Risk and Protective Factors

Epidemiologic and clinical research has revealed many risk factors which, taken together, can help estimate a person’s probability of developing esophageal adenocarcinoma (EAC). These include:

  • demographic factors,
  • host and lifestyle factors,
  • medications,
  • family history, and
  • genetic markers.

In the general population, symptomatic gastroesophageal reflux (sGERD), obesity, cigarette smoking, and family history of BE or EAC are the major factors associated with increased risk.1–6 Conversely, physical activity, use of non-steroidal anti-inflammatory drugs (NSAIDs) and statin drugs have been associated with decreased risk in observational studies and randomized clinical trials.7–11Many of these factors are thought to affect EAC risk through the exacerbation (or reduction) in inflammation (figure 1.)

Figure 1. Inflammation likely plays an important role in development of EAC.1

It is important to note that while the observational studies are generally very consistent in finding the above associations, they are not necessarily causal, and no randomized clinical trials have examined the extent to which behavioral change (e.g., losing weight, quitting smoking) actually affects risk of esophageal adenocarcinoma. In contrast, a number of clinical trials have reported on reduced risk associated with statin use, although esophageal cancer was not the primary endpoint. A recent trial11 of use of aspirin and/or a proton pump inhibitor did find a suggestion (not quite statistically significant) that aspirin might be effective, especially along with proton pump inhibitors; this finding is supported by a number of observational studies.

Regarding other potential risk factors, a strong body of epidemiologic evidence suggests that infection with Helicobacter pylori is associated with an approximately 50% decreased risk of EAC,12although the mechanism(s) remain unclear. Similarly, there is some evidence from observational studies that diet, in particular higher intake of fat and lower intake of fruits and vegetables, is associated with increased EAC risk.13. Finally, while almost two dozen genetic loci have been identified as associated with EAC risk,15 as a whole, their added discriminatory ability is still rather modest, especially compared to family history.16,17

References:

1.            Reid BJ, Li X, Galipeau PC,  et al. Barrett’s oesophagus and oesophageal adenocarcinoma: time for a  new synthesis. Nat Rev Cancer 2010;10:87–101.

2.            Cook MB, Corley DA, Murray LJ, et al. Gastroesophageal Reflux in Relation to Adenocarcinomas of the Esophagus: A Pooled Analysis from the Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON). PLoS ONE 2014;9:e103508.

3.            Hoyo C, Cook MB, Kamangar F, et al. Body mass index in relation to oesophageal and oesophagogastric junction adenocarcinomas: a pooled analysis from the International BEACON Consortium. Int J Epidemiol 2012;41:1706–18.

4.            Cook MB, Kamangar F, Whiteman DC, et al. Cigarette smoking and adenocarcinomas of the esophagus and esophagogastric junction: a pooled analysis from the international BEACON consortium. J Natl Cancer Inst 2010;102:1344–53.

5.            Sun X, Elston RC, Barnholtz-Sloan JS, et al. Predicting Barrett’s Esophagus in Families: An Esophagus Translational Research Network (BETRNet) Model Fitting Clinical Data to a Familial Paradigm. Cancer Epidemiol Biomarkers Prev 2016;25:727–735.

6.            Xie S-H, Lagergren J. Risk factors for oesophageal cancer. Best Pract Res Clin Gastroenterol 2018. Available at: http://www.sciencedirect.com/science/article/pii/S1521691818300933 [Accessed December 2, 2018].

7.            Thomas T, Loke Y, Beales ILP. Systematic Review and Meta-analysis: Use of Statins Is Associated with a Reduced Incidence of Oesophageal Adenocarcinoma. J Gastrointest Cancer 2017.

8.            Liao LM, Vaughan TL, Corley D a, et al. Nonsteroidal anti-inflammatory drug use reduces risk of adenocarcinomas of the esophagus and esophagogastric junction in a pooled analysis. Gastroenterology 2012;142:442–452.e5; quiz e22–3.

9.            Moore SC, Lee I, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med 2016;176:816–825.

10.          Rothwell PM, Fowkes FGR, Belch JFF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet 2011;377:31–41.

11.          Jankowski JAZ, Caestecker J de, Love SB, et al. Esomeprazole and aspirin in Barrett’s oesophagus (AspECT): a randomised factorial trial. Lancet Lond Engl 2018;392:400–408.

12.          Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res (Phila Pa) 2008;1:329–338.

13.          Abnet CC, Corley DA, Freedman ND, et al. Diet and Upper Gastrointestinal Malignancies. Gastroenterology 2015;148:1234-1243.e4.

14.          O’Doherty MG, Cantwell MM, Murray LJ, et al. Dietary fat and meat intakes and risk of reflux esophagitis, Barrett’s esophagus and esophageal adenocarcinoma. Int J Cancer 2011;129:1493–1502.

15.          Contino G, Vaughan TL, Whiteman D, et al. The evolving genomic landscape of Barrett’s esophagus and esophageal adenocarcinoma. Gastroenterology 2017.

16.          Dong J, Buas MF, Gharahkhani P, et al. Determining Risk of Barrett’s Esophagus and Esophageal Adenocarcinoma Based on Epidemiologic Factors and Genetic Variants. Gastroenterology 2018;154:1273-1281.e3.

17.          Kunzmann AT, Canadas Garre M, Thrift AP, et al. Information on Genetic Variants Does Not Increase Identification of Individuals at Risk of Esophageal Adenocarcinoma Compared to Clinical Risk Factors. Gastroenterology 2018.