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Sixty million people have gastroesophageal reflux disease // A fraction develop Barrett’s esophagus // And a fraction of those contract cancer // But why are those fractions getting bigger?

More Questions than Answers

By Anita Slomski // Portraits by Mackenzie Stroh // Spring 2007
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Esophageal adenocarcinoma

Custom Medical Stock Photography

A rarity two decades ago, this esophageal adenocarcinoma cell is now showing up with alarming frequency.

When David Kelsen embarked on a search in the late 1970s for potent chemotherapy drugs to fight cancers of the esophagus, everyone in his research trial had squamous cell carcinoma, caused principally by smoking and alcohol abuse. Ten years later, Kelsen, chief of gastrointestinal oncology at Memorial Sloan-Kettering Cancer Center in New York City, was the lead investigator of a national trial designed to compare the effectiveness of surgery alone to chemotherapy followed by surgery. This time, though, many patients screened for the study had adenocarcinoma, an unusual cell type for a tumor at the junction of the esophagus and stomach. What’s more, most appeared to be otherwise quite healthy. “It was striking people who didn’t smoke, didn’t drink and exercised like crazy—very healthy guys in the prime of life,” says Kelsen.

The rapid proliferation of esophageal adenocarcinoma has continued, its rate of occurrence in the U.S. population growing faster than the rate for any other cancer. During the past 30 years, the number of new cases annually has skyrocketed more than 300%, and among white men, once only rarely diagnosed with the disease, the increase is almost 600%. “That kind of growth is unprecedented,” says Thomas Vaughan, head of epidemiology at the Fred Hutchinson Cancer Research Center in Seattle. Meanwhile, the once predominant type of esophagus cancer—squamous cell carcinoma—has been steadily dropping 3% to 4% each year as smoking and alcohol abuse also decline.

Even now, esophageal adenocarcinoma has hardly reached epidemic proportions. There were 14,520 new cases of esophagus cancer diagnosed in 2005 in the United States, 60% of which were esophageal adenocarcinoma. Those numbers pale in comparison to the incidence of other cancers among Americans that year—145,290 new cases of colorectal cancer, 172,570 of lung cancer and 211,240 of breast cancer. “But if you extend the growth curve of esophageal adenocarcinoma over the next 10 years, the numbers get pretty big,” Vaughan says.

Although white men have become the primary target of this disease (82% of all cases now involve Caucasian males), increasing numbers of black men and white women are also developing the tumor. “At the Cleveland Clinic, one in four of those with esophageal adenocarcinoma is a woman, and the disease is now affecting men younger than 50,” says Gary Falk, professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. And though the numbers remain small, this is a cancer you really don’t want to have. The average five-year survival rate is a grim 13%, and most patients die within a year of being diagnosed. But if the cancer is caught very early, the five-year survival rate jumps to 70%.

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1. “Epidemiology and Pathogenesis of Esophageal Cancer,” by Rebecca S. Holmes and Thomas L. Vaughan, Seminars in Radiation Oncology, January 2007. A comprehensive discussion of the risk factors for esophageal adenocarcinoma, the theories that may explain why the incidence of this cancer is skyrocketing, and possible steps to reverse the trend.

2. “Gastroesophageal Reflux, Barrett Esophagus, and Esophageal Cancer: Scientific Review,” by Nicholas Shaheen and David Ransohoff, JAMA, April 17, 2002. An excellent overview of what we know about the association between GERD and esophageal cancer; argues against routine screening of individuals with reflux disease.

3. “Diet, Obesity and Reflux in the Etiology of Adenocarcinomas of the Esophagus and Gastric Cardia in Humans,” by Susan T. Mayne and Stephanie A. Navarro, The Journal of Nutrition, November 2002. Research presented at a symposium on food, nutrition and cancer held by the American Institute for Cancer Research and the World Cancer Research Fund International that explores how diet, obesity and GERD may interact to cause cancer.

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