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Esophageal Cancer Screening (PDQ®)

Health Professional Version

Evidence of Benefit

Squamous Cell Cancer

Squamous cell carcinoma of the esophagus does not have a highly prevalent predisposing condition, although the incidence increases in persons who have had long-standing exposure to tobacco and alcohol,[1] achalasia,[2] head and neck squamous cell cancer attributable most likely to long-standing alcohol and/or tobacco exposure,[3] tylosis,[4,5] history of lye ingestion,[6] celiac sprue,[7] and, in South America and China, hot liquid ingestion.[8] The etiological role of human papillomavirus infection in squamous cell cancer is under study.[9,10]

Efforts at early detection of squamous cell cancer of the esophagus have concentrated on cytological or endoscopic screening of populations in countries where there is a high incidence. Although these programs have demonstrated that it is possible to detect squamous cell cancers in an early asymptomatic stage, no data on efficacy (e.g., mortality reduction) have been published. Esophageal cytological screening studies have been reported from China,[11,12] Iran,[13] South Africa,[14,15] Italy,[16] and Japan.[17] In the United States, such efforts have been focused on individuals perceived to be at higher risk.[18,19] Studies of primary endoscopic screening have been reported from France [20] and Japan.[21]

Comparisons of both Chinese and U.S. cytological diagnoses with concurrent histological findings showed low (14% to 36%) sensitivities for the cytological detection of biopsy-proven cancers. Specificity ranged from 90% to 99% with a positive predictive value of 23% to 94%.[22] The development of uniform and accurate cytological criteria will require formal cytological-histological correlation studies of esophageal lesions. Such studies should become more feasible with the increasing availability of endoscopy in high-risk populations.

The efficacy of surveillance cytology or endoscopy for high-risk patients with tylosis or long-standing achalasia is not known.

Adenocarcinoma of the Esophagus

Considerable debate has ensued concerning the risk of cancer in patients with Barrett esophagus. Prospective studies have reported annual esophageal cancer incidence rates ranging from 0.2% to 1.9%.[23] Concern over publication bias has led some authors to suggest that the risk may be lower than the literature suggests.[24] A risk of 0.5% per year for development of adenocarcinoma is now thought to be a reasonable estimate for Barrett esophagus.[25]

Barrett esophagus is strongly associated with gastroesophageal reflux disease (GERD), and the changes of Barrett esophagus can be found in approximately 10% of patients who have GERD. However, GERD is very common; surveys have found that approximately 20% of adult Americans experience symptoms of GERD, such as heartburn, at least once each week.[26] The likelihood of finding Barrett esophagus on endoscopy is related to the duration of symptoms of gastroesophageal reflux. In a series of 701 individuals, 4% of those with symptoms for less than 1 year had Barrett esophagus on endoscopy, whereas Barrett esophagus was found in 21% of those with more than 10 years of symptoms of GERD. It has been estimated that physicians identify only approximately 5% of the population who have Barrett esophagus.[27] There is insufficient evidence that population screening for Barrett esophagus reduces cancer mortality.[28,29]

Surveillance of Barrett esophagus involves the use of tests to identify preneoplastic changes or curable neoplasms in patients who are known to have Barrett esophagus. Certain factors are essential in the implementation of an effective surveillance protocol, including low risk of the surveillance method, correct histological diagnosis of dysplasia, proof that surgical resection for high-grade dysplasia will decrease the risk of cancer, and successful resection of cancer. The interval between endoscopic evaluations is typically determined by histologic findings, in accordance with published guidelines by gastroenterological committees.[30] GERD should be treated prior to surveillance endoscopy to minimize confusion caused by inflammation in the interpretation of biopsy specimens. The technique of random, four-quadrant biopsies taken every 2 cm in the columnar-lined esophagus for standard histological evaluation has been recommended by some clinicians. For patients with no dysplasia, surveillance endoscopy at an interval of every 2 to 3 years has been recommended.[30] For patients with low-grade dysplasia, surveillance every 6 months for the first year has been recommended, followed by annual endoscopy if the dysplasia has not progressed in severity. For patients with high-grade dysplasia, two options have been recommended: surgical resection or repeated endoscopic evaluation until the diagnosis of intramucosal carcinoma is made. Although widely adopted in clinical practice, these practices are based on uncontrolled series and the opinion of expert gastrointestinal endoscopists and pathologists.

Other techniques to potentially identify dysplastic epithelium that could then be sampled extensively include chromoendoscopy [31] and laser-induced fluorescence spectroscopy.[29,32]

Evidence of Harm

Screening for esophageal cancer by the use of blind nonendoscopically directed balloon cytological sampling for squamous cell carcinoma is minimally inconvenient and uncomfortable. Endoscopic screening for esophageal adenocarcinoma is expensive, inconvenient, and usually requires sedation.

Complications such as perforation and bleeding can occur. The incidence of complications including perforation, respiratory arrest, and myocardial infarction, has been estimated to be 0 to 13 per 10,000 procedures with an associated mortality of 0 to 0.8 per 10,000 procedures.[33,34]

Individuals who are informed they have Barrett esophagus may consider themselves to be ill even though their risk of developing cancer is very low.

References

  1. Bollschweiler E, Schröder W, Hölscher AH, et al.: Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the oesophagus. Br J Surg 87 (8): 1106-10, 2000. [PUBMED Abstract]
  2. Aggestrup S, Holm JC, Sørensen HR: Does achalasia predispose to cancer of the esophagus? Chest 102 (4): 1013-6, 1992. [PUBMED Abstract]
  3. Abemayor E, Moore DM, Hanson DG: Identification of synchronous esophageal tumors in patients with head and neck cancer. J Surg Oncol 38 (2): 94-6, 1988. [PUBMED Abstract]
  4. Ellis A, Field JK, Field EA, et al.: Tylosis associated with carcinoma of the oesophagus and oral leukoplakia in a large Liverpool family--a review of six generations. Eur J Cancer B Oral Oncol 30B (2): 102-12, 1994. [PUBMED Abstract]
  5. Risk JM, Mills HS, Garde J, et al.: The tylosis esophageal cancer (TOC) locus: more than just a familial cancer gene. Dis Esophagus 12 (3): 173-6, 1999. [PUBMED Abstract]
  6. Isolauri J, Markkula H: Lye ingestion and carcinoma of the esophagus. Acta Chir Scand 155 (4-5): 269-71, 1989 Apr-May. [PUBMED Abstract]
  7. Ferguson A, Kingstone K: Coeliac disease and malignancies. Acta Paediatr Suppl 412: 78-81, 1996. [PUBMED Abstract]
  8. Rolón PA, Castellsagué X, Benz M, et al.: Hot and cold mate drinking and esophageal cancer in Paraguay. Cancer Epidemiol Biomarkers Prev 4 (6): 595-605, 1995. [PUBMED Abstract]
  9. Lagergren J, Wang Z, Bergström R, et al.: Human papillomavirus infection and esophageal cancer: a nationwide seroepidemiologic case-control study in Sweden. J Natl Cancer Inst 91 (2): 156-62, 1999. [PUBMED Abstract]
  10. Sur M, Cooper K: The role of the human papilloma virus in esophageal cancer. Pathology 30 (4): 348-54, 1998. [PUBMED Abstract]
  11. Shen O, Liu SF, Dawsey SM, et al.: Cytologic screening for esophageal cancer: results from 12,877 subjects from a high-risk population in China. Int J Cancer 54 (2): 185-8, 1993. [PUBMED Abstract]
  12. Dawsey SM, Lewin KJ, Wang GQ, et al.: Squamous esophageal histology and subsequent risk of squamous cell carcinoma of the esophagus. A prospective follow-up study from Linxian, China. Cancer 74 (6): 1686-92, 1994. [PUBMED Abstract]
  13. Dowlatshahi K, Daneshbod A, Mobarhan S: Early detection of cancer of oesophagus along Caspian Littoral. Report of a pilot project. Lancet 1 (8056): 125-6, 1978. [PUBMED Abstract]
  14. Jaskiewicz K, Venter FS, Marasas WF: Cytopathology of the esophagus in Transkei. J Natl Cancer Inst 79 (5): 961-7, 1987. [PUBMED Abstract]
  15. Tim LO, Leiman G, Segal I, et al.: A suction-abrasive cytology tube for the diagnosis of esophageal carcinoma. Cancer 50 (4): 782-4, 1982. [PUBMED Abstract]
  16. Aste H, Saccomanno S, Munizzi F: Blind pan-esophageal brush cytology. Diagnostic accuracy. Endoscopy 16 (5): 165-7, 1984. [PUBMED Abstract]
  17. Nabeya K: Markers of cancer risk in the esophagus and surveillance of high-risk groups. In: Sherlock P, Morson BC, Barbara L, et al., eds.: Precancerous Lesions of the Gastrointestinal Tract. New York, NY: Raven Press, 1983, pp 71-86.
  18. Dowlatshahi K, Skinner DB, DeMeester TR, et al.: Evaluation of brush cytology as an independent technique for detection of esophageal carcinoma. J Thorac Cardiovasc Surg 89 (6): 848-51, 1985. [PUBMED Abstract]
  19. Jacob P, Kahrilas PJ, Desai T, et al.: Natural history and significance of esophageal squamous cell dysplasia. Cancer 65 (12): 2731-9, 1990. [PUBMED Abstract]
  20. Meyer V, Burtin P, Bour B, et al.: Endoscopic detection of early esophageal cancer in a high-risk population: does Lugol staining improve videoendoscopy? Gastrointest Endosc 45 (6): 480-4, 1997. [PUBMED Abstract]
  21. Yokoyama A, Ohmori T, Makuuchi H, et al.: Successful screening for early esophageal cancer in alcoholics using endoscopy and mucosa iodine staining. Cancer 76 (6): 928-34, 1995. [PUBMED Abstract]
  22. Dawsey SM, Shen Q, Nieberg RK, et al.: Studies of esophageal balloon cytology in Linxian, China. Cancer Epidemiol Biomarkers Prev 6 (2): 121-30, 1997. [PUBMED Abstract]
  23. Drewitz DJ, Sampliner RE, Garewal HS: The incidence of adenocarcinoma in Barrett's esophagus: a prospective study of 170 patients followed 4.8 years. Am J Gastroenterol 92 (2): 212-5, 1997. [PUBMED Abstract]
  24. Shaheen NJ, Crosby MA, Bozymski EM, et al.: Is there publication bias in the reporting of cancer risk in Barrett's esophagus? Gastroenterology 119 (2): 333-8, 2000. [PUBMED Abstract]
  25. Spechler SJ: Barrett's esophagus: an overrated cancer risk factor. Gastroenterology 119 (2): 587-9, 2000. [PUBMED Abstract]
  26. Locke GR 3rd, Talley NJ, Fett SL, et al.: Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology 112 (5): 1448-56, 1997. [PUBMED Abstract]
  27. Spechler SJ: Barrett's esophagus: should we brush off this ballooning problem? Gastroenterology 112 (6): 2138-42, 1997. [PUBMED Abstract]
  28. Gerson LB, Triadafilopoulos G: Screening for esophageal adenocarcinoma: an evidence-based approach. Am J Med 113 (6): 499-505, 2002. [PUBMED Abstract]
  29. Wang KK, Wongkeesong M, Buttar NS: American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology 128 (5): 1471-505, 2005. [PUBMED Abstract]
  30. DeVault KR, Castell DO: Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 94 (6): 1434-42, 1999. [PUBMED Abstract]
  31. Canto MI, Setrakian S, Petras RE, et al.: Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus. Gastrointest Endosc 44 (1): 1-7, 1996. [PUBMED Abstract]
  32. Panjehpour M, Overholt BF, Vo-Dinh T, et al.: Endoscopic fluorescence detection of high-grade dysplasia in Barrett's esophagus. Gastroenterology 111 (1): 93-101, 1996. [PUBMED Abstract]
  33. Clarke GA, Jacobson BC, Hammett RJ, et al.: The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy 33 (7): 580-4, 2001. [PUBMED Abstract]
  34. Sieg A, Hachmoeller-Eisenbach U, Eisenbach T: Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists. Gastrointest Endosc 53 (6): 620-7, 2001. [PUBMED Abstract]
  • Updated: February 21, 2014