 in New Mexico. Squamous cell carcinoma remains predominant in minorities. Ethnicity may influence the histology or indicate an increased risk for certain types of esophageal cancer.
Esophageal cancer; Adenocarcinoma of the esophagus; Squamous cell carcinoma of the esophagus; Ethnicity; Race
Gastric and esophageal cancers are among the most lethal human malignancies. Their epidemiology is geographically diverse. This study compares the survival of gastric and esophageal cancer patients among several ethnic groups including Chinese, South Asians, Iranians and Others in British Columbia (BC), Canada.
Data were obtained from the population-based BC Cancer Registry for patients diagnosed with invasive esophageal and gastric cancer between 1984 and 2006. The ethnicity of patients was estimated according to their names and categorized as Chinese, South Asian, Iranian or Other. Cox proportional hazards regression analysis was used to estimate the effect of ethnicity adjusted for patient sex and age, disease histology, tumor location, disease stage and treatment.
The survival of gastric cancer patients was significantly different among ethnic groups. Chinese patients showed better survival compared to others in univariate and multivariate analysis. The survival of esophageal cancer patients was significantly different among ethnic groups when the data was analyzed by a univariate test (p = 0.029), but not in the Cox multivariate model adjusted for other patient and prognostic factors.
Ethnicity may represent underlying genetic factors. Such factors could influence host-tumor interactions by altering the tumor's etiology and therefore its chance of spreading. Alternatively, genetic factors may determine response to treatments. Finally, ethnicity may represent non-genetic factors that affect survival. Differences in survival by ethnicity support the importance of ethnicity as a prognostic factor, and may provide clues for the future identification of genetic or lifestyle factors that underlie these observations.
The effects of alcohol consumption and tobacco smoking on the prevalence of esophageal cancer vary considerably by country, race and lifestyle. Few data exist on the effect of the interaction between the amount and duration of alcohol consumption and tobacco smoking on the incidence of esophageal cancer. In this case-control study, the cases included patients with histologically confirmed esophageal squamous cell carcinoma (ESCC) younger than 60 years of age and recruited between January 1, 2002 and December 31, 2006. The controls had no abnormality during a medical checkup. A total of 835 pairs were created by pairing each case to a gender- and age-matched control. Conditional logistic regression analysis was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals. Univariate conditional logistic regression analyses revealed that the ORs according to both duration of alcohol consumption and tobacco smoking increased monotonically. Alcohol consumption and tobacco smoking may have a synergistic effect on the incidence of ESCC. Conditional logistic regression analysis using a forward stepwise selection procedure revealed that the incidence of ESCC was associated with the duration of tobacco smoking, the interaction between the amount and duration of alcohol consumption, and a family history of cancer. In particular, groups with a long duration of alcohol consumption and high alcohol intake had much higher ORs than those with short duration and low intake, which highlights the importance of the interaction between the amount and duration of alcohol intake. This study confirmed the significance of the interaction between alcohol consumption and tobacco smoking in esophageal cancer. This interaction between amount and duration is an accurate indicator for estimating the risk of esophageal cancer attributable to alcohol consumption and tobacco smoking. These findings suggest that decreasing the number of young and middle-aged drinkers and smokers will reduce the incidence of esophageal cancer.
alcohol consumption; tobacco smoking; esophageal cancer; interaction between amount and duration
AIM: To determine the effect of ethnicity on the severity of reflux esophagitis (RE) and its complications.
METHODS: A retrospective search of the endoscopy database at the University of Florida Health Science Center/Jacksonville for all cases of reflux esophagitis and its complications from January 1 to March 31, 2001 was performed. Inclusion criteria were endoscopic evidence of esophagitis using the LA classification, reflux related complications and self-reported ethnicity. The data obtained included esophagitis grade, presence of a hiatal hernia, esophageal ulcer, stricture and Barrett’s esophagus, and endoscopy indication.
RESULTS: The search identified 259 patients with RE or its complications, of which 171 were non-Hispanic whites and 88 were African Americans. The mean ages and male/female ratios were similar in the two groups. RE grade, esophageal ulcer, stricture and hiatal hernia frequency were likewise similar in the groups. Barrett’s esophagus was present more often in non-Hispanic whites than in African Americans (15.8% vs 4.5%; P < 0.01). Heartburn was a more frequent indication for endoscopy in non-Hispanic whites with erosive esophagitis than in African Americans (28.1% vs 7.9%; P < 0.001).
CONCLUSION: Distribution of RE grade and frequency of reflux-related esophageal ulcer, stricture and hiatal hernia are similar in non-Hispanic whites and African Americans. Heartburn was more frequently and nausea/vomiting less frequently reported as the primary endoscopic indication in non-Hispanic whites compared with African Americans with erosive esophagitis or its complications. African Americans have a decreased prevalence of Barrett’s esophagus compared with non-Hispanic whites.
Reflux esophagitis; African American; Hiatal hernia; Barrett’s esophagus
Patients 16 to 21 years of age with acute lymphoblastic leukemia (ALL) have an inferior outcome compared with younger children, leading some medical oncologists to advocate allogeneic stem-cell transplantation in first remission for these patients. We examined outcome for young adults with ALL enrolled onto the Children's Cancer Group (CCG) 1961 study between 1996 and 2002.
Patients and Methods
CCG 1961 entered patients with ALL 1 to 21 years of age with initial WBC count ≥ 50,000/μL and/or age ≥ 10 years. Randomly assigned therapies evaluated the impact of postinduction treatment intensification on outcome. We examined outcome and prognostic factors for 262 young adults with ALL.
Five-year event-free and overall survival rates for young adult patients are 71.5% (SE, 3.6%) and 77.5% (SE, 3.3%), respectively. Rapid responder patients (< 25% bone marrow blasts on day 7) randomly assigned to augmented therapy had 5-year event-free survival of 81.8% (SE, 7%), as compared with 66.8% (SE, 6.7%) for patients receiving standard therapy (P = .07). One versus two interim maintenance and delayed intensification courses had no significant impact on event-free survival. WBC count more than 50,000/μL was an adverse prognostic factor.
Young adult patients with ALL showing a rapid response to induction chemotherapy benefit from early intensive postinduction therapy but do not benefit from a second interim maintenance and delayed intensification phase. Given the excellent outcome with this chemotherapy, there seems to be no role for the routine use of allogeneic stem-cell transplantation in first remission for young adults with ALL.
Geographical variation and temporal trends in the incidence of esophageal and gastric cancers vary according to both tumour morphology and organ subsite. Both diseases are among the deadliest forms of cancer. The incidence and survival rates for gastric and esophageal carcinoma in British Columbia (BC) between 1990 and 1999 are described.
Incidence data for the period 1990 to 1999 were obtained from the BC Cancer Registry. Age-adjusted incidence and survival rates were computed by anatomical subsite, histological type and sex. All rates were standardized to the 1996 Canadian population. The estimated annual percentage change (EAPC) was used to measure incidence changes over time. Kaplan-Meier curves were used to show survival rates, and log-rank tests were used to test for differences in the curves among various groups.
Between 1990 and 1999, 1741 esophageal cancer cases and 3431 gastric cancer cases were registered in BC. There was an increase in the incidence of adenocarcinoma of the esophagus over time (EAPC=9.6%) among men, and of gastric cardia cancer among both women (EAPC=9.2%) and men (EAPC=3.8%). Patients with proximal gastric (cardia) cancer had significantly better survival rates than patients with cancer in the lower one-third of the esophagus. Among gastric cancers, patients with distal tumours had a significantly better survival rate than patients with proximal tumours.
The incidences of proximal gastric cancer and esophageal adenocarcinoma are increasing, and their survival patterns are different. Examining these cancers together may elucidate new etiological and prognostic factors.
British Columbia; Epidemiology; Esophageal cancer; Gastric cancer; Incidence; Survival
Esophageal cancer is the eighth most common cancer worldwide, and especially in some areas of China is the fourth most common cause of death and is of squamous cell carcinoma (SCC) histology in >90% of cases. Surgery alone was the mainstay of therapeutic intervention in the past, but high rates of local and systemic failure have prompted investigation into multidisciplinary management. In this review, we discuss the key issues raised by the recent availability of esophageal SCC treatment with the addition of chemotherapy, radiotherapy, and chemoradiotherapy to the surgical management of resectable disease and discuss how clinical trials and meta-analysis inform current clinical practice. None of the randomized trials that compared neoadjuvant radiotherapy or chemotherapy with surgery alone in esophageal SCC has demonstrated an increase in overall survival in those patients treated with neoadjuvant radiotherapy or chemotherapy. Neoadjuvant chemoradiotherapy has been accepted recently for esophageal cancer because such a regimen offers great opportunity for margin negative resection, improved loco-regional control and increased survival. The majority of the available evidence currently reveals that only selected locally advanced esophageal SCC are more likely to benefit from the adjuvant therapy. The focus of future trials should be on identification of the optimum regimen and should aim to minimize treatment toxicities and effect on quality of life, as well as attempt to identify and select those patients most likely to benefit from specific treatment options.
Esophageal cancer; Squamous cell carcinoma; Neoadjuvant therapy; Adjuvant therapy; Chemotherapy; Radiotherapy; Chemoradiotherapy
OBJECTIVE--To compare survival outcome for patients with breast cancer cared for by specialist and non-specialist surgeons in a geographically defined area. DESIGN--Retrospective study of all female patients aged under 75 years in the area treated between 1980 and June 1988 (before breast screening began). Patients were identified from the cancer registry and from pathology records of all hospitals in the area. Specialist surgeons were identified by one author. All other surgeons caring for patients from the area were considered non-specialists. SETTING--A geographically defined population in urban west of Scotland. SUBJECTS--3786 patients with histologically verified breast cancer operated on between 1 January 1980 and 30 June 1988 and followed to 31 December 1993. MAIN OUTCOME MEASURES--Five and 10 year survival rates for specialists and non-specialists; relative hazard ratios derived from Cox's proportional hazards model adjusted for prognostic factors--age, socioeconomic status, tumour size, and nodal involvement. RESULTS--The five year survival rate was 9% higher and the 10 year survival 8% higher for patients cared for by specialist surgeons. A reduction in risk of dying of 16% (95% confidence interval 6% to 25%) was found after adjustment for age, tumour size, socioeconomic status, and nodal involvement. The benefit of specialist care was apparent for all age groups, for small and large tumours, and for tumours that did and did not affect the nodes and was consistent across all socioeconomic categories. CONCLUSIONS--Survival differences of the magnitude demonstrated have implications for the provision of services for the treatment of women with breast cancer. There is a need to improve equity in the treatment of breast cancer.
Shorter survival has been associated with low socioeconomic status (SES) among elderly non-Hodgkin's lymphoma (NHL) patients; however it remains unknown whether the same relationship holds for younger patients. We explored the California Cancer Registry (CCR), to investigate this relationship in adolescent and young adult (AYA) NHL patients diagnosed from 1996 to 2005. A case-only survival analysis was conducted to examine demographic and clinical variables hypothesized to be related to survival. Included in the final analysis were 3,489 incident NHL cases. In the multivariate analyses, all-cause mortality (ACM) was higher in individuals who had later stage at diagnosis (P < .05) or did not receive first-course chemotherapy (P < .05). There was also a significant gradient decrease in survival, with higher ACM at each decreasing quintile of SES (P < .001). Overall results were similar for lymphoma-specific mortality. In the race/ethnicity stratified analyses, only non-Hispanic Whites (NHWs) had a significant SES-ACM trend (P < .001). Reduced overall and lymphoma-specific survival was associated with lower SES in AYAs with NHL, although a significant trend was only observed for NHWs.
N′-Nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) are tobacco-specific nitrosamines. NNN and NNK can induce cancers of the esophagus and lung, respectively, in laboratory animals, but data on human esophageal cancer are lacking. The association between levels of NNN and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), an NNK metabolite, in urine samples collected before diagnosis and risk of esophageal cancer was examined in 77 patients with esophageal cancer and 223 individually matched controls, all current smokers, from a cohort of 18244 Chinese men in Shanghai, China, followed from 1986 to 2008. Urinary total NNN (free NNN plus NNN-N-glucuronide) was significantly higher, whereas the percentage of its detoxification product NNN-N-glucuronide was significantly lower in cases than controls. Odds ratios (95% confidence intervals) of esophageal cancer for the second and third tertiles of total NNN were 3.99 (1.25–12.7) and 17.0 (3.99–72.8), respectively, compared with the first tertile after adjustment for urinary total NNAL and total cotinine and smoking intensity and duration (Ptrend < 0.001). The corresponding figures for the percentage of NNN-N-glucuronides were 0.37 (0.17–0.80) and 0.27 (0.11–0.62) (Ptrend = 0.001). Urinary total NNN and the percentage of NNN-N-glucuronides almost completely accounted for the observed association for urinary total NNAL (free NNAL plus its glucuronides), urinary total cotinine and smoking intensity with esophageal cancer risk. These findings along with results of previous studies in laboratory animals support a significant and unique role of NNN in esophageal carcinogenesis in humans.
MicroRNAs (miRNAs) can act as oncogenes or tumor suppressors and modulate the expression of approximately one-third of all human genes. To test the hypothesis that adverse alleles in miRNA-related genes may increase the risk for esophageal cancer, we assessed the associations between esophageal cancer risk and 41 potentially functional single-nucleotide polymorphisms (SNPs) in 26 miRNA-related genes in a case-control study of 346 Caucasian esophageal-cancer patients (85.5% with esophageal adenocarcinoma) and 346 frequencymatched (age, gender, and ethnicity) controls. Seven SNPs were significantly associated with esophageal cancer risk. The most notable finding was that the SNP rs6505162, which is located in the pre-mir423 region, was associated with a per-allele odds ratio of 0.64 (95% confidence interval [CI], 0.51-0.80; P for trend < 0.0001). This association remained significant after we corrected for multiple comparisons. A common haplotype of the GEMIN4 gene was associated with a significantly reduced risk of esophageal cancer (odds ratio = 0.65; 95% CI, 0.42-0.99). We performed a combined unfavorable genotype analysis to further evaluate the cumulative effects of the promising (risk-associated) SNPs. In comparison with the low-risk group (fewer than three unfavorable genotypes), the medium-risk group (three unfavorable genotypes) had a 2.00-fold (95% CI=1.31-3.08) increased risk and the high-risk group (more than three unfavorable genotypes) had a 3.14-fold (95% CI=2.03-4.85) increased risk (P for trend < 0.0001). Results for the risk of esophageal adenocarcinoma were similar to the overall risk results. The present study provides the first evidence that miRNAs may affect esophageal cancer risk in general and that specific genetic variants in miRNA-related genes may affect esophageal cancer risk individually and jointly.
microRNA; polymorphism; esophageal cancer
Squamous Cell Carcinoma of Esophagus is one of the most common malignancies in both men and women in eastern and south-eastern Africa. In Kenya, clinical observations suggest that this cancer is frequent in the Rift Valley area. However, so far, there has been no report on the molecular characteristics of esophageal squamous cell carcinoma (ESCC) in this area.
We have analyzed TP53 mutations, the presence of human papilloma virus (HPV) DNA and expression of inflammation markers Cyclooxygenase 2 (Cox-2) and Nitrotyrosine (NTyR) in 28 cases (13 males and 15 females) of archived ESCC tissues collected at the Moi Teaching and Referral Hospital in Eldoret, Kenya. Eleven mutations were detected in TP53 exons 5 to 8 (39%). All ESCC samples were negative for HPV 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 70, 73 and 82. Immunohistochemical analysis of Cox-2 and NTyR showed a low proportion of positive cases (17.4% and 39.1%, respectively). No association between the above markers and suspected risk factors (alcohol or tobacco use, hot tea drinking, use of charcoal for cooking) was found.
Our findings suggest that mechanisms of esophageal carcinogenesis in eastern Africa might be different from other parts of the world. Low prevalence of TP53 mutation compared with other intermediate or high incidence areas of the world highlights this hypothesis. Our data did not support a possible ole of HPV in this series of cases. Further studies are needed to assess and compare the molecular patterns of ESCC from Kenya with those of high-incidence areas such as China or Central Asia.
Background and Purpose
Atrial fibrillation is a common cause of stroke with a known preventative treatment. We compared post-stroke recurrence and survival in Mexican Americans (MAs) and non-Hispanic whites (NHWs) with atrial fibrillation in a population-based study.
Using surveillance methods from the Brain Attack Surveillance in Corpus Christi (BASIC) Project, cases of ischemic stroke/TIA with atrial fibrillation were prospectively identified January 2000-June 2008. Recurrent stroke and all-cause mortality were compared by ethnicity with survival analysis methods.
A total of 236 patients were available (88 MA, 148 NHW). MAs were younger than NHWs, with no ethnic differences in severity of the first stroke or proportion discharged on warfarin. MAs had a higher risk of stroke recurrence than NHWs (Kaplan Meier estimates of survival free of stroke recurrence risk at 28-days and 1-year were 0.99 and 0.85 in MAs and 0.98 and 0.96 in NHWs; p=0.01, log-rank test), which persisted despite adjustment for age and gender (hazard ratio 2.46, 95% CI: 1.19, 5.11). Severity of the recurrent stroke was higher in MAs than in NHWs (p=0.02). There was no ethnic difference in survival after stroke in unadjusted analysis or after adjusting for demographics and clinical factors (hazard ratio 1.03, 95% CI: 0.63–1.67).
MAs with atrial fibrillation have a higher stroke recurrence risk and more severe recurrences than NHWs, but no difference in all-cause mortality. Aggressive stroke prevention measures focused on MAs are warranted.
Atrial fibrillation; Stroke; Mexican Americans
The purpose of this study was to evaluate the changes in esophageal physiology that are produced after laparoscopic surgery in patients with gastroesophageal reflux disease (GERD).
From May 1996 until January 2000, 13 patients with GERD underwent antireflux laparoscopic surgery. In 8 patients, preoperative manometric studies showed motility disorders characterized by a decrease in the percentage of primary peristaltic waves (32% average), a reduction in the pressure of the waves (40 mm Hg average), and a decrease in the percentage of the physiological waves (7.4% average). Laparoscopic Toupet fundoplication was the surgical procedure used in all cases, without complications and with a good postoperative course. Esophageal manometry was performed 8 weeks after the operation in 7 patients.
The results revealed an increase in the percentage of primary peristaltic waves (76.4% average) (P = 0.05906 Wilcoxon Test); an increase in the wave pressure (57 mm Hg average) (P = 0.1056); and an increase in the percentage of the physiological waves (45.8% average) (P = 0.05906).
Our final conclusion was that antireflux laparoscopic surgery, in this specific case the Toupet (partial) fundoplication, induced recovery in esophageal motility in those patients with peristaltic alterations due to reflux. This plays an important role in disease control because the recovery of esophageal peristalsis allows an increase in its emptying and reduces the possibility of esophageal damage by reflux episodes that could persist even though a fundoplication was constructed.
Gastroesophageal reflux disease (GERD); Esophageal manometry; Fundoplication; Laparoscopy
Oral bisphosphonate use has increased dramatically in the USA. Recent case reports have suggested a link between bisphosphonate use and esophageal cancer, but this is yet to be robustly investigated.
To investigate the association between bisphosphonate use and esophageal cancer.
Design, setting and participants
Data were extracted from the UK General Practice Research to compare the incidence of esophageal and gastric cancer in a cohort of patients treated with oral bisphosphonates between January 1996 and December 2006 to a control cohort not treated with these drugs. Cancers were identified from relevant Read\OXMIS codes in the patient’s clinical files. Cox proportional hazards modelling was used to calculate hazard ratios (HRs) and 95% CIs for esophageal and gastric cancer risk in bisphosphonate users compared to non bisphosphonate users, with adjustment for potential confounders.
Main outcome measure
The HR for the risk of esophageal and gastric cancer in the bisphosphonate users compared to the non bisphosphonate users.
There were 41,826 members in each cohort; 81% female, mean (SD) age, 70.0 (11.4) years, excluding patients with under 6 months follow-up. 116 esophageal or gastric cancers (79 esophageal) occurred in the bisphosphonate cohort and 115 (72 esophageal) in the control cohort. Mean follow-up time was 4.5 and 4.4 years in the bisphosphonate and control cohorts, respectively. There was no difference in combined esophageal and gastric cancer risk between the cohorts for any bisphosphonate use; adjusted HR (95% CI), 0.96 (0.74, 1.25) or esophageal risk alone; adjusted HR (95% CI), 1.07 (0.77, 1.49). There was also no difference in esophageal or gastric cancer risk by level of bisphosphonate intake.
This large study does not provide evidence for an increased risk of esophageal (or gastric) cancer in persons using oral bisphosphonates.
Bisphosphonates; esophageal cancer; gastric cancer; epidemiology
Background. Although many reports concerning the use of endoscopic submucosal dissection (ESD) for esophageal cancer have been published, the feasibility of ESD in elderly patients has not been reported. Therefore, we evaluated the efficacy and safety of ESD for treating early esophageal cancer in elderly patients. Methods. A total of 62 cases (52 men, 10 women; mean age ± standard deviation, 66.5 ± 10.5 years) for which the first resection (first treatment) of esophageal cancer was performed by ESD were identified from 77 consecutive esophageal epithelial cancers in 67 patients treated at our institution from January 2005 to March 2011. Patient characteristics, clinical findings, and outcomes were retrospectively assessed for patients separated into older (aged 75 years and older) and younger (aged under 75 years) groups. Results. No significant differences in specimen size, procedure time, median length of the hospital stay (8 versus 9 days; P = 0.252) or procedure-associated complications (8% versus 27%; P = 0.264) were observed between the older (n = 13) and younger (n = 49) groups. Lesions were completely resected in 12 patients and 44 patients, in the younger and older groups, respectively, and the curative resection rate was 77% and 59%, respectively. There were no deaths attributable to procedure-associated complications. Conclusions. ESD is an effective treatment for early esophageal cancer and is well tolerated by elderly patients.
An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula.
An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.
Aberrant right subclavian artery; Esophagectomy; Gastric pull-up; Gastrointestinal bleeding; Subclavian artery-esophageal fistula
The prognostic value of sex for esophageal cancer survival is currently unclear, and growing data suggest that hormonal influences may account for incidence disparities between men and women. Therefore, moving from the hypothesis that hormones could affect the prognosis of patients with esophageal cancer, we investigated the primary hypothesis that sex is associated with survival and the secondary hypotheses that the relationship between sex and survival depends, at least in part, on age, histology, and race/ethnicity.
Patients and Methods
By using the SEER databases from 1973 to 2007, we identified 13,603 patients (34%) with metastatic esophageal cancer (MEC) and 26,848 patients (66%) with locoregional esophageal cancer (LEC). Cox proportional hazards model for competing risks were used for analyses.
In the multivariate analysis, women had longer esophageal cancer-specific survival (ECSS) than men in both MEC (hazard ratio [HR], 0.949; 95% CI, 0.905 to 0.995; P = .029) and LEC (HR, 0.920; 95% CI, 0.886 to 0.955; P < .001) cohorts. When age and histology were accounted for, there was no difference for ECSS between men and women with adenocarcinoma. In contrast, women younger than age 55 years (HR, 0.896; 95% CI, 0.792 to 1.014; P = .081) and those age 55 years or older (HR, 0.905; 95% CI, 0.862 to 0.950; P < .001) with squamous cell LEC had longer ECSS than men. In the squamous cell MEC cohort, only women younger than age 55 years had longer ECSS (HR, 0.823; 95% CI, 0.708 to 0.957; P = .011) than men.
Sex is an independent prognostic factor for patients with LEC or MEC. As secondary hypotheses, in comparison with men, women age 55 years or older with squamous cell LEC and women younger than age 55 years with squamous cell MEC have a significantly better outcome. These last two findings need further validation.
The success of community case management in improving access to effective malaria treatment for young children relies on broad utilization of community health workers (CHWs) to diagnose and treat fever cases. A better understanding of the factors associated with CHW utilization is crucial in informing national malaria control policy and strategy in Kenya. Specifically, little is known in Kenya on the extent to which CHWs are utilized, the characteristics of families who report utilizing CHWs and whether utilization is associated with improved access to prompt and effective malaria treatment. This paper examines factors associated with utilization of CHWs in improving access to malaria treatment among children under five years of age by women caregivers in two malaria endemic districts in Kenya.
This study was conducted in 113 hard-to-reach and poor villages in Malindi and Lamu districts in the coastal region classified as having endemic transmission of malaria. A cross-sectional household survey was conducted using a standardized malaria indicator questionnaire at baseline (n = 1,187) and one year later at endline assessment (n = 1,374) using two-stage cluster sampling.
There was an increase in reported utilization of CHWs as source of advice/treatment for child fevers from 2% at baseline to 35% at endline, accompanied by a decline in care-seeking from government facilities (from 67% to 48%) and other sources (26% to 2%) including shops. The most poor households and poor households reported higher utilization of CHWs at 39.4% and 37.9% respectively, compared to the least poor households (17.0%). Households in villages with less than 200 households reported higher CHWs utilization as compared to households in villages having >200 households. Prompt access to timely and effective treatment was 5.7 times higher (95% CI 3.4-9.7) when CHWs were the source of care sought. Adherence was high regardless of whether source was CHWs (73.1%) or public health facility (66.7%).
The potential for utilization of CHWs in improving access to malaria treatment at the community level is promising. This will not only enhance access to treatment by the poorest households but also provide early and appropriate treatment to vulnerable individuals, especially those living in hard to reach areas.
Malaria; Kenya; Community case management; Community health worker; Children under five
In the last decade the importance of ethnicity, socio-economic and gender differences in relation to disease incidence, diagnosis, and prognosis has been realized. Differences in these areas have become a major health policy focus in the United States. Our study was undertaken to examine the demographic and clinical features of chronic myelogenous leukemia (CML) patients presenting initially at the LAC+USC Medical Center, which serves an ethnically diverse population.
Patients were evenly split by gender, overwhelmingly Hispanic (60.9%), and quite young (median age 39, range 17–65) compared with previously reported CML patient populations. Previous CML studies identified significant anemia (Hgb <12 g/dl), significant thrombocytosis (platelets >450 × 109/l), and significant leukocytosis (WBC >50 × 109/l) as significant adverse pretreatment prognostic factors. Using these indicators, in addition to the validated Hasford and Sokal scores, patients were stratified and analyzed via gender and ethnicity. A significantly greater proportion of women presented with significant anemia (p = 0.019, Fisher's exact test) and significant thrombocytosis (p = 0.041, Fisher's exact test) compared to men, although no differences were found in risk stratification or treatment response. MCV values for women were significantly (p = 0.02, 2-sample t-test) lower than those for men, suggesting iron deficiency anemia. Focusing on ethnicity, Hispanics as a whole had significantly lower Hasford risk stratification (p = 0.046, Fisher's exact test), and significantly greater likelihood (p = 0.016, Fisher's exact test) of achieving 3-month complete haematological remission (CHR) compared with non-Hispanics at LAC+USC Medical Center, though differences in treatment outcome were no longer significant with analysis limited to patients treated with first-line imatinib.
Female CML patients at LAC+USC Medical Center present with more significant adverse pre-treatment prognostic factors compared to men, but achieve comparable outcomes. Hispanic patients present with lower risk profile CML and achieve better treatment responses compared to non-Hispanic patients as a whole; these ethnic differences are no longer significant when statistical analysis is limited to patients given imatinib as first-line therapy. Our patients achieve response rates inferior to those of large-scale national studies. This constellation of findings has not been reported in previous studies, and is likely reflective of a unique patient population.
A geographical pathology survey of a large area in central Africa is described and a contrast is recognized between neighbouring areas with apparently many and apparently few cases of oesophageal cancer. This distribution is compared first with other known areas of high and low incidence in sub-Saharan Africa and then with the drinking of indigenous types of distilled spirits. A significant order of spatial correlation is shown between the geographical pattern of the disease and the drinking of sugar-based alcoholic spirit in central Africa. Samples of spirits from eastern Zambia, central Kenya, and the Transkei, although prepared in apparently dissimilar utensils, were all shown to be contaminated in varying degree with zinc. Nitrosamine-like compounds in native spirits were also reported in all these areas.
The need for a geographical survey of indigenous drinking habits in Africa is illustrated. Since legislation against distilling is ineffective, a simple means of excluding carcinogenic compounds from illicit spirits should be ascertained and widely promulgated at village level.