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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 8-11

Esophageal carcinoma: An epidemiological analysis and study of the time trends over the last 20 years from a single center in India


Department of Radiation Oncology, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission27-Sep-2021
Date of Acceptance29-Sep-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Dr. Shahida Nasreen
Department of Radiation Oncology, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_38_21

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  Abstract 


Aims: Esophageal carcinoma is a common gastrointestinal malignancy. The aim of the study was to evaluate the time trends over 20 years and observe how they differ from the West. Materials and Methods: The study was conducted at SKIMS Regional Cancer Centre in Radiation Oncology Department. This was a retrospective study. Retrospective analysis was carried out from records available at the Regional Cancer Center from 1993 to 2013. The case records of 2090 patients with histological proven squamous and adenocarcinoma (AC) of the esophagus were studied in terms of age, sex, risk factors, and mode of presentation. Results: Data of 2190 patients with esophageal cancer were retrieved. Out of 2190 patients, group A included 1060 and group B had 1130 patients. The mean age at presentation was 59 years in both groups. Five hundred and thirty-eight (56.4%) were male and 477 (43.6%) were females in group A, whereas in group B, 615 were male and 515 were female. Most of the patients presented with dysphagia 2139 (97.67%). In group A, 1030 (97.16%) presented with dysphagia, whereas 1090 (96.46%) presented with dysphagia in group B. Most of the patients had lesion in middle 3rd of esophagus, 849 (80%) in group A whereas 903 (79.9%) in group B. Squamous cell carcinoma (SCC) was the most common histology in both groups, 1010 (95.2%) in group A whereas 1060 (93.8%) in group B. Most common appearance was proliferative (37.7% in group A and 37.6% in group B). Most of the patients were salt tea takers in both groups (98.11% in group A and 97.34% in group B). Conclusion: Our study suggests that esophageal cancer occurs a decade earlier in India. It affects males more than females. SCC is still the most common histological subtype and is way ahead of AC. The mid esophagus is still the most common site. There is no evidence of an increase in the rate of lower esophageal malignancy in our study as opposed to western literature.

Keywords: Epidemiology, esophageal cancer, histology, risk factors, trends


How to cite this article:
Nasreen S, Hussain S, Andleeb A, Manzoor A, Fatima K, Sofi MA. Esophageal carcinoma: An epidemiological analysis and study of the time trends over the last 20 years from a single center in India. J Radiat Cancer Res 2022;13:8-11

How to cite this URL:
Nasreen S, Hussain S, Andleeb A, Manzoor A, Fatima K, Sofi MA. Esophageal carcinoma: An epidemiological analysis and study of the time trends over the last 20 years from a single center in India. J Radiat Cancer Res [serial online] 2022 [cited 2022 May 17];13:8-11. Available from: https://www.journalrcr.org/text.asp?2022/13/1/8/332111




  Introduction Top


Carcinoma esophagus is the eighth most common cancer and the sixth leading cause of death in the world with 80% both in incidence as well as in mortality contributed by developing nations.[1] Unfortunately, overall 5-year survival of EC is poor, which varies from 4% to 40% based on the progression of the disease, with a total 5-year overall survival rate of only 18%.[2] Esophageal carcinoma has a very good prognosis if detected early.[3] Squamous cell carcinoma (SCC) and adenocarcinoma (AC) are the two main histological types of esophageal cancer. About 90% of the esophageal carcinoma in the residents of Asia, Africa, and Eastern European countries is SCC.[4] In the western world, the incidence of SCC has declined whereas AC has increased simultaneously. AC is now the most dominant histological type in the western world.[5] Studies from India show that the proportion of AC varies from 6% to 54% of all esophageal cancers.[6],[7],[8],[9] Some studies identify the upper third, whereas others, the middle third as the most common site for SCC.[10] In India, as per WHO, GLOBOCAN 2018, esophageal cancer is the 6th most common cancer with incidence of 5.04%. It is 5th most common cancer in males and 6th most common cancer in females.[11]

We present the epidemiology of carcinoma esophagus and the time trends in the location and the histology over a period of 20 years from a single radiation oncology department of a tertiary care hospital in Northern India.


  Materials and Methods Top


The study was conducted at SKIMS Regional Cancer Centre in Radiation Oncology Department. This was a retrospective study. Retrospective analysis was carried out from records available at the Regional Cancer Centre from 1993 to 2013.

The case records of 2090 patients with histologically proven squamous and AC of the esophagus were studied in terms of age, sex, risk factors, and mode of presentation. Mean and standard deviation were calculated for quantitative data. Ratio was calculated for qualitative data. A Chi-square test was used to assess the trend in the location, gender, and the histologic type of the tumor. P < 0.05 was considered significant. For time trend evaluation, the study period was divided into two time frames of 10 years each, namely, 1993–2003 (Group A) and 2004–2013 (Group B). The patient distribution was studied in the two time frames according to the histology, site, and gender.


  Results Top


Data of 2190 patients with esophageal cancer were retrieved. The results of all 2190 patients are described below. Out of 2190 patients, group A included 1060 and group B had 1130 patients.

Demographics

Total of 2190 case records were analyzed. Mean age at presentation was 59 years in both groups. Five hundred and thirty-eight (50.75%) were male and 522 (49.24%) were female in group A, whereas in group B, 615 (54.42%) were male and 515 (45.57%) were female [Table 1]. The difference was not statistically significant (P = 0.868).
Table 1: Gender wise distribution in the study period

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Symptoms and signs

Most of the patients presented with dysphagia 2139 (97.67%). In group A, 1030 (97.16%) presented with dysphagia, whereas 1090 (96.46%) presented with dysphagia in group B. The distribution of grades of dysphagia in both groups is shown in [Table 2]. Eighty (7.5%) presented with epigastric pain in group A whereas 91 (8%) in group B, 10 (0.94%) presented with hematemesis in group A whereas 9 (079%) in group B, 12 (1.1%) presented with other symptoms in group A whereas 13 (1.2%) in group B [Table 3]. Most of the patients reported within 3 months of symptoms in both groups.
Table 2: Dysphasia as presenting symptom in both groups with grades

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Table 3: Other presenting symptoms in both groups

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Location

Most of the patients had lesion in middle 3rd of esophagus, 849 (80%) in group A whereas 903 (79.9%) in group B, followed by lower 3rd 151 (14.2%) in group A whereas 168 (4.8%) in group B, followed by upper 3rd 60 (5.6%) in group A whereas 59 (5.2%) in group B, respectively [Table 4].
Table 4: Location wise distribution of malignancy in both groups

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Histology

SCC was the most common histology in both groups, 1010 (95.2%) in group A whereas 1060 (93.8%) in group B, followed by AC 50 (4.7%) in group A and 70 (6.1%) in group B. Most of the AC cases were located in lower 3rd of esophagus, 99 (99%) followed by middle 3rd, and 1 (10%) in both groups [Table 5].
Table 5: Histology in both groups

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Endoscopic appearance

Most common appearance was proliferative (37.7% in group A and 37.6% in group B). Infiltrative lesions were seen in 220 (20.75%) in group A and 221 (19.55%) in group B. Ulceroinfiltrative lesions were seen in 60 (5.6%) in group A and 60 (5.3%) in group B of patients. Ulceroproliferative lesions were seen in 150 (15%) in group A and 170 (15%) in group B of patients. Stenosing lesions were seen in 70 (6.6%) of patients in group A and 89 (7.8%) in group B of patients. [Table 6] depicts the endoscopic appearance in both groups.
Table 6: Morphological appearance on EGD in both groups

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Risk factors

History of smoking was present in 487 (46.75%) in group A and 540 (47.78%) in group B. Seven (0.6%) had history of alcohol intake in group A and 11 (0.9) in group B. Most of the patients were salt tea takers in both the groups (98.11% in group A and 97.34% in group B) [Table 7].
Table 7: Risk factor distribution in both groups

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  Discussion Top


Carcinoma esophagus has poor prognosis and patients usually present with locally advanced or metastatic disease. Prevention is the best method to adopt to prevent this dreaded mostly incurable disease. Prevention is possible only by public awareness regarding healthy lifestyles and avoidance of addiction. Incidence of carcinoma esophagus is very high in Kashmir part of India so statewide campaign is required to generate public awareness about this dreaded disease along with identifying the high-risk population.

Dysphagia is one of the earliest and predominant presenting symptoms of EC.[12] Most of our patients in both groups presented with dysphagia (97.16% in group A and 96.46% in group B).

SCC is the most prevalent esophageal cancer worldwide, but in developed countries, AC predominates.[13] A drop of 30% in incidence of SCC is observed in the USA between 1973 and 2002, while there is four-fold increase in AC over the same period.[13] As per our study, SCC is the most common histology with 95.2% compared to 4.7% AC in group A and 93.8% and 6.1% in group B, respectively. This result is similar to other studies from India, which show SCC predominance. The high percentage distribution of SCC over AC suggests that it is unlikely that AC would surpass SCC soon, at least in our part of the world. The presence of risk factors such as smoking, tobacco consumption, and dietary deficiencies is some of the possible reasons for such high rates of SCC. Tobacco use is a well-known risk factor for both SCC as well as adenocarcinoma of esophagus.[14],[15],[16] In our study, 487 (45.94%) in group A and 540 (47.78%) in group B were smokers.

Most of our patients has been taking very hot beverages (salt tea, 1040 [98.11%] in group A and 1100 [97.34%] in group B) and intake of hot beverage over a period of time causes thermal injury and is known risk factor for carcinoma esophagus.[17]

The appearance of lesions during endoscopy has been reported to be helpful in assessing the likelihood of lymph node metastasis. In particular, flat lesions are said to metastasize less likely to a lymph node than a depressed or elevated lesion.[18] Most common endoscopic appearance of lesions in our study was proliferative in both groups.

Mean age in our study group was 58 years in both groups which is almost similar to other studies from India[19] but it is one decade early as compared to some of the western data.[20] The mean age in India as per recent data is 51.7 years.[19] The male-to-female ratio in our study was 1.12:1 in group A and 1.19:1 in group B which is similar to Indian data from all major cancer registries with a national average of 1.2:1.[19] The WHO data suggests carcinoma esophagus is two to three times more common in males as compared to females (male-to-female ratio 2.4). Similarly, one recent study from Africa has shown male predominance.[21] High consumption of tobacco in any form in Indian females may be responsible for this. Most common location in our study was mid esophagus (80% vs. 79.9%), followed by lower thoracic (14.2% vs. 14.8%), followed by upper esophagus (5.6% vs. 5.2%). This finding is similar to the rest of India where the most common location is mid esophagus.[19] However, unlike western studies, our study did not show increase trend in the occurrence of lower esophageal malignancy, or increase in the rates of AC in lower esophagus.


  Conclusion Top


Our study suggests that esophageal cancer occurs a decade earlier in India. It affects males more than females. SCC is still the most common histological subtype and is way ahead of AC. The mid esophagus is still the most common site. There is no evidence of an increase in the rate of lower esophageal malignancy in our study as opposed to western literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Martin RE, Letsos P, Taves DH, Inculet RI, Johnston H, Preiksaitis HG. Oropharyngeal dysphagia in esophageal cancer before and after transhiatal esophagectomy. Dysphagia 2001;16:23-31.  Back to cited text no. 12
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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