Increasing frequency of esophageal cancer among black male veterans

AIDS and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology

The social identity of HIV/AIDS in the U.S. has been shaped, for the most part, by two factors, the prevailing configuration of social relations across class, racial, gender, and sexual orientation, on the one hand, and the prevailing array of public health, especially epidemiological, categories of disease transmission, on the other. Focusing on the AIDS epidemic among inner city people of color, this paper challenges the distortions wrought in our understanding from both of these factors and instead develops an alternative perspective for AIDS research among medical anthropologists and health social scientists generally.

Endoscopically defined treatment strategies in patients with locally advanced esophageal cancer

Sixty-five consecutive, locally advanced esophageal cancer patients were treated by the West Side Medical Center Esophageal Service at the Cook County and University of Illinois hospitals. Each patient was prospectively evaluated with multiple endoscopies including esophagogastroduodenoscopy, bronchoscopy, nasopharyngoscopy, and laryngoscopy. Twenty-four patients (37%) had endoscopic findings that significantly altered therapeutic regimens. Patients identified as having an obvious or impending esophageal fistula or poor performance status were treated in a palliative fashion. Forty (61.5%) patients were considered candidates for treatment with multimodal therapy which included radiation, chemotherapy, and surgery. There was a response rate of 82.5% and a 1-year disease-free survival of 88.9% which was statistically significant when compared to the other patient treatment groups. These data illustrate the necessity of multiple endoscopic evaluation of locally advanced esophageal cancer patients for stratification into appropriate treatment groups. Aggressive treatment afforded selected patients excellent relief of presenting symptomatology, as well as an improved, more acceptable, disease-free survival.

Cancer prevention and early detection in ethnically diverse populations

Providing cancer screening to the diverse minority subgroups of the United States is a challenge. In order to effectively screen the African American, Hispanic, Asian/Pacific Islander, Native American, Native Alaskan, and Native Hawaiian populations, cancer screening methods must be ethically and culturally based. Nurses must also strive make preventive care accessible to the underserved.

Natural history and significance of esophageal squamous cell dysplasia

Balloon-mesh cytologic screening for esophageal cancer done in 255 asymptomatic high-risk United States veterans (age greater than 40 years, ethanol abuse for greater than 20 years, and cigarette smoking greater than 20 pack years) identified 37 patients with squamous cell dysplasia. Of the 37 patients with dysplasia, 28 were re-evaluated prospectively at 6-month intervals for up to 36 months by balloon-mesh cytology, esophagoscopy with vital staining and biopsies, chest radiographs, oropharyngeal examination, and indirect laryngoscopy. During prospective follow-up evaluation, cytology specimens were repetitively normal in 16 patients (57%), showed inflammatory changes in eight patients (29%), persisted as dysplasia in two patients (7%) (both had endoscopic and histologic evidence of esophagitis), and progressed to carcinoma in two patients (7%) (one esophageal, one laryngeal). Although histologic findings concurred with the resolution of dysplasia, biopsy specimens were characterized by a similar difficulty in distinguishing dysplasia from inflammation. Erroneous histologic diagnoses of carcinoma in situ were made in two patients with reflux esophagitis evident endoscopically and confirmed during the course of a 24-36 month follow-up period. The authors conclude that squamous cell dysplasia detected by balloon-mesh cytology is seldom a precursor of esophageal cancer in the high-risk U.S. population but, rather, is often related to esophagitis. Thus, balloon-mesh cytology has limited use as a screening method for the early detection of esophageal cancer in the United States.

Water contamination and esophageal cancer at Gassim Region, Saudi Arabia

Between January 1980 and December 1982, 183 patients with histologically confirmed carcinoma of the esophagus who were referred to a tertiary referral hospital were studied. Thirty-two (17%) patients were referred from Gassim Region at the north central part of Saudi Arabia. In contrast, only 5% of total cancer patient referrals were from this area. A case-control study showed a significant regional difference within Saudi Arabia and the most referrals from Gassim area. A prospective case-control study showed persistently high numbers of referrals from that region during 1983-1987. When patients from Gassim Region were compared with those referred from other locations, no statistical differences were noted between the two groups except for the source of drinking water. Water analysis from Gassim area showed a high solid content with elevated levels of calcium, magnesium, and to a lesser extent, chromium iron, cadmium, and cobalt. Traces of petroleum oil were found in five of six water samples from Gassim during 1983, compared with 3 of 49 samples from other areas. Mutagenicity tests on water specimens form Gassim Region indicated the presence of possible carcinogens. It is being suggested that the high prevalence of esophageal cancer in this region may be related to contamination of water by impurities such as petroleum oils. Malnutrition, particularly vitamin A deficiency, as well as other factors may have promoted such malignancies.

Reliability of balloon-mesh cytology in detecting esophageal carcinoma in a population of US veterans

A catheter, equipped with a terminal balloon covered with nylon mesh, was developed to study the reliability of abrasive cytology for the diagnosis of esophageal carcinoma. Eighty-seven balloon cytology analyses were attempted in 82 subjects. Four patients were unable to swallow the balloon. In the 78 successful attempts, the initial diagnoses were: esophagitis (34) and esophageal carcinoma (13), established by endoscopic examination and histologic sampling; and normal esophagus (31) confirmed histologically in 25. The remaining 6 controls were younger than 40 years old, without any significant history of smoking, drinking and esophageal symptoms. For esophageal carcinoma, the sensitivity of balloon cytology was 91% and the specificity was 94% with four false-positives. Balloon cytology was generally well-tolerated and easily performed. This method is now being tested for screening high-risk patients for esophageal carcinoma.

Alcohol and cancer

The cancers consistently associated with ingestion of alcohol, the head and neck cancers, are also associated with tobacco use and arise from epithelia that are in direct contact with both agents. Tobacco smoking-related cancers at sites not directly in contact with alcoholic beverages, that is, lung, bladder, and perhaps pancreas, do not consistently show a relationship to alcohol consumption, although lung and pancreatic tumors are associated in some studies. Liver cancer was thought to be strongly related to alcohol consumption on epidemiological grounds and because of its relationship to cirrhosis. As knowledge of the viral etiology of some cirrhoses has evolved and as methods to detect viruses have developed, the significant association between hepatitis B virus and hepatocellular carcinoma has become clear. Alcohol and hepatitis B virus may interact in the etiology of the disease and have important separate roles as well. There are epidemiologic and experimental data showing that malnutrition (resulting from poor food choice), economic deprivation, or alcoholism contributes to the risk for head, neck, and liver cancers. Colon cancers occur about equally in men and women, are found in well-nourished populations, and are not associated with tobacco smoking. Rectal cancers show a preponderance of cases in men but are frequently found in women as well and are not thought to be associated with smoking or malnutrition. The association between colorectal cancers and alcohol consumption, when it is found, apparently occurs at even relatively low alcohol intakes and is often stronger for consumption of beer than of other beverages. Nutritional and metabolic mechanisms proposed for the influence of alcohol on carcinogenesis are supported by studies in human subjects and laboratory animals. Animal models are needed in which effects of ethanol on carcinogenesis can be consistently demonstrated and which can then be used to examine mechanisms.

Balloon cytology in screening of asymptomatic alcoholics for esophageal cancer, Part I

We assessed the feasibility of using balloon cytology to screen an asymptomatic group of alcoholics at increased risk for esophageal cancer. The results indicate that this group can be studied with minimal morbidity and that useful material can be obtained in 85% of subjects. Keratinization was present in 68% of specimens and fungus was noted in 9%. Individuals with moderate to large amounts of keratinization consumed significantly more alcohol than those without cytologic evidence of keratin. We speculate that keratinization and fungus may represent markers of enhanced malignant potential in this population.

Analysis of adenocarcinoma in Barrett's esophagus utilizing a staging system

Based on a retrospective review of nine patients with adenocarcinoma in a Barrett's esophagus and the reports of similar cases in the literature, a staging system for this malignancy was devised. A progression of changes could be identified that corresponded to the stages. These changes consisted of dysplasia progressing to carcinoma in situ and invasive malignancy with metastases. Stage III disease carried the same grim prognosis as a similar stage of squamous cell carcinoma of the esophagus. Earlier stages of adenocarcinoma of the esophagus appeared to have a better prognosis. White men with symptoms of reflux esophagitis, esophageal strictures, and/or hiatal hernias who have Barrett's esophagus extending proximal to the distal 10 cm of the esophagus appear to have a propensity to develop adenocarcinoma of the esophagus. Consideration should be given to antireflux surgery and close follow-up by periodic esophagoscopy and biopsy of the esophagus in these patients. If neoplasia is found, the thoracic esophagus should be totally removed with the stomach or left colon anastomosed to the cervical esophagus. Because of the poor prognosis of Stage III disease, postoperative chemotherapy should be considered.

Black drinking practices in northern California

The data for this research come from three independent community surveys conducted between 1979 and 1980 in the San Francisco Bay Area. All surveys followed the same sampling plan and only probability techniques were employed. Of a total of 4,150 adult respondents, 1,206 identified themselves as Blacks and are analyzed in this report. A total of 29% of the females and 16% of the males are abstainers. Frequent heavier drinkers comprise 22% of the males but only 6% of the females. Among males, heavier drinking and alcohol problems are highest among those in their thirties and, therefore, cannot be associated with a youthful lifestyle as it happens in the United States general population. Characteristics such as income, employment status, and education are not associated with drinking. Religion, however, is associated with drinking patterns, and Fundamentalists have significantly more abstainers and light drinkers than other religious groups. These findings are also discussed in the light of Black culture and minority status. It is suggested that drinking patterns among Blacks are influenced more by internal norms originated from common cultural and socio-political characteristics than from norms associated with class affiliations in the larger society.