Endoscopic Surveillance for Premalignant Esophageal Lesions: A Community-Based Multicenter, Prospective Cohort Study

How should extra-large Lugol-unstained lesions of the esophagus be treated? Results from a population-based cohort study

BACKGROUND

Current guidelines recommend only severe dysplasia and above (SDA) lesions of the esophageal squamous epithelium for clinical intervention. However, the histopathologic diagnosis derived from tissue biopsies may be subject to underestimation of severity.

METHODS

1073 participants from whom biopsies were taken at baseline chromoendoscopic examination in a population-based screening trial were enrolled in this study. The size of the Lugol-unstained lesions (LULs) was mainly analyzed. The outcome was defined as SDA lesions either identified at baseline screening, or during follow-up, collectively referred to as the cumulative risk of SDA. Multivariable logistic regression models were used to evaluate the cumulative risk of SDA.

RESULTS

One hundred and forty-six SDA cases were identified in the study period. Participants with large LULs had a high cumulative incidence of SDA (cumulative incidence16-20mm : 55.88%; cumulative incidence>20mm : 76.92%) in the median of 7-year duration. LULs of large size were significantly associated with a higher cumulative risk of SDA, regardless of the pathologic diagnosis (adjusted OR16-20mmvs.≤5mm  = 21.02, 95% CI: 7.56-58.47; adjusted OR>20mmvs.≤5mm  = 33.62, 95% CI: 11.79-95.87).

CONCLUSIONS

Results from this study suggest physician-patient shared decision-making regarding clinical treatment or intensive surveillance should be carried out for LULs >20 mm in the esophagus, regardless of the histologic diagnosis. For those with LULs of 16-20 mm, intensive surveillance would also best be considered.

Long-term esophageal cancer risk and distinct surveillance intervals after a single endoscopy screening: a multicentre population-based cohort study

Background

Endoscopy surveillance is recommended for mild-moderate dysplasia and negative endoscopy findings every 3 years and 5 years, respectively, but evidence is limited. This study aimed to assess long-term esophageal cancer (EC) incidence and mortality after a single endoscopy screening.

Methods

We included individuals at high risk of EC aged 40-69 years who underwent endoscopy screening in 2007-2012 at six centres in rural China and had a baseline diagnosis of negative endoscopy findings, mild dysplasia, or moderate dysplasia. Participants were followed up for EC incidence and mortality. Cumulative incidence and mortality rates of EC were estimated by Kaplan-Meier analyses. Cox regression models were used to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between baseline endoscopy diagnosis and the risk of EC incidence and mortality. EC incidence and mortality after a single endoscopy screening were compared with those of the population in rural China by the standardized incidence ratio (SIR) and standardized mortality ratio (SMR).

Findings

A total of 42,827 participants (40,977 with negative endoscopy findings, 1562 with mild dysplasia, and 288 with moderate dysplasia) were included; 268 EC cases and 128 EC deaths were identified during a median follow-up of 10.62 years. The cumulative EC incidence at 10 years was 0.45% (0.38-0.52) in the group with negative endoscopy findings, 2.39% (1.62-3.16) in the mild dysplasia group, and 8.90% (5.57-12.24) in the moderate dysplasia group, and the cumulative EC mortality at 10 years was 0.23% (0.18-0.27), 0.96% (0.46-1.46), and 2.50% (0.67-4.33), respectively. Compared with individuals with negative endoscopy findings, the HRs for EC incidence and mortality in the mild dysplasia group were 3.52 (2.49-4.97) and 2.43 (1.41-4.19), and those in the moderate dysplasia group were 13.18 (8.78-19.76) and 6.46 (3.13-13.29), respectively. The SIR was 0.53 (0.40-0.70) for the group with negative endoscopy findings, 1.95 (1.69-2.24) for the mild dysplasia group, and 6.75 (6.25-7.28) for the moderate dysplasia group, with the SMRs of 0.43 (0.31-0.58), 1.07 (0.88-1.29) and 2.67 (2.36-3.01), respectively.

Interpretation

Individuals with negative endoscopy findings after a single endoscopy screening had a lower EC risk than the general population for up to 10.62 years, while those with mild-moderate dysplasia had an elevated risk. Our results support endoscopy surveillance for mild-moderate dysplasia every 3 years and suggest extending the interval to 10 years after a negative endoscopy finding.

Funding

National Key R&D Programme of China, Special Project of Beijing-Tianjin-Hebei Basic Research Cooperation, and Sanming Project of Medicine in Shenzhen.

The NCC mathematical modeling framework for decision-making of six major cancers

Objective

Mathematical modeling and simulation is a useful research method to inform decision-making. This article aims to describe the National Cancer Center (NCC) modeling framework and how well it reproduces observed empirical data for six major cancers.

Methods

We developed the NCC modeling framework for six major cancers in China (lung, liver, stomach, colorectal, esophageal, and breast), which simulates the life-histories represented by states among normal, precancerous lesion, stage-specific invasive cancer, and death for six cancers separately. Each NCC simulation model could be illustrated as an integrated framework of 3 modules: a demography module, natural history module, and screening module. Combined with costs and health utilities data, the models could have many detailed outputs for informing decisions, including the harm of screening (e.g., false positives, complications, and overdiagnosis), healthcare costs, and benefits (quality-adjusted life years gained, cancer incidence and mortality, and investment returns). We calibrated the models to Chinese population-based observations on cancer incidence, mortality, and stage distribution. All models are validated by comparing model simulated results to data observed from nationwide cancer registration and a large prospective cohort study.

Results

The simulated results from the calibrated models consistently match the epidemiological patterns in six major cancer incidence, mortality, and stage distributions in China. Model projected age-specific cancer incidence and mortality were close to the observed data in the national cancer registration. The NCC modeling framework reproduced the cumulative cancer cases and deaths observed in the prospective cohort study at 7.0 and 10.8 years of follow-up. Model estimated net survival rates also consistent with population-based statistics.

Conclusion

The NCC modeling framework's ability to reproduce the observed population-level cancer statistics and the cancer cases in a prospective cohort study suggests its results are reliable to inform decision-making related to six major cancers in China.