Trends in esophageal cancer incidence by histology, United States, 1998–2003
Katrina F. Trivers*, Susan A. Sabatino and Sherri L. Stewart
Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta, GA
Esophageal adenocarcinoma rates may be increasing, whereas,
squamous cell carcinoma rates appear to be decreasing in the
United States. Previous population-based research on esophageal
cancer has only covered up to 68% of the country. Additional,
updated research on a larger percentage of the country is needed
to describe racial, ethnic and regional trends in histologic subtypes
of esophageal cancer. Invasive esophageal cancer cases diagnosed
between 1998 and 2003 (n 5 65,926), collected by the National
Program of Cancer Registries or the Surveillance, Epidemiology,
and End Results program, were included. These data cover 83%
of the US population. Esophageal squamous cell carcinoma inci-
dence fell by 3.6%/year, whereas esophageal adenocarcinoma
increased by 2.1%/year. Squamous cell carcinoma rates decreased
among both sexes in most racial or ethnic groups, whereas adeno-
carcinoma rates increased primarily among white or non-His-
panic men. Except for white or non-Hispanic men, squamous cell
carcinoma rates were similar to, or greater than, adenocarcinoma
rates for men and women of all other races and ethnicities. The
largest decrease in squamous cell carcinoma rates occurred in the
West census region, which also exhibited no increase in adenocar-
cinoma rates. The rate of regional and distant-staged adenocarci-
nomas increased, while rates for local-staged adenocarcinoma
remained stable. This is the first article to characterize esophageal
cancer trends using data covering the majority of the US. Substan-
tial racial, ethnic and regional variation in esophageal cancer is
present in the US. Our work may inform interventions related to
tobacco and alcohol use, and overweight/obesity prevention, and
provide avenues for further research.
Published 2008 Wiley-Liss, Inc. This article is a US Government work
and, as such, is in the public domain in the United States of America.
Key words: esophageal neoplasms; epidemiology; United States
Little is known about the incidence of histologic subtypes of
esophageal cancer at the national level. Esophageal cancer is rela-
tively rare in the United States with 15,560 cases and 13,940
deaths expected to have occurred in 2007.1However, rates of
esophageal adenocarcinoma increased dramatically between the
1970s and 1990s, particularly among white men, with a reported
rate of increase (>350%) greater than for any other cancer.2,3
Racial and ethnic,2–11and geographic12differences in incidence
have been observed, as well as differences by tumor stage.8,13
Nonetheless, few reports on esophageal cancer have included
recent incidence and trend data2–13; no reports have published
race- and sex-specific esophageal cancer trend estimates using
data since 1998. Continued updates on esophageal cancer rates
and trends at the national level are warranted given associations
between esophageal adenocarcinoma and elevated body mass
index14and gastroesophageal reflux disease,15both of which have
increased over the past few decades.16,17Furthermore, previous
studies2–13have only captured up to 68% of the population with
limited geographic diversity, limiting the ability to monitor
national and regional trends in esophageal cancer incidence. In
datasets with greater population coverage, such as the National
Program of Cancer Registries (NPCR), evidence suggests that
rates for tobacco-related cancers, including esophageal cancer, are
higher than in the Surveillance, Epidemiology and End Results
(SEER) program,18possibly due to the inclusion of states with
higher tobacco use in the former. Therefore, further research with
such an expanded dataset covering a greater proportion of the US
will allow for a more complete characterization of esophageal can-
cer incidence in the US, as was recently reported for Europe.19
The greater number of cases will also enable examination of
rates and trends among smaller racial and ethnic groups, such as
American Indian/Alaskan Natives (AI/AN) and Asian and Pacific
Islanders (API) that have not been adequately studied.
The aim of our study was to fully characterize the incidence and
trends of histologic subtypes of esophageal cancer by race, ethnic-
ity, sex, geographic region and tumor characteristics (e.g., stage,
grade) in the United States between 1998 and 2003. To date, this is
the largest population-based nationwide study of esophageal cancer,
based on data used to publish official national cancer statistics. Data
in this analysis included >65,000 cases of esophageal cancer and
covered 83% of the US population for these years. Whether rates of
esophageal adenocarcinoma have continued to increase and what
groups are disproportionately affected remain an important public
health concern and may inform appropriate interventions.
Material and Methods
This report is comprised of data on newly diagnosed primary
esophageal cancers from population-based statewide cancer regis-
tries participating in the Centers for Disease Control and Preven-
tion’s NPCR and/or the National Cancer Institute’s SEER pro-
gram.20,21These are the 2 major sources of cancer surveillance data
in the US and in combination are used to publish official national
cancer statistics. Both sources use uniform methodologies for data
collection and reporting. Only data from statewide registries that
met strict high-quality standards22for all years (1998–2003) are
included in this report. High-quality standards for all cancer sites
combined included ?90% complete case ascertainment, ?5% of
cases ascertained solely based on death certificates, ?3% of cases
missing information on sex or age, ?5% of cases missing informa-
tion on race and ?97% of registry’s records passing a set of single-
and inter-field edits.22Included registries were from Alabama,
Alaska, Arkansas, California, Colorado, Connecticut, Delaware, the
District of Columbia, Florida, Hawaii, Idaho, Illinois, Indiana,
Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michi-
gan, Minnesota, Missouri, Montana, Nebraska, New Jersey, New
Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode
Island, South Carolina, Texas, Utah, Vermont, Washington, West
Virginia and Wisconsin. All registries were established prior to
1997 and were required to submit data to CDC as of 1997; only
incident cases were reportable and included.22Data were continu-
ously updated and monitored every year for quality and included all
incident cases in a given state for the time period analyzed.22Data
from these registries covered 83% of the US population. Coverage
Abbreviations: AI/AN, American Indian or Alaskan Native; APC, an-
nual percent change; API, Asian or Pacific Islander; CI, confidence inter-
val; IR, incidence rate; NPCR, National Program of Cancer Registries;
SEER, Surveillance Epidemiology and End Results Program.
Grant sponsors: Research Participation Program at the Centers for Dis-
ease Control and Prevention (CDC) [Oak Ridge Institute for Science and
Education], Centers for Disease Control and Prevention’s National Pro-
gram of Cancer Registries.
*Correspondence to: Division of Cancer Prevention and Control,
National Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, 4770 Buford Highway, NE,
MS K-55, Atlanta, GA 30341, USA. Fax: 1770-488-4639.
Received 17 January 2008; Accepted after revision 16 April 2008
Published online 10 June 2008 in Wiley InterScience (www.interscience.
Int. J. Cancer: 123, 1422–1428 (2008)
' 2008 Wiley-Liss, Inc.
Publication of the International Union Against Cancer
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