Increasing incidence of young-onset esophageal adenocarcinoma compounded by a higher proportion of individuals under age 50 being diagnosed at advanced stages is resulting in poorer disease-free survival and worsening mortality rates than is being seen in older patients, a new Mayo Clinic study shows.
Although young-onset esophageal adenocarcinoma remains uncommon, it may be time to evaluate current diagnostic and management strategies for patients with the disease, noted the study's authors, led by Don C. (Chamil) Codipilly, MD, a gastroenterology fellow at the clinic's main campus in Rochester, Minn.
Esophageal adenocarcinoma is relatively rare in all ages, accounting for about 1 percent of cancer cases in the U.S., with nearly 18,440 cases expected to be diagnosed in the U.S. in 2020, according to the Surveillance, Epidemiology, and End Results (SEER) database. It is an extremely aggressive cancer, however, and has a dismal 5-year survival rate of only 19.9 percent.
Study Details
For the study, which aimed to spot trends in incidence, stage, and survival rates, the Mayo Clinic researchers used the SEER database to identify 34,443 cases of esophageal adenocarcinoma diagnosed between 1975 and 2015, splitting them into three age groups (under 50, 50-69, and 70 and over) while focusing on three specific periods of time, including 1975-89, 1990-99, and 2000-2015. Staging was further stratified as localized, regional, and distant with univariate and multivariate models created to identify predictors of mortality (Cancer Epidemiol Biomarkers Prev 2021; doi:10.1158/1055-9965.EPI-20-0944).
While incidence increased in all age groups, patients under 50 increased 2.9 percent per year for 40 consecutive years. Younger patients also were more likely to be diagnosed at advanced stages of the disease, with 84.9 percent of those under age 50 at regional or distant stages compared with 67.3 percent of those over age 50.
The younger group also had poorer survival outcomes, according to the researchers. For example, during the most recent time period calculated in the study, 2000-2011, patients under 50 had a 5-year disease-free survival rate of 22.9 percent, compared to 29.6 percent for both the 50-69 and >70 age groups.
Much like cases of young-onset colorectal cancer, however, the rarity of young-onset esophageal adenocarcinoma may lead some physicians to attribute symptoms like difficulty swallowing to other causes, creating potentially lethal delays in diagnoses, cautioned Codipilly, who shared additional insights into the Mayo Clinic study with the Oncology Times.
What inspired you to investigate this research question?
"We were concerned by earlier research from our institution demonstrating that young patients had poorer survival compared to older cohorts. However, this was based on a referral population at the Mayo Clinic and we were concerned that perhaps these findings could not be generalized to the whole population. As such, we wanted to assess esophageal cancer outcomes in a broad, nationally representative database."
What were the most important findings in your study?
"The key finding in our study is that young people present disproportionately with late-stage disease compared to older cohorts, resulting in higher cancer-specific mortality. This may be due to multiple factors, including poorer access to health care and less suspicion for cancer as a diagnosis in the young."
Were there any unexpected or surprising results in your study?
"While we suspected the main findings discussed above based on preliminary research, it was surprising the degree to which young patients present with late-stage disease (85% in the younger cohort compared to 67% in the older cohort)."
Is there anything about the results of your study that others might get wrong?
"One thing to keep in mind regarding these results is that we are not minimizing the impact that this disease has on older cohorts, who still have the bulk of the disease and in whom targeted screening is recommended in high-risk populations."
What are the potential clinical implications, if any, of your research?
"Probably the most important implication is that we, as clinicians, should not minimize symptoms in young patients, as it is clear disease outcomes, when diagnosed with esophageal cancer, are poorest in this age group. Further, we may need to adjust our current management of Barrett's esophagus, a pre-cancerous condition, in young people who incidentally have it."
What further research needs to be done on this topic?
"It is important to better understand the underlying pathophysiology of cancer in younger patients. For instance, is there a unique genetic determinant that may portend poorer outcomes in this young cohort of patients?"
Is there anything else about your research study that you would like to add?
"Overall, we feel that this is an important research topic and we would encourage providers and young patients alike to have meaningful conversations regarding esophageal symptoms, so that a team-based approach could be utilized to formulate a plan that is in the patient's best interest."
Chuck Holt is a contributing writer.
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