Surveillance & Risk Assessment, Centre for Chronic Disease Prevention and Control, Population and Public Health Branch, Health Canada, Tunney's Pasture AL0601C1, Ottawa, Ontario K1A 0L2, Canada. Yang_Mao@hc-sc.gc.ca
This study assessed the influence of active and passive smoking on the risk of stomach cancer by subsite. Mailed questionnaires were used to obtain information on 1171 newly diagnosed histologically confirmed stomach cancer cases and 2207 population controls between 1994 and 1997 in eight Canadian provinces. Data were collected on socio-economic status, lifestyle and passive smoking status. Odds ratios (OR) and 95% confidence intervals (95% CI) were derived by logistic regression. Compared with those who had never smoked, there was strongly increased risk for ex- and current smokers among subjects with cardial stomach cancer. For men with cardial cancer, the adjusted ORs were 1.9 (95% CI 1.2-3.0) and 2.6 (95% CI 1.6-4.3) for ex-smokers and current smokers, respectively, with a similar pattern among women. Among men, the adjusted ORs were lower for subsites of stomach cancer other than cardia. These findings suggest that active and passive smoking may play an important role in the development of cardial stomach cancer.
One hundred twenty-nine adenocarcinomas involving the esophagus and/or gastric cardia differed significantly from 212 cancers of the rest of the stomach as follows: male-female ratio, 6:1 versus 2:1, birth outside Canada, US or UK, 12% versus 34%; parent or sibling with gastric cancer, 5% versus 13%; previous duodenal ulcer, 23% versus 9%; chronic reflux symptoms, 25% versus 3%; hiatal hernia, 51% versus 11%. Of the 129 esophagocardia cancers, 24 involved the esophagus alone, 48 the cardia and esophagus, 33 the cardia alone or cardia and fundus, and 24 the upper stomach and lower esophagus extensively. Thirty-four were associated with Barrett's esophagus. The 72 patients with involvement of both the upper stomach and lower esophagus (48 cardia and esophagus, 24 extensive) were identical with the esophagocardia group as a whole. The 24 patients with esophageal cancer and the 34 with Barrett's epithelium were the same clinically as the whole esophagocardia group except more had chronic reflux and hiatal hernia. The 33 patients with cancer confined to the cardia or cardia and fundus resembled the whole esophagocardia group but did not have Barrett's esophagus. Adenocarcinoma of the esophagocardia region is probably a different disease from cancer of the rest of the stomach.
One hundred and ninety-five patients operated on for adenocarcinoma of the gastric cardia during the years 1961-90 were analysed and the present data indicate that the more enthusiastic attitude adopted towards resective surgery led to a significant increase in operative explorations performed and in resectability rate, from 50% (44/88) and 35% (28/88) during the years 1961-75 to 84% (90/107) and 56% (60/107) during the years 1976-90, respectively. The difference between radical resections, 54% (15/28) and 67% (34/60), remained non-significant. The overall postoperative mortality and morbidity after resective surgery were 14% and 35% and these rates did not rise with time. The anastomotic leakage rate was 15%. Anastomotic leakage was, in fact, not only the most common postoperative complication but also the most common cause of death. Overall cumulative survivals at 1, 3 and 5 years were 47%, 11% and 5%. Comparison of the cumulative survival rates between the 15-year periods indicated that there were no differences in overall survival or in survival after resective surgery. We regard these results disappointing, because over half of the patients died in 1 year and because the long-term survival remained dismal.
BACKGROUND: The reasons for the increasing incidence of and strong male predominance in patients with oesophageal and cardia adenocarcinoma remain unclear. The authors hypothesised that airborne occupational exposures in male dominated industries might contribute. METHODS: In a nationwide Swedish population based case control study, 189 and 262 cases of oesophageal and cardia adenocarcinoma respectively, 167 cases of oesophageal squamous cell carcinoma, and 820 frequency matched controls underwent personal interviews. Based on each study participant's lifetime occupational history the authors assessed cumulative airborne occupational exposure for 10 agents, analysed individually and combined, by a deterministic additive model including probability, frequency, and intensity. Furthermore, occupations and industries of longest duration were analysed. Relative risks were estimated by odds ratios (OR), with 95% confidence intervals (CI), using conditional logistic regression, adjusted for potential confounders. RESULTS: Tendencies of positive associations were found between high exposure to pesticides and risk of oesophageal (OR 2.3 (95% CI 0.9 to 5.7)) and cardia adenocarcinoma (OR 2.1 (95% CI 1.0 to 4.6)). Among workers highly exposed to particular agents, a tendency of an increased risk of oesophageal squamous cell carcinoma was found. There was a twofold increased risk of oesophageal squamous cell carcinoma among concrete and construction workers (OR 2.2 (95% CI 1.1 to 4.2)) and a nearly fourfold increased risk of cardia adenocarcinoma among workers within the motor vehicle industry (OR 3.9 (95% CI 1.5 to 10.4)). An increased risk of oesophageal squamous cell carcinoma (OR 3.9 (95% CI 1.2 to 12.5)), and a tendency of an increased risk of cardia adenocarcinoma (OR 2.8 (95% CI 0.9 to 8.5)), were identified among hotel and restaurant workers. CONCLUSIONS: Specific airborne occupational exposures do not seem to be of major importance in the aetiology of oesophageal or cardia adenocarcinoma and are unlikely to contribute to the increasing incidence or the male predominance.
To examine the risk of gastric cancer associated with alcohol consumption and smoking in men and women in Moscow, Russia.
A case-control study which includes 448 cases and 610 controls was conducted. Cases consisted of patients with newly diagnosed histologically confirmed gastric cancer. Controls were patients admitted during the study period to the hospital with diagnoses other than cancer and/or gastrointestinal diseases. Information on demographic variables, smoking, alcohol consumption and diet was collected from all subjects. Venous blood was drawn from 361 cases and 441 controls. A serological test for Helicobacter pylori immunoglobulin G was performed.
Alcohol consumption, particularly vodka consumption, was found to increase the risk of gastric cancer. In men the effect of hard liquor drinking was stronger for cancer of the cardia (OR = 3.4, CI = 1.2-10.2), while in women the effect was stronger for cancer of sites other than gastric cardia (OR = 1.5, CI = 1.0-2.3). Smoking increased the risk of developing gastric cancer in men, but not in women. In men a dose-response relationship between mean number of cigarettes smoked per day (p = 0.03), pack-years of cigarettes smoked (p = 0.01) and duration of smoking (p = 0.08) and the risk of cancer of gastric cardia was observed. Further statistical analysis revealed interactions between effect of smoking and alcohol consumption and between smoking and H. pylori infection status.
The findings further support the role of alcohol consumption and smoking in the etiology of gastric cancer.
Antioxidant vitamins have attracted considerable attention in previous studies of esophageal squamous-cell carcinoma, but dietary studies of adenocarcinoma of the esophagus and gastric cardia remain sparse. Treating these tumors as distinct diseases, we studied intakes of vitamin C, beta-carotene and alpha-tocopherol in a nationwide population-based case-control study in Sweden, with 185, 165, and 258 cases of esophageal adenocarcinoma, esophageal squamous-cell carcinoma, and gastric cardia adenocarcinoma, respectively, and 815 controls. Subjects with a high parallel intake of vitamin C, beta-carotene, and alpha-tocopherol showed a 40-50% decreased risk of both histological types of esophageal cancer compared with subjects with a low parallel intake. Antioxidant intake was not associated with the risk of gastric cardia adenocarcinoma. Separately, vitamin C and beta-carotene reduced the risk of esophageal cancers more than alpha-tocopherol. We found that antioxidant intake is associated with similar risk reductions for both main histological types of esophageal cancer. Our findings indicate that antioxidants do not explain the diverging incidence rates of the 2 histological types of esophageal cancer. Moreover, our data suggest that inverse associations with esophageal squamous-cell carcinoma and adenocarcinoma may be stronger among subjects under presumed higher oxidative stress due to smoking or gastroesophageal reflux, respectively. Our results may be relevant for the implementation of focused, cost-effective preventive measures.
A case-control study of stomach cancer which includes 448 cases and 610 hospital controls has been conducted in Moscow, Russia. Information on life-style habits, such as smoking, alcohol consumption, diet, medical history and use of different medications including aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) was collected using a self-administered structured questionnaire. Venous blood was drawn from 361 cases and 441 controls. A serological test for Helicobacter pylori immunoglobulin G was performed to detect infected individuals. Use of aspirin and other NSAIDs was associated with protection against cancer of the stomach (OR = 0.60, 95% CI 0.41-0.90). Analysis by subsite revealed that aspirin did not affect the risk of cancer of the gastric cardia but had a protective effect for non-cardia gastric cancer. The OR associated with use of aspirin adjusted for age and education for both sexes combined was 0.49 (95% CI 0.31-0.77). A decrease in relative risk was statistically significant for men (OR = 0.48, 95% CI 0.25-0.92) and women (OR = 0.52, 95% CI 0.28-0.97). Controlling for major risk factors did not attenuate the reduction in risk. The observed associations were also present in individuals who were H. pylori immunoglobulin G-positive. There was no reduction in risk associated with aspirin and/or non-aspirin NSAIDs among non-infected subjects.
BACKGROUND: The incidence of esophageal and gastric cardia adenocarcinoma is, for unknown reasons, increasing dramatically. A weak and inconsistent association between body mass index (BMI) and adenocarcinoma of the esophagus and gastric cardia has been reported. OBJECTIVE: To reexamine the association between BMI and development of adenocarcinoma of the esophagus and gastric cardia. DESIGN: Nationwide, population-based case-control study. SETTING: Sweden, 1995 through 1997. PATIENTS: Patients younger than 80 years of age who had recently received a diagnosis were eligible. Comprehensive organization ensured rapid case ascertainment. Controls were randomly selected from the continuously updated population register. Interviews were conducted with 189 patients with adenocarcinoma of the esophagus and 262 patients with adenocarcinoma of the gastric cardia; for comparison, 167 patients with incident esophageal squamous-cell carcinoma and 820 controls were also interviewed. MEASUREMENTS: Odds ratios were determined from BMI and cancer case-control status. Odds ratios estimated the relative risk for the two adenocarcinomas studied and were calculated by multivariate logistic regression with adjustment for potential confounding factors. RESULTS: A strong dose-dependent relation existed between BMI and esophageal adenocarcinoma. The adjusted odds ratio was 7.6 (95% CI, 3.8 to 15.2) among persons in the highest BMI quartile compared with persons in the lowest. Obese persons (persons with a BMI > 30 kg/m2) had an odds ratio of 16.2 (CI, 6.3 to 41.4) compared with the leanest persons (persons with a BMI
BACKGROUND: The incidence of esophageal adenocarcinoma is increasing rapidly. Gastroesophageal reflux is a strong risk factor for this disease. The increase in incidence of esophageal adenocarcinoma coincided with the introduction of medications that promote reflux by relaxing the lower esophageal sphincter (LES), such as nitroglycerin, anticholinergics, beta-adrenergic agonists, aminophyllines, and benzodiazepines. OBJECTIVE: To test the possible association between use of LES-relaxing medications and risk for adenocarcinoma of the esophagus and gastric cardia. DESIGN: A nationwide population-based case-control study with in-person interviews. SETTING: Sweden, 1995 through 1997. PATIENTS: 189 patients with newly diagnosed esophageal adenocarcinoma, 262 with adenocarcinoma of the gastric cardia, and 167 with esophageal squamous-cell carcinoma were compared with 820 population-based controls. MEASUREMENTS: Estimated incidence rate ratios, calculated by using multivariate logistic regression from case-control data with adjustment for potential confounding. RESULTS: Past use of LES-relaxing drugs was positively associated with risk for esophageal adenocarcinoma. Among daily, long-term users (>5 years) of LES-relaxing drugs, the estimated incidence rate ratio was 3.8 (95% CI, 2.2 to 6.4) compared with persons who had never used these drugs. Drugs of all classes contributed to the increased risk, but the association was particularly strong for anticholinergics. Short-term use of other types of LES-relaxing drugs did not seem to be strongly associated with risk. The association almost disappeared after adjustment for reflux symptoms, indicating that promotion of reflux is the link between use of LES-relaxing drugs and esophageal adenocarcinoma. If 15,490 men in any age group take LES-relaxing drugs daily for 5 years, 1 additional case of adenocarcinoma would be expected (number needed to treat for harm); in men older than 60 years of age, the number needed to treat for harm is 5,570. Assuming a causal relation, about 10% of the esophageal adenocarcinomas occurring in the population may be attributable to intake of LES-relaxing drugs. Cardia adenocarcinoma and esophageal squamous-cell carcinoma were not associated with use of LES-relaxing drugs. CONCLUSIONS: The widespread use of LES-relaxing drugs may have contributed to the increasing incidence of esophageal adenocarcinoma.
Comment In: Ann Intern Med. 2000 Aug 1;133(3):227-910906839
INTRODUCTION: The incidence of adenocarcinoma in esophagus and cardia has been reported as increasing in a number of countries over recent decades. We examined if a similar increase has occurred in Denmark. The study evaluates the incidence trends for esophagus- and stomach cancer in the period 1943-2003 with focus on changes since 1978. MATERIALS AND METHODS: All data were retrieved from the Danish Cancer Register, which contains information on cancer cases in Denmark since 1943, including detailed information about histology since 1978. Age-standardized incidence rates were calculated based on the age distribution in the World Standard Population (WSP) and the Danish population in 2000 (DK-2000). RESULTS: The age-standardized (DK-2000) incidence rates for esophagus cancer in Denmark were stable in the period 1943-1977, but then increased from 3.7 per 100,000 in the period 1978-1982 to 6.8 per 100,000 in the period 1998-2003. The corresponding incidence rate for stomach cancer decreased over the entire study period from 21.9 per 100,000 in 1943-1947 to 9.7 per 100,000 in 1998-2003. The increased incidence of esophagus cancer in the period from 1978 was mainly due to an increase in the incidence of adenocarcinomas, particularly among men. During the period 1978-2003 we observed a marked decrease in the incidence of adenocarcinoma in the distal stomach, whereas the incidence of adenocarcinoma in the cardia was constant in this period. CONCLUSION: The incidence of esophageal adenocarcinoma has increased during the past 25 years in Denmark, whereas the incidence of adenocarcinoma in the cardia has remained constant.