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Crowe BR, Krigel A, Li T, Haile R, Al-Ani F, Lebwohl B, Abrams JA, Araujo JL. Veterans with multiple risk factors for Barrett's esophagus are infrequently evaluated with upper endoscopy. Dis Esophagus 2023; 36:doad007. [PMID: 36892169 DOI: 10.1093/dote/doad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 03/10/2023]
Abstract
Recent guidelines recommend screening for patients with chronic gastroesophageal reflux disease who have three or more additional risk factors for Barrett's esophagus (BE). Failure to screen high-risk individuals represents a missed opportunity in esophageal adenocarcinoma prevention and early detection. We aimed to determine the frequency of upper endoscopy and prevalence of BE and esophageal cancer in a cohort of United States veterans who possessed four or more risk factors for BE. All patients at VA New York Harbor Healthcare System with at least four risk factors for BE between 2012 and 2017 were identified. Procedure records were reviewed for upper endoscopies performed between January 2012 and December 2019. Multivariable logistic regression was used to determine risk factors associated with undergoing endoscopy and factors associated with BE and esophageal cancer. 4505 patients with at least four risk factors for BE were included. 828 patients (18.4%) underwent upper endoscopy, of which 42 (5.1%) were diagnosed with BE and 11 (1.3%) with esophageal cancer (10 adenocarcinoma; 1 squamous cell carcinoma). Among individuals who underwent upper endoscopy, risk factors associated with undergoing endoscopy included obesity (OR, 1.79; 95% CI, 1.41-2.30; P < 0.001) and chronic reflux (OR, 3.86; 95% CI, 3.04-4.90; P < 0.001). There were no individual risk factors associated with BE or BE/esophageal cancer. In this retrospective analysis of patients with 4 or more risk factors for BE, fewer than one-fifth of patients underwent upper endoscopy, supporting the need for efforts aimed at improving BE screening rates.
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Affiliation(s)
- Brooks R Crowe
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Anna Krigel
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Tian Li
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Rozina Haile
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Firas Al-Ani
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - James L Araujo
- Division of Gastroenterology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
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Correlation of Ethnicities and Prevalence of Histological Barrett's Esophagus. Am J Gastroenterol 2022; 117:1539. [PMID: 35973137 DOI: 10.14309/ajg.0000000000001814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/26/2022] [Indexed: 12/11/2022]
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Zhao Z, Yin Z, Zhang C. Lifestyle interventions can reduce the risk of Barrett's esophagus: a systematic review and meta-analysis of 62 studies involving 250,157 participants. Cancer Med 2021; 10:5297-5320. [PMID: 34128354 PMCID: PMC8335822 DOI: 10.1002/cam4.4061] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/12/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
Background Barrett's esophagus (BE) is a well‐established risk factor for esophageal adenocarcinoma. Our objective was to investigate the effectiveness of lifestyle interventions on BE risk. Methods We searched PubMed, Embase, and Web of Science up to 30 September 2020. The summary relative risks (RRs) and 95% confidence intervals (CIs) for the highest versus lowest categories of exposure were assessed. Analyses of subgroup, dose–response, sensitivity, and publication bias were conducted. Results Sixty‐two studies were included that involved more than 250,157 participants and 22,608 cases. Seven lifestyle factors were investigated: smoking, alcohol, body mass index (BMI), physical activity, sleep time, medication, and diet. We observed statistically significant increased BE risks for smoking (RR = 1.35, 95% CI = 1.16–1.57), alcohol intake (RR = 1.23, 95% CI = 1.13–1.34), body fatness (RR = 1.08, 95% CI = 1.03–1.13), less sleep time (RR = 1.76, 95% CI = 1.24–2.49), and proton pump inhibitors use (RR = 1.64, 95% CI = 1.17–2.29). Reduced risks of BE were found for aspirin (RR = 0.70, 95% CI = 0.58–0.84) and the intake of vitamin C (RR = 0.59, 95% CI = 0.44–0.80), folate (RR = 0.47, 95% CI = 0.31–0.71), and fiber (RR = 0.95, 95% CI = 0.93–0.97). The quality of most included studies was high and the subgroup analysis according to the quality score showed significant results (p < 0.05). There was no publication bias for smoking and alcohol. Although the analysis suggested significant evidence of publication bias for BMI, sensitivity analysis showed that the changes in the recalculated RRs were not significant. Conclusions The large meta‐analysis revealed that lifestyle modifications could reduce the risks of BE and, consequently, esophageal adenocarcinoma.
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Affiliation(s)
- Zhanwei Zhao
- Department of General Surgery, the Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Zifang Yin
- Department of Obstetrics, the Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Chaojun Zhang
- Department of General Surgery, the Sixth Medical Center of PLA General Hospital, Beijing, China
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Racial Disparities in Adherence to Quality Indicators in Barrett's Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry. Am J Gastroenterol 2021; 116:1201-1210. [PMID: 33767105 DOI: 10.14309/ajg.0000000000001230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Racial disparities in outcomes in esophageal adenocarcinoma are well established. Using a nationwide registry, we aimed to compare clinical and endoscopic characteristics of blacks and whites with Barrett's esophagus (BE) and adherence to defined quality indicators. METHODS We analyzed data from the Gastrointestinal Quality Improvement Consortium Registry between January 2012 and December 2019. Patients who underwent esophagogastroduodenoscopy with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to recommended endoscopic surveillance intervals of 3-5 years for nondysplastic BE and adherence to Seattle biopsy protocol were assessed. Multivariate logistic regression was conducted to assess variables associated with adherence. RESULTS A total of 100,848 esophagogastroduodenoscopies in 84,789 patients met inclusion criteria (blacks-3,957 and whites-96,891). Blacks were less likely to have histologically confirmed BE (34.3% vs 51.7%, P < 0.01), had shorter BE lengths (1.61 vs 2.35 cm, P < 0.01), and were less likely to have any dysplasia (4.3% vs 7.1%, P < 0.01). Although whites were predominantly male (62.2%), about half of blacks with BE were female (53.0%). Blacks with nondysplastic BE were less likely to be recommended appropriate surveillance intervals (OR 0.78; 95% CI 0.68-0.89). Adherence rates to the Seattle protocol were modestly higher among blacks overall (OR 1.12, 95% CI 1.04-1.20), although significantly lower among blacks with BE segments >6 cm. DISCUSSION The use of sex as a risk factor for BE screening may be inappropriate among blacks. Fewer blacks were recommended appropriate surveillance intervals, and blacks with longer segment BE were less likely to undergo Seattle biopsy protocol.
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Tan MC, Mallepally N, Ho Q, Liu Y, El-Serag HB, Thrift AP. Dietary Factors and Gastric Intestinal Metaplasia Risk Among US Veterans. Dig Dis Sci 2021; 66:1600-1610. [PMID: 32535778 PMCID: PMC8845052 DOI: 10.1007/s10620-020-06399-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies on diet and gastric intestinal metaplasia (GIM) risk are lacking in US populations. AIM To determine the associations of dietary factors and risk of GIM among a US population with typical American diet. METHODS We analyzed data from a cross-sectional study of veterans attending primary care and endoscopy clinics at the Houston VA Medical Center. Patients completed a 110-item Block Food Frequency Questionnaire then underwent upper endoscopy with gastric mapping biopsies. We compared cases defined by GIM on ≥ 1 non-cardia gastric biopsy to controls without GIM. Associations of dietary factors and GIM were estimated using logistic regression models as odds ratios (OR) and 95% confidence intervals (CI). RESULTS Among 423 GIM cases and 1796 controls, cases were older (62.1 vs. 59.9 years) and more likely to be male (97.2% vs. 90.8%) and non-White (58.6% vs. 39.0%). GIM cases had lower fat intake (percent kcal from fat tertile 1: 43.6% vs. 33.4%) and higher carbohydrate intake (percent kcal from carbohydrate T3: 41.8% vs. 33.3%) than controls. Adjusting for age, gender, race, smoking, and Helicobacter pylori, percent kcal from carbohydrates (T3 vs. T1: OR 1.35, 95% CI 1.08-1.67), fruit intake (T3 vs. T1: OR 1.28, 95% CI 1.02-1.61), and fiber intake (T3 vs. T1: OR 1.37, 95% CI 1.04-1.80) were associated with GIM. In subgroup analyses, these associations were primarily seen in non-White patients. CONCLUSIONS Few dietary factors, including high carbohydrate intake, are associated with increased risk of GIM in US populations, independent of H. pylori or smoking.
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Affiliation(s)
- Mimi C Tan
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA.
| | | | - Quynh Ho
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
- University of St. Thomas, Houston, TX, USA
| | - Yan Liu
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Hashem B El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
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Isseh M, Mueller L, Abunafeesa H, Imam Z, Shakaroun D, Abu Ghanimeh M, Isseh N, Miller J, Jafri SM, Lenhart A. An Urban Center Experience Exploring Barriers to Adherence to Endoscopic Surveillance for Non-Dysplastic Barrett's Esophagus. Cureus 2021; 13:e13030. [PMID: 33665052 PMCID: PMC7924167 DOI: 10.7759/cureus.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Data regarding barriers to Barrett’s esophagus (BE) surveillance is limited. Studying an urban center population, we aimed to characterize non-dysplastic BE surveillance rates and identify health, racial, and socioeconomic disparities affecting surveillance. Methods Patients with biopsy-confirmed BE were retrospectively identified between January 2002 and December 2012. Non-dysplastic BE patients were analyzed for adherence to established surveillance guidelines. Demographic, racial, comorbidities, and socioeconomic variables were extracted. Annual gross income (AGI) was utilized as a marker of socioeconomic status (SES). Univariate and multivariate analyses compared adherent vs. non-adherent patients to surveillance guidelines. Results A total of 217 patients with non-dysplastic BE were analyzed. The majority were male (67.3%) and Caucasian (75.6%), with only 47.5% adherent with the first surveillance endoscopy. Patients with a high average AGI were more likely to be adherent with the initial surveillance endoscopy than those with low AGI (p=0.032). Initial compliance with first surveillance was associated with better surveillance at regular intervals (p=0.001). No significant differences in age, primary language, insurance type, marital status, or Charlson Comorbidity Index (CCI) between adherent and non-adherent patients were found. Conclusions Although overall adherence to guidelines was suboptimal, this study identifies important socioeconomic disparities in the endoscopic surveillance for non-dysplastic BE. Identifying and understanding the barriers to care among these lower socioeconomic groups may ultimately lead to improved screening compliance and early BE detection.
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Affiliation(s)
- Mahmoud Isseh
- Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Laurel Mueller
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | | | - Zaid Imam
- Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, USA
| | | | | | - Nazih Isseh
- Internal Medicine, The University of Tennessee Health Science Center, Memphis, USA
| | - Joseph Miller
- Emergency Medicine, Henry Ford Health System, Detroit, USA
| | | | - Adrienne Lenhart
- Gastroenterology, University of California Los Angeles, Los Angeles, USA
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Association Between Helicobacter pylori Infection and Short-segment/Long-segment Barrett's Esophagus in a Japanese Population: A Large Cross-Sectional Study. J Clin Gastroenterol 2020; 54:439-444. [PMID: 31524650 DOI: 10.1097/mcg.0000000000001264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOAL The goal of this study was to investigate the relationship between Helicobacter pylori (H. pylori) infection and short-segment and long-segment Barrett's esophagus (SSBE and LSBE). BACKGROUND H. pylori infection is reported to be inversely associated with Barrett's esophagus (BE) in western countries. However, the impact of BE segment length on the association between BE and H. pylori infection has scarcely been investigated. MATERIALS AND METHODS The study subjects were 41,065 asymptomatic Japanese individuals who took medical surveys between October 2010 and September 2017. Using this large database of healthy Japanese subjects, we investigated the association between H. pylori infection and SSBE/LSBE. We used multivariable logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Among the study subjects, 36,615 were eligible for the analysis. H. pylori seropositivity was significantly associated with a lower rate of LSBE (OR: 0.42; 95% CI: 0.16-0.91) and a higher rate of SSBE (OR: 1.66; 95% CI: 1.56-1.78) after multivariate adjustment. In the subgroup analysis, H. pylori seropositivity was significantly associated with a high rate of SSBE in subjects without reflux esophagitis (RE) (OR: 1.73; 95% CI: 1.61-1.85). However, H. pylori seropositivity was not associated with SSBE in subjects with RE (OR: 1.07; 95% CI: 0.84-1.37). CONCLUSION In a Japanese population, H. pylori infection was inversely associated with LSBE but significantly associated with SSBE only in subjects without RE. H. pylori may be a risk factor for SSBE, especially in individuals without RE.
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Incidence and Survival Changes in Patients with Esophageal Adenocarcinoma during 1984-2013. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7431850. [PMID: 31915702 PMCID: PMC6930790 DOI: 10.1155/2019/7431850] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 08/28/2019] [Indexed: 02/06/2023]
Abstract
Purpose The morbidity of esophageal adenocarcinoma (EAC) has significantly increased in Western countries. We aimed to identify trends in incidence and survival in patients with EAC in the recent 30 years and then analyzed potential risk factors, including race, sex, age, and socioeconomic status (SES). Methods All data were collected from the Surveillance, Epidemiology, and End Results or SEER database. Kaplan–Meier analysis and the Cox proportional hazards model were conducted to compare the differences in survival between variables, including sex, race, age, and SES, as well as to evaluate the association of these factors with prognosis. Results A total of 16,474 patients with EAC were identified from 1984 to 2013 in the United States. Overall incidence increased every 10 years from 1.8 to 3.1 to 3.9 per 100. Overall survival gradually improved (p < 0.0001), which was evident in male patients ((hazard ratio (HR) = 1.111; 95% confidence interval (CI) (1.07, 1.15)); however, the 5-year survival rate remained low (20.1%). The Cox proportional hazards model identified old age, black ethnicity, and medium/high poverty as risk factors for EAC (HR = 1.018; 95% CI (1.017, 1.019; HR = 1.240, 95% CI (1.151,1.336), HR = 1.000, 95% CI (1.000, 1.000); respectively). Conclusions The incidence of EAC in the United States increased over time. Survival advantage was observed in white patients and patients in the low-poverty group. Sex was an independent prognostic factor for EAC, but this finding has to be confirmed by further research.
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Na'amnih W, Katz R, Goren S, Ben-Tov A, Ziv-Baran T, Chodick G, Muhsen K. Correlates of gastroenterology health-services utilization among patients with gastroesophageal reflux disease: a large database analysis. Isr J Health Policy Res 2019; 8:66. [PMID: 31429808 PMCID: PMC6700833 DOI: 10.1186/s13584-019-0335-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/09/2019] [Indexed: 01/01/2023] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is associated with high utilization of health care services. Diagnostic tests usually are not required to establish GERD diagnosis, but endoscopy is recommended for patients with alarm symptoms such as dysphagia and unintentional weight loss, and those whose symptoms are not relieved by proton pump inhibitors (PPIs) therapy. Evidence on the correlates of utilization of gastroenterology health services among GERD patients is limited. The study aim was to examine associations of patient and physician’s characteristics with high utilization of gastroenterology services. Methods In a cross-sectional study using the database of the second largest integrated care organization in Israel, data of all adult GERD patients (N = 75,219) in 2012–2015 were analyzed. High utilization of services was assessed using two dependent variables analyzed separately: undergoing two or more gastroscopies or having six or more visits to a gastroenterology consultant during the study-period. Results Overall, 11,261 (15.0%) patients had two or more gastroscopies and 23,703 (31.5%) had six or more visits to a gastroenterology consultant. The likelihood of high utilization of gastroscopy increased with age; in immigrants from the Former Soviet Union versus patients who were born in Israel; residents of Jerusalem, the south, the north and Haifa districts versus the center district; in patients with high PPI purchases, and in patients who belonged to clinics in which the physician-manger had no board certification. The correlates were similar for visits to a gastroenterology consultant. Conclusions Patient and physician’s characteristics were related to high utilization of gastroenterology services among GERD patients. The associations with age and country of birth might reflect more severe disease. The regional differences warrant further research and interventions at the district level. Training in gastroenterology of primary care physicians without a board certification is warranted. Electronic supplementary material The online version of this article (10.1186/s13584-019-0335-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wasef Na'amnih
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | | | - Sophy Goren
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | | | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Gabriel Chodick
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.,Maccabi Healthcare Services, Tel Aviv, Israel
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
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Münch NS, Fang HY, Ingermann J, Maurer HC, Anand A, Kellner V, Sahm V, Wiethaler M, Baumeister T, Wein F, Einwächter H, Bolze F, Klingenspor M, Haller D, Kavanagh M, Lysaght J, Friedman R, Dannenberg AJ, Pollak M, Holt PR, Muthupalani S, Fox JG, Whary MT, Lee Y, Ren TY, Elliot R, Fitzgerald R, Steiger K, Schmid RM, Wang TC, Quante M. High-Fat Diet Accelerates Carcinogenesis in a Mouse Model of Barrett's Esophagus via Interleukin 8 and Alterations to the Gut Microbiome. Gastroenterology 2019; 157:492-506.e2. [PMID: 30998992 PMCID: PMC6662596 DOI: 10.1053/j.gastro.2019.04.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Progression from BE to cancer is associated with obesity, possibly due to increased abdominal pressure and gastroesophageal reflux disease, although this pathogenic mechanism has not been proven. We investigated whether environmental or dietary factors associated with obesity contribute to the progression of BE to EAC in mice. METHODS Tg(ED-L2-IL1RN/IL1B)#Tcw mice (a model of BE, called L2-IL1B mice) were fed a chow (control) or high-fat diet (HFD) or were crossbred with mice that express human interleukin (IL) 8 (L2-IL1B/IL8 mice). Esophageal tissues were collected and analyzed for gene expression profiles and by quantitative polymerase chain reaction, immunohistochemistry, and flow cytometry. Organoids were established from BE tissue of mice and cultured with serum from lean or obese individuals or with neutrophils from L2-IL1B mice. Feces from mice were analyzed by 16s ribosomal RNA sequencing and compared to 16s sequencing data from patients with dysplasia or BE. L2-IL1B were mice raised in germ-free conditions. RESULTS L2-IL1B mice fed an HFD developed esophageal dysplasia and tumors more rapidly than mice fed the control diet; the speed of tumor development was independent of body weight. The acceleration of dysplasia by the HFD in the L2-IL1B mice was associated with a shift in the gut microbiota and an increased ratio of neutrophils to natural killer cells in esophageal tissues compared with mice fed a control diet. We observed similar differences in the microbiomes from patients with BE that progressed to EAC vs patients with BE that did not develop into cancer. Tissues from dysplasias of L2-IL1B mice fed the HFD contained increased levels of cytokines that are produced in response to CXCL1 (the functional mouse homolog of IL8, also called KC). Serum from obese patients caused organoids from L2-IL1B/IL8 mice to produce IL8. BE tissues from L2-IL1B mice fed the HFD and from L2-IL1B/IL8 mice contained increased numbers of myeloid cells and cells expressing Cxcr2 and Lgr5 messenger RNAs (epithelial progenitors) compared with mice fed control diets. BE tissues from L2-IL1B mice raised in germ-free housing had fewer progenitor cells and developed less dysplasia than in L2-IL1 mice raised under standard conditions; exposure of fecal microbiota from L2-IL1B mice fed the HFD to L2-IL1B mice fed the control diet accelerated tumor development. CONCLUSIONS In a mouse model of BE, we found that an HFD promoted dysplasia by altering the esophageal microenvironment and gut microbiome, thereby inducing inflammation and stem cell expansion, independent of obesity.
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Affiliation(s)
- Natasha Stephens Münch
- Department of Internal Medicine, Technical University of Munich, Germany,Chair of Molecular Nutritional Medicine, Technical University of Munich, Germany
| | - Hsin-Yu Fang
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Jonas Ingermann
- Department of Internal Medicine, Technical University of Munich, Germany,Chair of Molecular Nutritional Medicine, Technical University of Munich, Germany
| | - H. Carlo Maurer
- Department of Internal Medicine, Technical University of Munich, Germany,Irvine Cancer Research Center, Columbia University, New York, USA
| | - Akanksha Anand
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Victoria Kellner
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Vincenz Sahm
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Maria Wiethaler
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Theresa Baumeister
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Frederik Wein
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Henrik Einwächter
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Florian Bolze
- Chair of Molecular Nutritional Medicine, Technical University of Munich, Germany,EKFZ – Else Kröner-Fresenius Center for Nutritional Medicine, Technical University of Munich, Germany,ZIEL – Institute of Food & Health, Technical University of Munich, Germany
| | - Martin Klingenspor
- Chair of Molecular Nutritional Medicine, Technical University of Munich, Germany,EKFZ – Else Kröner-Fresenius Center for Nutritional Medicine, Technical University of Munich, Germany,ZIEL – Institute of Food & Health, Technical University of Munich, Germany
| | - Dirk Haller
- Chair of Nutrition and Immunology; Technical University of Munich, Germany
| | - Maria Kavanagh
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
| | - Richard Friedman
- Irvine Cancer Research Center, Columbia University, New York, USA
| | | | | | | | | | - James G. Fox
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mark T. Whary
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Yoomi Lee
- Irvine Cancer Research Center, Columbia University, New York, USA
| | - Tony Y. Ren
- Irvine Cancer Research Center, Columbia University, New York, USA
| | | | | | - Katja Steiger
- Institute of Pathology, Technical University of Munich, Germany
| | - Roland M. Schmid
- Department of Internal Medicine, Technical University of Munich, Germany
| | - Timothy C. Wang
- Irvine Cancer Research Center, Columbia University, New York, USA
| | - Michael Quante
- Department of Internal Medicine, Technical University of Munich, Germany.
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Thota PN, Zackria S, Sanaka MR, Patil D, Goldblum J, Lopez R, Chak A. Racial Disparity in the Sex Distribution, the Prevalence, and the Incidence of Dysplasia in Barrett's Esophagus. J Clin Gastroenterol 2019; 51:402-406. [PMID: 27306940 PMCID: PMC5159321 DOI: 10.1097/mcg.0000000000000559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOALS Our aim was to study the prevalence of dysplasia and progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in African Americans (AA) with Barrett's esophagus (BE) and compare it with that of non-Hispanic white (NHW) controls. BACKGROUND BE, a precursor of EAC, is a disease of predominantly white men and is uncommon in AA. The prevalence of dysplasia and progression to HGD and EAC in AA patients with BE is not clearly known. STUDY All AA or NHW patients with confirmed BE, that is specialized intestinal metaplasia, seen between 2002 and 2013 at our institution were included. Variables such as age, gender, medication use, the body mass index, the date of endoscopy, the hiatal hernia size, the BE length, and histologic findings were noted. Progression to HGD/EAC was evaluated. RESULTS Fifty-two AA and 2394 NHW patients with BE were identified. There was a higher percentage of women in the AA cohort (46.2%) than in the NHW cohort (24.9%, P<0.001). Nondysplastic BE was more prevalent in AA than in NHW (80.8% vs. 68.4%, P=0.058). In the surveillance cohort of 20 AA and 991 NHW, no racial differences in progression to HGD/EAC were observed during a median follow-up of 43 months. CONCLUSIONS This study includes the largest number of AA with histologically confirmed BE reported so far. About 46.2% of the AA cohort with BE in our study consisted of women. There was a trend toward a higher prevalence of nondysplastic BE in AA compared with NHW.
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Affiliation(s)
- Prashanthi N. Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, USA
| | - Shamiq Zackria
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, USA
| | | | - Deepa Patil
- Department of Pathology, Cleveland Clinic, Cleveland, USA
| | - John Goldblum
- Department of Pathology, Cleveland Clinic, Cleveland, USA
| | - Rocio Lopez
- Department of Biostatistics, Cleveland Clinic, Cleveland, USA
| | - Amitabh Chak
- Department of Gastroenterology, University Hospitals, Cleveland, USA
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Tan MC, Kanthasamy KA, Yeh AG, Kil D, Pompeii L, Yu X, El-Serag HB, Thrift AP. Factors Associated With Recurrence of Barrett's Esophagus After Radiofrequency Ablation. Clin Gastroenterol Hepatol 2019; 17:65-72.e5. [PMID: 29902646 DOI: 10.1016/j.cgh.2018.05.042] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/22/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) is effective treatment for Barrett's esophagus (BE). However, some patients have recurrence after complete eradication of intestinal metaplasia (CEIM). We investigated the incidence of and factors associated with BE recurrence, with or without neoplasia, after RFA and CEIM using data from the national Veterans Affairs (VA) healthcare system. METHODS We performed a retrospective cohort study of Veterans with BE treated by RFA from 2005 through 2016 with follow-up endoscopy. Subjects were followed until BE recurrence, neoplasia, death until October 2016. CEIM, BE recurrence, and factors associated with recurrence were identified by review of medical records. We calculated incidence rates of BE recurrence, with and without neoplasia, after CEIM and identified predictors using Cox proportional hazards models. RESULTS We identified 430 Veterans with BE who were treated with RFA; of these 337 achieved CEIM (78.4%). Most were men (98.6%), White (83.7%), and 66.0% had baseline dysplasia. Of those with CEIM, 98 patients (29.1%) had recurrence of BE during a total 906.0 patient-years of follow-up (median 1.9 years) after CEIM (incidence, 10.8%/patient-year). Dysplasia developed in 20 patients (2.2%/patient-year) and cancer in 3 patients (0.3%/patient-year). Baseline dysplasia (hazard ratio [HR], 1.71; 95% CI, 1.03-2.84) and long-segment BE (HR, 1.59; 95% CI, 1.01-2.51) increased risk of BE recurrence whereas treatment at high-volume RFA facilities reduced risk of BE recurrence (for quartile 4 vs quartile 1: HR, 0.19; 95% CI, 0.05-0.68). CONCLUSIONS In a nationwide VA system study of outcomes of RFA for BE, we associated baseline dysplasia, long-segment BE, and treatment at low-volume RFA centers with recurrence of BE after CEIM. The findings call for performing these procedures in high-volume centers.
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Affiliation(s)
- Mimi C Tan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Allison G Yeh
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Daniel Kil
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Lisa Pompeii
- Department of Epidemiology, University of Texas School of Public Heath, Houston, Texas
| | - Xiaoying Yu
- Office of Biostatistics, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
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Alkaddour A, McGaw C, Hritani R, Palacio C, Munoz JC, Vega KJ. Protective Propensity of Race or Environmental Features in the Development of Barrett's Esophagus in African Americans - A Single Center Pilot Study. J Natl Med Assoc 2018; 111:198-201. [PMID: 30366610 DOI: 10.1016/j.jnma.2018.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/25/2018] [Accepted: 09/24/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND STUDY AIMS Barrett's Esophagus (BE) is a well-recognized pre-malignant condition. Previous data indicate histologically confirmed BE frequency varies by ethnicity in the United States. However, clinical factor assessment to explain this has only occurred in a veteran population to date. The study aim was to determine which clinical factors may be associated with the ethnic variation seen in histologically confirmed BE among a general population. PATIENTS AND METHODS The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to October 2012. Histologic BE was diagnosed only if salmon colored, columnar-appearing esophageal mucosa was seen at endoscopy and biopsy revealed intestinal metaplasia with Alcian blue-stained goblet cells. Data collected included: age/BMI at diagnosis, ethnicity, sex, GERD history, atypical manifestations, endoscopic BE length, presence of esophageal stricture/ulcer/hiatal hernia, presence/absence of dysplasia and medication use (aspirin/NSAIDs/statin/PPI). RESULTS Salmon colored esophageal mucosa was observed in 1105 of 15,564 patients (7.1%) with BE histologically confirmed in 249 of 1105 patients (23%). Ethnic distribution of histologic BE patients: 83% non-Hispanic white (nHw), 13% African American (AA) and 4% other. No difference was seen between groups with regard to BMI, GERD symptom/complications, BE length, and cigarette, alcohol or medication use. CONCLUSION BE occurs primarily in nHw in north Florida. This occurs despite similarities in GERD history, cigarette/alcohol use, medications prescribed and BMI. Molecular level investigation is necessary to explain this observed disparity between nHw and AA.
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Affiliation(s)
- Ahmad Alkaddour
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Camille McGaw
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Rama Hritani
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Carlos Palacio
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Juan Carlos Munoz
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Kenneth J Vega
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA; Division of Gastroenterology and Hepatology, Augusta University-Medical College of Georgia, Augusta, GA.
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Erőss B, Farkas N, Vincze Á, Tinusz B, Szapáry L, Garami A, Balaskó M, Sarlós P, Czopf L, Alizadeh H, Rakonczay Z, Habon T, Hegyi P. Helicobacter pylori infection reduces the risk of Barrett's esophagus: A meta-analysis and systematic review. Helicobacter 2018; 23:e12504. [PMID: 29938864 PMCID: PMC6055671 DOI: 10.1111/hel.12504] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The prevalence of Helicobacter pylori infection (HPI) has been decreasing in developed countries, with an increasing prevalence of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) at the same time. The aim of our meta-analysis was to quantify the risk of BE in the context of HPI. METHODS A systematic search was conducted in 3 databases for studies on BE with data on prevalence of HPI from inception until December 2016. Odds ratios for BE in HPI were calculated by the random effects model with subgroup analyses for geographical location, presence of dysplasia in BE, and length of the BE segment. RESULTS Seventy-two studies were included in the meta-analysis, including 84 717 BE cases and 390 749 controls. The overall analysis showed that HPI reduces the risk of BE; OR = 0.68 (95% CI: 0.58-0.79, P < .001). Subgroup analyses revealed risk reduction in Asia OR = 0.53 (95% CI: 0.33-0.84, P = .007), Australia OR = 0.56 (95% CI: 0.39-0.80, P = .002), Europe OR = 0.77 (95% CI: 0.60-0.98, P = .035), and North-America OR = 0.59 (95% CI: 0.47-0.74, P < .001). The risk was significantly reduced for dysplastic BE, OR = 0.37 (95% CI: 0.26-0.51, P < .001) for non-dysplastic BE, OR = 0.51 (95% CI: 0.35-0.75, P = .001), and for long segment BE, OR = 0.25 (95% CI: 0.11-0.59, P = .001) in case of HPI. CONCLUSIONS This extensive meta-analysis provides additional evidence that HPI is associated with reduced risk of BE. Subgroup analyses confirmed that this risk reduction is independent of geographical location. HPI is associated with significantly lower risk of dysplastic, non-dysplastic, and long segment BE.
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Affiliation(s)
- Bálint Erőss
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Nelli Farkas
- Institute of BioanalysisMedical SchoolUniversity of PécsPécsHungary
| | - Áron Vincze
- Department of GastroenterologyFirst Department of MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Benedek Tinusz
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
| | - László Szapáry
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
| | - András Garami
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Márta Balaskó
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Patrícia Sarlós
- Department of GastroenterologyFirst Department of MedicineMedical SchoolUniversity of PécsPécsHungary
| | - László Czopf
- Department of CardiologyFirst Department of MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Hussain Alizadeh
- Department of HematologyFirst Department of MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Zoltán Rakonczay
- Department of PathophysiologyMedical SchoolUniversity of SzegedSzegedHungary
| | - Tamás Habon
- Department of CardiologyFirst Department of MedicineMedical SchoolUniversity of PécsPécsHungary
| | - Péter Hegyi
- Institute for Translational MedicineMedical SchoolUniversity of PécsPécsHungary
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15
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Gross SA, Smith MS, Kaul V. Increased detection of Barrett's esophagus and esophageal dysplasia with adjunctive use of wide-area transepithelial sample with three-dimensional computer-assisted analysis (WATS). United European Gastroenterol J 2017; 6:529-535. [PMID: 29881608 DOI: 10.1177/2050640617746298] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 11/06/2017] [Indexed: 12/22/2022] Open
Abstract
Background Barrett's esophagus (BE) and esophageal dysplasia (ED) are frequently missed during screening and surveillance esophagoscopy because of sampling error associated with four-quadrant random forceps biopsy (FB). Aim The aim of this article is to determine if wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS) used adjunctively with FB can increase the detection of BE and ED. Methods In this multicenter prospective trial, patients screened for suspected BE and those with known BE undergoing surveillance were enrolled. Patients at 25 community-based practices underwent WATS adjunctively to targeted FB and random four-quadrant FB. Results Of 4203 patients, 594 were diagnosed with BE by FB alone, and 493 additional cases were detected by adding WATS, increasing the overall detection of BE by 83% (493/594, 95% CI 74%-93%). Low-grade dysplasia (LGD) was diagnosed in 26 patients by FB alone, and 23 additional cases were detected by adding WATS, increasing the detection of LGD by 88.5% (23/26, 95% CI 48%-160%). Conclusions Adjunctive use of WATS to FB significantly improves the detection of both BE and ED. Sampling error, an inherent limitation associated with screening and surveillance, can be improved with WATS allowing better informed decisions to be made about the management and subsequent treatment of these patients.
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Affiliation(s)
- Seth A Gross
- NYU School of Medicine, Gastroenterology, New York, NY, USA
| | - Michael S Smith
- Temple University School of Medicine, Gastroenterology, Philadelphia, PA, USA
| | - Vivek Kaul
- University of Rochester Medical Center, Gastroenterology, Rochester, NY, USA
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16
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Alkaddour A, Palacio C, Vega KJ. Risk of histologic Barrett's esophagus between African Americans and non-Hispanic whites: A meta-analysis. United European Gastroenterol J 2017; 6:22-28. [PMID: 29435310 DOI: 10.1177/2050640617707862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/29/2017] [Indexed: 12/16/2022] Open
Abstract
Background Barrett's esophagus (BE) is rare in African Americans (AA). However, the risk difference magnitude in histologic BE prevalence between AA and non-Hispanic whites (nHw) has not been quantified to date. Objective The objective of this article is to determine the degree of histologic BE risk difference between AA and nHw. Methods PubMed, Web of Science and EMBASE were searched for studies reporting histologic BE in AA/nHw for inclusion. Pooled odds ratios (ORs) with risk estimates of histologic BE occurrence between AA/nHw were calculated along with 95% confidence intervals (CIs). Forest plots were used to quantify heterogeneity. Funnel plots and the Cochrane Collaboration Risk of Bias tool were used to assess bias risk. Results Eight studies reported BE histologic confirmation in AA/nHw. Analysis demonstrated a nearly 400% increased histologic BE risk in nHw patients compared to AA (OR 3.949, 95% CI 3.069-5.082). In the model without the case-control study, histologic BE risk remained elevated at approximately 360% in nHw compared to AA (OR 3.618, 95% CI 2.769-4.726). Heterogeneity was not present in either model. Risk of bias was significant. Conclusions Histologic BE risk is elevated in nHw by 3.6-4 times compared to AA. Investigation into understanding any clinical, molecular or genetic mechanisms underlying this risk disparity is warranted.
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Affiliation(s)
- Ahmad Alkaddour
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Carlos Palacio
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Kenneth J Vega
- Division of Gastroenterology, National Jewish Health, Denver, CO, USA
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17
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Chisholm SS, Khoury JE, Jamal MM, Palacio C, Pudhota S, Vega KJ. The frequency of histologically confirmed Barrett's esophagus varies by the combination of ethnicity and gender. J Gastrointest Oncol 2017; 8:102-108. [PMID: 28280615 DOI: 10.21037/jgo.2016.12.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Barrett's esophagus (BE) is the primary risk factor for esophageal adenocarcinoma (EAC). Limited data exists regarding the frequency of histologically confirmed BE by both gender and ethnicity in the United States. The study aim was to determine whether the frequency of histologically confirmed BE varies by ethnicity and gender. METHODS The University of Florida-Jacksonville endoscopy database was reviewed for all cases of salmon colored esophageal mucosa from September 2002 to August 2007. Histologic BE was diagnosed only if salmon colored esophageal mucosa was seen endoscopically and biopsy confirmed intestinal metaplasia with goblet cells. Data collected included: age at diagnosis, self-reported ethnicity [non-Hispanic white (nHw) or African American (AA)], gender, procedure indication, gastroesophageal reflux disease (GERD) history, atypical manifestations, cigarette smoking, alcohol use, proton pump inhibitor (PPI) use, BE endoscopic length, absence/presence of hiatal hernia, stricture or ulcer, and absence/presence/grade of dysplasia. RESULTS Salmon colored esophageal mucosa was identified in 391/7,308 patients, distributed ethnically as 306 nHw and 85 AA. Histologic BE was confirmed in 111/391 patients with ethnic distribution of: 95 nHw and 16 AA. Histologically confirmed BE frequency varied both by gender and ethnicity with nHw males having the highest (42.3%) and AA females the lowest (12.3%). Histologically confirmed BE frequency differed significantly between nHw males and nHw/AA females only (P<0.005). CONCLUSIONS Histologically confirmed BE frequency varies by ethnicity and gender with nHw males having the highest frequency/risk and AA females the lowest. Investigation to improve understanding of the impact of race and gender in BE formation should be performed.
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Affiliation(s)
- Sian S Chisholm
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Joe E Khoury
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - M Mazen Jamal
- Division of Gastroenterology, VAMC, Long Beach, CA and University of California, Irvine, California, USA
| | - Carlos Palacio
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Sunitha Pudhota
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Kenneth J Vega
- Division of Gastroenterology, University of Florida/Jacksonville, Jacksonville, FL, USA;; Division of Gastroenterology, National Jewish Health, Denver, CO, USA
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Huang Q, Sun Q, Fan XS, Zhou D, Zou XP. Recent advances in proximal gastric carcinoma. J Dig Dis 2016; 17:421-32. [PMID: 27129018 DOI: 10.1111/1751-2980.12355] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/19/2016] [Accepted: 04/24/2016] [Indexed: 12/11/2022]
Abstract
The American Joint Committee on Cancer (AJCC) staging scheme requires staging proximal gastric carcinoma (PGC) as esophageal adenocarcinoma (EAC), which has been shown to be controversial by recent research results. To update the current research findings on PGC, we systematically reviewed and analyzed the scientific evidence on key arguments related to PGC. The data of high-quality research articles showed that PGC arised in the cardiac mucosa in the proximal stomach within 3 cm below the gastroesophageal junction. Its incidence is rising in East Asian countries, but decreasing in the West, and plateaued at a low level in the United States. PGC is a slowly progressive cancer with unknown independent risk factors and the mechanisms of pathogenesis. This carcinoma exhibits a wide histopathological spectrum and heterogeneous post-resection patient survival characteristics, and cannot be adequately staged for prognotic stratification by the current AJCC staging classification. The results on PGC genomics reveal unique genetic profiles, especially in East Asian populations. In conclusion, mounting evidence defies a simple placement of PGC in a single category of EAC for disease classification; further investigations on the mechanisms of PGC pathogenesis are urgently needed.
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Affiliation(s)
- Qin Huang
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China. .,Department of Pathology and Laboratory Medicine, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA.
| | - Qi Sun
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Xiang Shan Fan
- Department of Pathology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
| | - Dan Zhou
- Department of Pathology and Laboratory Medicine, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, China
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Abstract
PURPOSE OF REVIEW The incidence of esophageal adenocarcinoma and its precursor, Barrett's esophagus, have increased greatly over the past 40 years and continue to rise. This report summarizes the most recent data on the risk factors for Barrett's esophagus and esophageal adenocarcinoma. RECENT FINDINGS Other factors, highly correlated with increasing trends for obesity, are the dominant driver of the increase in incidence of esophageal adenocarcinoma, interacting with gastroesophageal reflux disease symptoms. Abdominal obesity, independently of gastroesophageal reflux disease symptoms, is associated with increased risk of Barrett's esophagus and this association is likely mediated by high levels of leptin and insulin. Use of aspirin, nonsteroidal anti-inflammatory drugs, statins, and proton pump inhibitors are associated with a reduced risk of Barrett's esophagus as well as lower risk of neoplastic progression in patients with Barrett's esophagus. An increasing number of genetic loci have been associated with risk of Barrett's esophagus and esophageal adenocarcinoma. SUMMARY Recent advances in identifying risk factors and reporting of more precise estimates of effect for the main risk factors will positively impact clinical risk stratification efforts for Barrett's esophagus and esophageal adenocarcinoma. Large pooling studies are underway to derive and validate reliable clinical risk models.
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Suna N, Parlak E, Kuzu UB, Yildiz H, Koksal AS, Oztas E, Sirtas Z, Yuksel M, Aydinli O, Bilge Z, Taskiran I, Sasmaz N. The Prevalence of Barrett Esophagus Diagnosed in the Second Endoscopy: A Retrospective, Observational Study at a Tertiary Center. Medicine (Baltimore) 2016; 95:e3313. [PMID: 27057907 PMCID: PMC4998823 DOI: 10.1097/md.0000000000003313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
At present, we do not know the exact prevalence of Barrett esophagus (BE) developing later in patients without BE in their first endoscopic screening. The purpose of this study was to determine the prevalence of BE on the second endoscopic examination of patients who had no BE in their first endoscopic examination.The data of the patients older than 18 years who had undergone upper gastrointestinal system endoscopy more than once at the endoscopy unit of our clinic during the last 6 years were retrospectively analyzed.During the last 6 years, 44,936 patients had undergone at least one endoscopic examination. Among these patients, 2701 patients who had more than one endoscopic screening were included in the study. Of the patients, 1276 (47.3%) were females and 1425 (52.7%) were males, with an average age of 54.9 (18-94) years. BE was diagnosed in 18 (0.66%) of the patients who had no BE in the initial endoscopic examination. The patients with BE had reflux symptoms in their medical history and in both endoscopies, they revealed a higher prevalence of lower esophageal sphincter laxity, hiatal hernia, and reflux esophagitis when compared to patients without BE (P < 0.001).Our study showed that in patients receiving no diagnosis of BE on their first endoscopic examination performed for any reason, the prevalence of BE on their second endoscopy within 6 years was very low (0.66%).
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Affiliation(s)
- Nuretdin Suna
- From the Department of Gastroenterology, the Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara (NS, UBK, HY, EO, ZS, MY, OA, ZB, IT, NS), and Department of Gastroenterology, Sakarya University Medical School, (EP, ASK), Sakarya, Turkey
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21
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Premature Birth and Large for Gestational Age Are Associated with Risk of Barrett's Esophagus in Adults. Dig Dis Sci 2016; 61:1139-47. [PMID: 26611860 PMCID: PMC4791183 DOI: 10.1007/s10620-015-3967-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/08/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND Birth characteristics, including weight and gestational age, may be associated with risk of Barrett's esophagus (BE), the only known precursor for esophageal adenocarcinoma; however, data are limited. AIMS To examine associations between various birth characteristics and BE, and whether these associations are mediated by known risk factors for BE. METHODS Data were obtained from a cross-sectional study among eligible Veterans Affairs patients scheduled for an upper endoscopy, and a sample identified from primary care clinics. Participants underwent an esophagogastroduodenoscopy and completed a survey that captured information on sociodemographic and clinical factors, as well as birth information. We compared 263 patients with histologically confirmed BE to 1416 controls without BE on endoscopy. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using multivariate logistic regression. RESULTS Premature birth was independently associated with risk of BE after adjusted by age, sex, race, and other birth characteristics (OR 3.28, 95 % CI 1.22-8.79). On the other hand, large for gestational age was inversely associated with risk of BE (OR 0.46, 95 % CI 0.21-0.98). These effects were stronger for patients with long-segment BE than with short-segment BE. The associations were not mediated by gastroesophageal reflux disease symptoms, use of proton pump inhibitors, Helicobacter Pylori infection, waist-hip-ratio, height or the presence of hiatus hernia. CONCLUSIONS Premature birth and large for gestational age may be associated with risk of BE in adults. These associations do not appear to be mediated through known risk factors for BE; however, additional studies are required to confirm our findings.
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Thrift AP, El-Serag HB. Sex and Racial Disparity in Incidence of Esophageal Adenocarcinoma: Observations and Explanations. Clin Gastroenterol Hepatol 2016; 14:330-2. [PMID: 26528803 DOI: 10.1016/j.cgh.2015.10.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Aaron P Thrift
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas
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Thrift AP. The epidemic of oesophageal carcinoma: Where are we now? Cancer Epidemiol 2016; 41:88-95. [PMID: 26851752 DOI: 10.1016/j.canep.2016.01.013] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 12/16/2022]
Abstract
Since the early 1970s, the incidence of oesophageal adenocarcinoma has increased dramatically in most Western populations. In contrast, the incidence of oesophageal squamous-cell carcinoma has decreased in these same populations. Epidemiological studies conducted over the past decade have provided great insights into the etiology of oesophageal cancer. These studies have identified gastro-oesophageal reflux disease, obesity and cigarette smoking as risk factors for oesophageal adenocarcinoma, while use of nonsteroidal anti-inflammatory drugs and infection with Helicobacter pylori are associated with reduced risk of oesophageal adenocarcinoma. For oesophageal squamous-cell carcinoma, alcohol and cigarette smoking are the two major risk factors underlying most cases. This review combines a synthesis of these studies with an analysis of data from the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program to discuss the change in incidence of oesophageal cancer and summarize current knowledge of risk factors.
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Affiliation(s)
- Aaron P Thrift
- Department of Medicine and Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
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Yang CS, Chen X, Tu S. Etiology and Prevention of Esophageal Cancer. Gastrointest Tumors 2016; 3:3-16. [PMID: 27722152 DOI: 10.1159/000443155] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 12/07/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Esophageal cancer (EC) occurs commonly, especially in Asia, and is the sixth leading cause of cancer deaths worldwide. Recently, great progress has been made in research on the etiology and prevention of EC. SUMMARY The major risk factors for esophageal squamous cell carcinoma (ESCC) are tobacco smoking and alcohol drinking, which act synergistically. Dietary parameters, including dietary carcinogens and insufficiency of micronutrients, could also be important risk factors in certain areas. A common etiological factor for both EC and some other cancers are low levels of intake of fruits and vegetables. With improvements in diet and drinking water in developing countries, the incidence of ESCC decreased. However, in economically well-developed countries, the incidence of esophageal adenocarcinoma (EAC) has markedly increased in the past 40 years. The major etiological factor for EAC is gastroesophageal reflux, which is also an etiological factor for gastric cardia adenocarcinoma (GCA). In certain areas of China, the occurrence of GCA is closely related to ESCC. Susceptibility genes for EC are starting to be discovered, and this may help to identify high-risk groups that have more need for preventive measures. Mitigation of the risk factors, early detection and treatment of precancerous lesions are effective approaches for prevention. Smoking cessation, avoidance of excessive alcohol, meat and caloric consumption, increasing physical activity and frequent consumption of vegetables and fruits are prudent lifestyle modifications for the prevention of EC as well as other diseases. KEY MESSAGE The etiology of EC includes tobacco smoking, alcohol drinking, low levels of intake of fruits and vegetables as well as gastroesophageal reflux and susceptibility genes. PRACTICAL IMPLICATIONS A healthy lifestyle including smoking cessation, increasing physical activity, consumption of vegetables as well as reduction of alcohol intake and caloric consumption are major approaches to the prevention of EC.
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Affiliation(s)
- Chung S Yang
- Department of Chemical Biology, Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, N.J, USA
| | - Xiaoxin Chen
- Julius L. Chambers Biomedical/Biotechnology Research Institute, North Carolina Central University, Durham, N.C, USA; Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, N.C., USA
| | - Shuiping Tu
- Department of Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
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Venerito M, Vasapolli R, Malfertheiner P. Helicobacter pylori and Gastric Cancer: Timing and Impact of Preventive Measures. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 908:409-18. [PMID: 27573783 DOI: 10.1007/978-3-319-41388-4_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori (H. pylori) is a Gram negative spiraliform bacterium that is commonly found in the stomach. H. pylori infection is still one of the world's most frequent infections, present in the stomachs of approximately one-half of the world's people. H. pylori infection is etiologically linked to histologic chronic active gastritis, peptic ulcer disease, and primary B-cell gastric lymphoma (gastric MALT lymphoma) and represents the major risk factor for the development of sporadic non-cardia gastric cancer (GC) of both intestinal and diffuse type. Studies that have examined the impact of GC prevention through H. pylori eradication have shown mixed results, but recent data suggest that prevention is only efficacious in patients without intestinal metaplasia or dysplasia. This indicates that, like in Barrett's esophagus, we need better clinical risk markers to indicate which patients are at greatest risk of developing cancer to guide clinical strategies. Furthermore, recent epidemiological data have suggested a possible contribution of H. pylori in modifying the risk of developing other gastrointestinal malignancies (including esophageal, pancreatic, hepatocellular, and colorectal cancer), although mechanistically these associations remain unexplained. We review clinically relevant aspects of H. pylori infection in the context of GC development as well as studies that have examined the impact of eradication on GC development and, lastly, discuss these recent epidemiological studies connecting H. pylori infection to extragastric gastrointestinal malignancies.
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Affiliation(s)
- Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, 39120, Germany
| | - Riccardo Vasapolli
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, 39120, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, 39120, Germany.
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Chung CS, Lee YC, Wu MS. Prevention strategies for esophageal cancer: Perspectives of the East vs. West. Best Pract Res Clin Gastroenterol 2015; 29:869-83. [PMID: 26651249 DOI: 10.1016/j.bpg.2015.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023]
Abstract
Esophageal cancer is the eighth most common cancer worldwide. Esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) are the two major phenotypes in Western and Eastern countries, respectively. Because of different pathways in carcinogenesis, the risk factors and effective steps for prevention of esophageal cancer are different between EAC and ESCC. The carcinogenesis of EAC is initiated by the acid exposure of the esophageal mucosa from stomach while that of the ESCC are related to the chronic irritation of carcinogens mainly by the alcohol, cigarette, betel quid, and hot beverage. To eliminate the burden of esophageal cancer on the global health, the effective strategy should be composed of the primary, secondary, and tertiary prevention. In this article, we perform a systematic review of the preventive strategies for esophageal cancer with special emphasis on the differences from the perspectives of Western and Eastern countries.
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Affiliation(s)
- Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Venerito M, Vasapolli R, Rokkas T, Malfertheiner P. Helicobacter pylori and Gastrointestinal Malignancies. Helicobacter 2015; 20 Suppl 1:36-9. [PMID: 26372823 DOI: 10.1111/hel.12255] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Helicobacter pylori infection is the principal trigger of gastric carcinogenesis and gastric cancer (GC) and remains the third leading cause of cancer-related death in both sexes worldwide. In a big Japanese study, the risk of developing GC in patients with peptic ulcer disease who received H. pylori eradication therapy and annual endoscopic surveillance for a mean of 9.9 years was significantly lower after successful eradication therapy compared to the group with persistent infection (0.21%/year and 0.45%/year, respectively, p = .049). According to a recent meta-analysis, H. pylori eradication is insufficient in GC risk reduction in subjects with advanced precancerous conditions (i.e., intestinal metaplasia and dysplasia). A microsimulation model suggested screening smokers over the age of 50 in the U.S. for serum pepsinogens. This would allow to detect advanced gastric atrophy with endoscopic follow-up of subjects testing positive as a cost-effective strategy to reduce GC mortality. In a Taiwanese study, the anti-H. pylori IgG-based test-and-treat program had lower incremental cost-effectiveness ratios than that with (13)C-urea breath test in both sexes to prevent GC whereas expected years of life lost for GC were higher and the incremental cost-effectiveness ratios of test-and-treat programs were more cost-effective in young adults (30-69 years old) than in elders (>70 years old). With respect to gastrointestinal malignancies other than GC, a meta-analysis confirmed the inverse association between H. pylori infection and esophageal adenocarcinoma. In a Finnish study, H. pylori seropositivity was associated with an increased risk of biliary tract cancers (multivariate adjusted OR 2.63; 95% CI: 1.08-6.37), another meta-analysis showed a slightly increased rate of pancreatic cancer in patients with CagA-negative strains (OR: 1.30; 95% CI: 1.02-1.65), whereas current data suggest that the association between H. pylori and colorectal neoplasms may be population dependent.
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Affiliation(s)
- Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Riccardo Vasapolli
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | | | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
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Realdon S, Antonello A, Arcidiacono D, Dassie E, Cavallin F, Fassan M, Nardi MT, Alberti A, Rugge M, Battaglia G. Adherence to WCRF/AICR lifestyle recommendations for cancer prevention and the risk of Barrett's esophagus onset and evolution to esophageal adenocarcinoma: results from a pilot study in a high-risk population. Eur J Nutr 2015; 55:1563-71. [PMID: 26155779 DOI: 10.1007/s00394-015-0975-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/29/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE While adherence to the World Cancer Research Fund (WCRF) guidelines on lifestyle and cancer was recently proven to be associated with an increased risk of esophageal cancer, no investigation has yet been carried out on its role on Barrett's esophagus (BE) development and its progression to esophageal adenocarcinoma (EAC). The primary aim of this study was to evaluate the role of adherence to WCRF lifestyle recommendations in BE onset and progression. The secondary aim was to investigate the association between disease progression and specific aspects of diet and lifestyle. METHODS Established risk factors for BE and EAC development and adherence to WCRF guidelines were assessed in 107 consecutive patients undergoing an upper gastrointestinal endoscopy for symptoms suggesting gastroesophageal reflux (GERD) and a suspected diagnosis of BE/dysplasia on BE. Patients were divided according to histology: those with GERD without metaplasia, with non-dysplastic BE, with low-grade dysplasia, with high-grade dysplasia or with early EAC. The four groups were expressed as an ordered categorical variable of disease progression. An ordered logit model was estimated to identify the independent predictors of disease progression. RESULTS Adherence to WCRF guidelines was identified as independent protective factor (OR 0.51, 95 % CI 0.37-0.67) of disease progression. Disease progression was associated with reduced adherence to guidelines on physical activity (from 48.2 to 5.3 %, p = 0.001), sedentary habits (from 33.3 to 0 %, p = 0.03), fruit consumption (from 37.0 to 5.6 %, p = 0.02) and processed meat consumption (from 51.9 to 10.5 %, p = 0.002). CONCLUSION Adherence to WCRF guidelines has a protective factor in BE onset and its evolution to EAC.
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Affiliation(s)
- Stefano Realdon
- Digestive Endoscopy Unit, Veneto Institute of Oncology IOV - I.R.C.S.S., Via Gattamelata 64, 35128, Padua, Italy.
| | - Alessandro Antonello
- Digestive Endoscopy Unit, Veneto Institute of Oncology IOV - I.R.C.S.S., Via Gattamelata 64, 35128, Padua, Italy
| | - Diletta Arcidiacono
- Venetian Institute for Molecular Medicine, Via Orus 2, 35128, Padua, Italy.,Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Elisa Dassie
- Venetian Institute for Molecular Medicine, Via Orus 2, 35128, Padua, Italy
| | - Francesco Cavallin
- Oncological Surgery Unit, Veneto Institute of Oncology IOV - I.R.C.S.S., Via Gattamelata 64, 35128, Padua, Italy
| | - Matteo Fassan
- Department of Medicine, Surgical Pathology and Cytopathology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Maria Teresa Nardi
- Clinical Nutrition Unit, Veneto Institute of Oncology IOV - I.R.C.S.S., Via Gattamelata 64, 35128, Padua, Italy
| | - Alfredo Alberti
- Venetian Institute for Molecular Medicine, Via Orus 2, 35128, Padua, Italy.,Department of Molecular Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Massimo Rugge
- Department of Medicine, Surgical Pathology and Cytopathology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giorgio Battaglia
- Digestive Endoscopy Unit, Veneto Institute of Oncology IOV - I.R.C.S.S., Via Gattamelata 64, 35128, Padua, Italy
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