Dramatic 50% Rise in Esophageal Cancer in British Men

Zosia Chustecka

September 22, 2010

September 22, 2010 — Esophageal cancer rates have risen by 50% over the past 25 years in men in the United Kingdom, according to new figures released by Cancer Research UK.

As well as a dramatic increase in incidence, there has been a change in the histology of the cancer, with most cases now being adenocarcinoma instead of squamous cell carcinoma (SCC). A similar huge increase in incidence and flip in histology has occurred in the United States, as previously reported by Medscape Medical News.

The latest British figures show that 5100 men were diagnosed with esophageal cancer in 2007, compared with 2600 men in 1983.

The incidence rate is now 14.4 per 100,000 men, which is 50% higher than the rate of 9.6 per 100,000 men in 1983. The most dramatic rise was in men in their 50s, in whom the rate was increased by 67%.

Esophageal cancer has also increased in women, but not as dramatically; there was an 8% increase from 1983 to 2007 (55.1 to 5.5 per 100,000).

"We don't know exactly why we're seeing this steep rise in esophageal cancer rates, or why it's having such a dramatic effect on men," said Janusz Jankowski, MD, PhD, from the London School of Medicine & Density, and visiting professor of gastrointestinal oncology at Oxford University in the United Kingdom. "We think the obesity epidemic may be a big reason behind the increase," he added.

Being overweight significantly increases the risk for adenocarcinoma, the main type of esophageal cancer that is increasing in incidence, he explained. In fact, white men in the United Kingdom have the highest incidence of adenocarcinoma of the esophagus in the world.

Adenocarcinoma develops from gastroesophageal reflux disease. The acid that returns into the esophagus wears away the squamous cell lining, and over time it changes into Barrett's mucosa, a common premalignant lesion; that, in turn, converts to adenocarcinoma.

Dr. Jankowski's team has several clinical trials underway in which patients with Barrett's esophagus are being treated with proton-pump inhibitors as a chemoprevention strategy (e.g., the ASPECT trial of aspirin and esomeprazole, funded by Cancer Research UK and AstraZeneca).

When asked about the sex difference seen in the incidence in the United Kingdom, Dr. Jankowski explained that men have more severe reflux than women. They also have central waist obesity as opposed to hip obesity (i.e., apples vs pears), which increases the rate of reflux, he told Medscape Medical News.

Wide Variation Worldwide

"These new figures are particularly concerning, as esophageal cancer is a very difficult cancer to treat," said Dr. Lesley Walker, director of cancer information at Cancer Research UK. The 5-year survival rate is only 8%, she noted.

"Esophageal cancer rates have risen dramatically in the United Kingdom, compared with many other Western countries, so we need to determine the underlying causes," she added.

Statistics compiled by Cancer Research UK show that esophageal cancer is the ninth most common cancer in the United Kingdom, and that incidence rates are significantly higher in the United Kingdom than the average in the European Union. British men have the second highest incidence rates in Europe (after French men), and British women have the highest — almost 15 times higher than the rates reported in Cyprus.

Within the United Kingdom, the highest rates are recorded in Scotland. There is a clear north/south divide across Great Britain, with the highest rates reported in Scotland and in urban areas of northwest England and north Wales.

Different Histology

In addition to an increase in incidence, there has been a change in the histology in recent decades. Until the 1970s, the vast majority of esophageal cancer diagnosed in the United Kingdom was SCC; this is still the main histology diagnosed in developing countries.

This SCC type of esophageal cancer is associated with smoking and drinking, Dr. Jankowski said, whereas adenocarcinoma is due to heartburn.

Worldwide, the majority of cases of esophageal cancer (80% to 85%) are diagnosed in developing countries, where it is the fourth most common cancer, and most cases are SCC.

However, since the 1970s, the incidence of SCC has remained stable or decreased in most western countries, while the incidence of adenocarcinoma has increased. If these trends continue, adenocarcinoma will become the dominant histology, Cancer Research UK warns — and points out that this has already happened in white men in the United Kingdom and the United States.

Flip Already Seen in the United States

The United States has already seen a dramatic change in the nature of esophageal cancer, and the "incidence rates have virtually flipped over," said Mark Orringer, MD, from the University of Michigan in Ann Arbor.

"Whereas 20 years ago, most esophageal cancer was squamous cell carcinoma in people who drank alcohol and smoked excessively, and only a small portion was adenocarcinoma, now the majority of cases, about 85%, of esophageal cancer are adenocarcinomas resulting from reflux disease and the obesity epidemic," Dr. Orringer told Medscape Medical News in a previous interview.

The incidence of adenocarcinoma has increased by about 350% in the past 30 years, he continued, closely following the "horrendous epidemic of obesity that we've been seeing, both in the United States and Europe."