UK Oesophageal Cancer incidence statistics

UK Oesophageal Cancer incidence statistics

This section contains oesophageal cancer incidence statistics by age and sex, deprivation, geographical distribution and trends over time. The ICD code for oesophageal cancer is ICD9 150, and ICD10 C15.

Oesophageal cancer incidence by age and sex

In the UK in 2006, 7,824 people were diagnosed with oesophageal cancer. The male/female ratio of UK is 1.8:1 ( Table 1.1) 1-4.

Table showing the number of new cases and rates of oesophagus cancer in the UK

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However, the male/female ratio reported for adenocarcinomas (ACs) is much higher, generally around 5 to10-fold, which makes it one of the highest sex differentials of any non-occupational cancer 5. In 1998 the male/female ratio for adenocarcinomas in England and Wales was 4.8:1 6.

Oesophageal cancer is the ninth most common cancer in the UK. The risk of developing the disease increases with age with very few cases diagnosed in people aged under 40 years as Figure 1.1 shows 1-,4.

It has been estimated that the lifetime risk of developing oesophageal cancer is 1 in 64 for men and 1 in 116 for women in the UK. These were calculated in February 2009 using incidence and mortality data for 2001-2005. 31

Figure showing the numbers of new cases and age-specific incidence rates cancer of the oesophagus, by sex, in the UK

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Oesophageal cancer incidence and deprivation

Overall there is a clear positive association with social deprivation. Data for England in 1995-99 and 2000-04 reported rates in the most deprived quintile 22% and 14% higher, respectively, compared to the least deprived 7. However, there is evidence that this gradient differs for the main histological groups, suggestive of different aetiological backgrounds. An analysis of Scottish data showed a clear association between deprivation and non-adenocarcinoma but no clear association with deprivation for adenocarcinoma 8,9.

Geographical distribution of oesophageal cancer incidence

Each year 462,000 people are diagnosed with oesophageal cancer worldwide and 386,000 people die from it. There is an eighteen fold variation in male incidence rates between the different regions of the world and an almost forty fold variation in female rates and variation in mortality rates are similar. 10

The majority of cases (80-85%) are diagnosed in developing countries where it is the fourth most common cancer in men and most cases are squamous cell carcinoma (SCC) 10 ( Figure 1.2).

Figure 1.2: World age-standardised incidence rates for oesophageal cancer, 2002 estimates

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Wide variation in incidence 10 has been reported both between countries and in different ethnic groups and populations within a country. For example, in the USA, the incidence of SCC is almost six times higher in black men than in white men, while the incidence of AC is almost four times higher in white men than in black men. 11

The area with the highest reported incidence for oesophageal cancer is the so-called Asian ‘oesophageal cancer belt’, which stretches from eastern Turkey through north-eastern Iran, northern Afghanistan and southern Russia to northern China. 12 In the high risk area of Gonbad in Iran, world age-standardised rates are more than 200 per 100,000 and the male/female ratio is reported as 0.8:1.0. 13

In the Cixian province of China, world age-standardised rates per 100,000 are 184 for men and 123 for women compared with 8.4 for English men and 3.5 for English women. 14 High rates have also been reported for south and south-east Africa, parts of south America and parts of Europe. 15-,20Incidence rates in the UK are significantly higher than the EU average; French men have the highest rates, followed by men from the UK and Hungary, while UK women have the highest reported incidence of female oesophageal cancer, almost fifteen times higher than the rates reported for Cypriot women ( Figure 1.3) 21.

Figure 1.3: Age-standardised (European) incidence rates, oesophageal cancer, EU countries, 2002 estimates

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Within the UK the highest rates are recorded in Scotland as shown in Table 1.1 above. A recent analysis of cancer incidence in the UK and Ireland, recorded a clear north/south divide across Great Britain with highest incidence for oesophageal cancer in Scotland, urban areas of North West England and north Wales 22. Scotland currently has some of the highest rates in Europe 8.

Trends in oesophageal cancer incidence

Over the last thirty years incidence rates for oesophageal cancer have increased in Britain, particularly for men ( Figure 1.4) 23.

Chart showing the age-standardised (European) incidence rates for oesophageal cancer, by sex, in Great Britain

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The male European age-standardised incidence rates in Britain rose from 8.8 per 100,000 population in 1975 to 14.1 in 2006 with the corresponding female rates rising from 4.8 to 5.7.

In Scotland, particularly, the male rates have show a substantial increase, with the male European age-standardised rates rising from 11.3 per 100,000 population in 1975 to 17.3 in 2006. For Scottish women, the European age-standardised rates increased from 6.6 in 1975 to 9.2 in 1993 but have since decreased to 6.9 in 2006. 2

Figure 1.5 shows the oesophageal cancer incidence trend in the UK.

Figure showing the age-standardised (European) incidence rates for oesophageal cancer, by sex, in the UK

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Anatomy and Histology

The oesophagus (gullet) extends from the back of the mouth to the stomach and in adults is approximately 26 centimetres (cms) in length and 2cms wide. In the chest region it lies between the trachea and spinal cord that need to be protected during treatment. The oesophagus is traditionally divided into three sections as shown in Figure One.

There are two main histological types of oesophageal cancer: squamous cell carcinoma (SCC) and adenocarcinoma (AC). In the upper two-thirds the most common histology is SCC: in the lower third AC. Until the 1970s SCC accounted for the vast majority of oesophageal cancer diagnosed in the UK and they still do in developing countries.

However, since the 1970s the incidence of SCC has remained stable or decreased in most western countries while that of AC has increased, particularly in men. 24 If these trends continue, AC will become the dominant histology - this has happened for white men in the USA and UK. Indeed the reported rates of adenocarcinoma for white men in the UK are the highest in the world. 25,26,27

The nearest (proximal) part of the stomach adjacent to the oesophagus is the cardia with the cardiac sphincter operating to prevent the regurgitation of acidic gastric contents into the oesophagus. The area around the lower oesophagus and the gastric-cardia is known as the gastro-oesophageal junction (GOJ).

The GOJ is associated with a medical condition called Barrett’s oesophagus, first described by Barrett in 1950. 28 It has been suggested that ACs of the GOJ and gastric cardia, which share aetiological and clinico-pathological features, should be classified as a distinct subsite from the proximal parts of the oesophagus and distal stomach. 29, 30

Updated: 24/07/2009 0:00

UK Oesophageal Cancer mortality statistics

This page presents oesophageal cancer mortality statistics including age and sex, and trends over time.

Oesophageal cancer mortality by age and sex

The numbers of oesophageal cancer deaths and their age distribution is very similar to the incidence data shown on the incidence page - this is due to the poor prognosis for this disease.

In the UK 7,353 people died from oesophageal cancer in 2007 ( Table 2.1). 1-3

Number of deaths and mortality rates of oesophageal cancer in the UK

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Oesophageal cancer is responsible for around 5% of all cancer deaths, making it the sixth most common cause of cancer death overall, the fourth in men and the sixth in women.

Figure 2.1 shows the numbers of deaths and age-specific mortality rates by sex for oesophageal cancer in the UK for 2007. 1-3

Numbers of deaths and age-specific mortality rates by sex for oesophageal cancer in the UK

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Oesophageal cancer mortality trends over time

Mortality rates for males have risen sharply over the last thirty years in the UK as illustrated in Figure 2.2. The male European age-standardised rate per 100,000 population between 1971 and 2007 rose from 7.8 to 13.0. The corresponding rates for women were 4.1 to 4.8.

Age-standardised (European) mortality rates for oesophageal cancer, by sex, in the UK

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Updated: 12/05/2009 0:00

Oesophageal Cancer survival statistics

This page presents oesophageal cancer survival statistics including five and ten year survival rates, and survival by age at diagnosis and sex.

Population-based five-year relative survival rates for all patients diagnosed with oesophageal cancer in 2000-01 in England and Wales were 8% for both men and women (30% for men and 27% for women at one year after diagnosis). 1 Similar rates are reported for Scotland. 2

Oesophageal cancer five and ten year survival rates

An earlier study of patients in England and Wales estimated that five-year survival had improved by 1% for each quinquennium between 1971-75 and 1986-90 and suggested that this might be due to reductions in peri-operative mortality. 3

Women tend to have slightly higher survival rates than men ( Figure 3.1).

Figure 3.1: Five- and ten-year relative age-standardised survival for oesophageal cancer patients aged 15-99, England and Wales, 1971-2001

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One of the reasons for low survival rates is that many of the patients (40% in the Scottish Audit study) have severe co-existing medical conditions which preclude them from certain treatments 2.

In the Scottish study, one year survival for gastric and oesophageal cancer patients with minimal pre-morbid disease was 39.7% compared with 19.1% for patients with significant co-existing disease.

Oesophageal cancer survival rates by age and sex

Many patients are also elderly (median age of gastric and oesophageal cancer patients in the Scottish Audit was 72 years) and survival decreases with increasing age. This is illustrated in Figure 3.2 using data for oesophageal cancer patients diagnosed in England and Wales in 1986-1990.

Figure 3.2: Five-year relative survival for patients diagnosed with oesophageal cancer in England and Wales during 1986-1990 by age at diagnosis

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Updated: 30/12/2004 0:00

Oesophageal Cancer Risk Factors

This page presents information on the risk factors for oesophageal cancer, including for squamous cell carcinoma (SCC), adenocarcinoma (AC), and for both squamous cell carcinoma and adenocarcinoma.

There are well established risk factors for both types of oesophageal tumour. 1A few risk factors probably account for the majority of cases.

American data suggest that smoking, higher body mass index (BMI), low intake of fresh fruit and vegetables and gastro-oesophageal reflux are responsible for an estimated 79% of adenocarcinomas; while tobacco consumption, excess alcohol consumption and low fruit and vegetable intake are estimated to cause 89% of squamous cell carcinomas (SCC). 2

Tobacco consumption whether by smoking cigarettes, cigars or pipes or by chewing increases the risk of both SCC and AC, although the effect is stronger for SCC.

Risk factors for squamous cell carcinoma of the oesophagus (SCC)

Tobacco and alcohol, acting independently and together, are the main risk factors for SCC of the oesophagus in western countries. The quantity of cigarettes smoked and the duration of smoking appear to be directly related to risk: risk declines on smoking cessation and falls to that of a non-smoker 10 or more years after giving up. 3

Alcohol multiplies the effect of tobacco consumption. 4 Data from Sweden was used to estimate the effect of smoking and alcohol on the risk for SCC and AC as shown in Figure 4.1. 5

Figure 4.1: The effect of tobacco smoking, alcohol and bodyweight on the risk of SCC and AC of the oesophagus

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Heavy smoking and drinking increased the risk by 20-fold for SCC of the oesophagus, although odds ratios as high as 50 and 130 for combined categories of heavy drinking and smoking have been reported in studies carried out in Italy and South America. 3,6

Alcohol consumption increases the risk of SCC independently of smoking ( Figure 4.1). Risk increases at moderate levels of alcohol consumption with a meta-analysis estimating an 18% increase in risk for each additional 100g/week of alcohol consumption. 4

Risk increases significantly with higher alcohol consumption: a recent European case-control study reported an odds ratio of almost 25 in men drinking 84 or more drinks a week. 3 However, in a recent UK case-control study of SCC in women, no association was found with alcohol although there was a significant association with smoking. 7

A diet low in fruit and vegetables is the third main risk factor for SCCof the oesophagus in developed countries. A recent meta-analysis of case-control and cohort studies reported a significant reduction in risk with higher consumption of fruit and a non-significant protective role of vegetable consumption. 8 However, in contrast to adenocarcinoma, there is no association between obesity and SCC.

Although diet, smoking and alcohol explain the majority of oesophageal SCC in developed countries, a number of other conditions may explain a small proportion of cases: in high risk areas these factors may be responsible for a higher proportion.

Certain rare conditions such as Tylosis, an autosomal dominant inherited condition associated with palmoplantar keratosis (thickening of the skin on the palms of the hands and soles of the feet) and Plummer-Vinson syndrome (a condition in which iron deficiency anaemia, glossitis - inflammation of the tongue - and dysphagia are associated) are linked with an increased risk of SCC.

Patients with untreated achalasia (a condition in which the cardiac sphincter malfunctions) and coeliac disease (a disorder usually characterised by sensitivity to dietary gluten, small intestinal mucosal damage and malabsorption) also have an increased risk. A possible link with human papillomavirus (HPV) has also been reported. 9

At least 15% of tumours analysed worldwide with polymerise chain reaction have been positive for HPV DNA. The detection rate is much higher in high risk areas such as China and Iran. 10

Early studies in the high risk areas around northern Iran and in China, identified additional risk factors such as opium use, nutritional deficiences (eg zinc) in addition to a diet deficient in fruit and vegetables, specific foods which contain high levels of mycotoxins and nitrosamines and thermal injury from consumption of very hot beverages. 11,12

Temperature of food and drink may also be a factor in other countries including the UK.

A case-control study of women with SCC in England and Scotland found that the risk of this cancer was reduced by two-thirds in women who consumed tea and coffee warm rather than burning hot. 7 However, a nationwide case-control study in Sweden reported no association between temperature of drinking hot beverages and oesophageal cancer. 13

In the high risk areas of South America (northeastern Argentina, southern Brazil, Uruguay and Paraguay) an analysis of five case-control studies confirmed that the consumption of very hot drinks was associated with a 2- to 4-fold increased risk. 14 In this same area the drinking of maté, a locally grown herbal infusion, was also positively associated with oesophageal cancer. The effect of maté was increased if drunk at high temperatures. 14,15

Risk factors for squamous cell carcinoma (SCC) of the oesophagus and adenocarcinoma (AC) of the oesophagus

Risk of oesophageal cancer is increased in people who have had radiotherapy to the mediastinum for another primary cancer. A record linkage study carried out in the south east of England reported a two-fold increase in risk of oesophageal cancer in women treated with radiotherapy for breast cancer more than 15 years previously. 16

A pooled analysis of studies from America and Europe reported a greatly increased risk of oesophageal cancer in people treated with radiotherapy for Hodgkin’s lymphoma, with an observed/expected ratio of 19.5 reported 20-24 years after a diagnosis with the first cancer. 17

Use of non-steroidal anti-inflammatory drugs (NSAIDS) reduces risk of AC and SCC, with a recent meta-analysis reporting significant summary relative risks of 0.65 for any NSAID use and 0.51 for aspirin use. 18

The predominance of male cases suggests that occupational exposures may play a role, but occupational risk factors have been difficult to study because of the confounding effect of smoking and alcohol use. Amongst other studies it has been suggested that exposure to trichlorethylene in the dry-cleaning industry and silica dust may increase risk but this is likely to account for only a very small number of cases. 19,20

Risk factors for adenocarcinoma (AC) of the oesophagus

One of the strongest risk factors for adenocarcinoma of the oesophagus is an acquired premalignant condition known as Barrett’s oesophagus or metaplasia (BM).

BM usually develops in adult life arising principally as a result of gastro-oesophageal reflux disease (GORD), although any insult, which causes distal oesophageal irritation, such as chemical injury, and medical conditions including scleroderma (disease of connective tissue which can affect multiple organs including the skin), achalasia and hiatus hernia, are also associated with metaplasia.

Genetic factors may occasionally play a role in a small proportion of BM as this lesion can exhibit familial clustering and occurs in twins. 21. Short segment Barrett’s oesophagus, less than 3cm in length from the estimated GOJ, is frequently missed by endoscopists and is more prevalent than long segment Barrett’s mucosa. 22

Inflammation of the oesophagus (oesophagitis) caused by GORD is a very common medical condition in Western countries with 30% of adults complaining of heartburn at least once per month. 23,24

Forty per cent of patients will improve spontaneously, 50% will have persistent oesophagitis and around 10% will progress to BM. 23,24

Between 0.5-2% of adults in western populations are thought to have BM. 25 The risk of AC in people with BM is low in absolute terms with an annual risk of carcinoma of about 0.5-1% but this represents a risk which is 30-125 times higher than the general population. 26

People with very long segments of Barrett’s oesophagus (8-10 cm) have an increased risk (1.7 times) of oesophageal cancer compared to people with shorter segments (3-8cm). 27 Approximately 10-20% of individuals with Barrett’s oesophagus develop dysplasia including those with short segment Barrett’s oesophagus. 28

The clinical risk factors for both Barrett’s metaplasia and its related adenocarcinoma are summarised in Table 4.1. 29-,41

Table 4.1: Clinical risk factors for Barrett's metaplasia and associated adenocarcinoma

Risk is highest in older, white, obese men experiencing severe symptoms of reflux over a long period. A strong dose-dependent relationship between body mass index (BMI) and AC has been found which is not the case for SCC. 34 However, the precise way in which body fat raises risk is not yet certain. 34

Anticholinergics and other drugs which relax the oesophageal sphincter are associated with increased risk of AC and this may be because they predispose to reflux. 42

Drugs given to asthmatics such as ?-agonists and aminophyllines also have the effect of relaxing the sphincter and this is the likely reason for the higher incidence of AC observed in asthmatics. 43

The presence of helicobacter pylori may protect against the acidic effect of gastric reflux. Elimination of helicobacter pylori, which is known to reduce the risk of stomach cancer, can make acid suppression with proton pump inhibitors more difficult in GORD. While this effect is statistically significant it may not be clinically significant in the management of individual patients.

As yet none of the risk factors in Table 4.1, above, are sensitive or specific enough to identify accurately ‘high risk’ individuals.

Updated: 08/03/2006 0:00

References

UK Oesophageal Cancer incidence statistics

  1.  Office for National Statistics. Cancer Statistics registrations: Registrations of cancer diagnosed in 2006, England. Series MB1 no.37. 2008
  2.  ISD Online. Cancer Incidence, Mortality and Survival data. 2009
  3.  Northern Ireland Cancer Registry. Cancer Registrations in Northern Ireland, 2006. 2008
  4.  Welsh Cancer Intelligence and Surveillance Unit. Cancer Incidence in Wales. 2009
  5.  Wild, C.P. and L.J. Hardie, Reflux, Barrett's oesophagus and adenocarcinoma: burning questions. Nat Rev Cancer, 2003. 3(9): p. 676-84.
  6.  Newnham, A., et al., Trends in the subsite and morphology of oesophageal and gastric cancer in England and Wales 1971-1998. Aliment Pharmacol Ther, 2003. 17(5): p. 665-76.
  7.  National Cancer Intelligence Network, 2008 Cancer Incidence by Deprivation, England 1995-2004
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  10.   Parkin, D.M., et al., Global cancer statistics, 2002. CA Cancer J Clin, 2005. 55(2): p. 74-108.
  11.  Vizcaino, A.P., et al., Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973-1995. Int J Cancer, 2002. 99(6): p. 860-8.
  12.  Parkin, D.M., International variation. Oncogene, 2004. 23(38): p. 6329-40.
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  31.  Statistical Information Team, Cancer Research UK, 2009

UK Oesophageal Cancer mortality statistics

  1.  Office for National Statistics Mortality Statistics: Cause. England and Wales 2007 London TSO 2009
  2.  Northern Ireland Cancer Registry, 2009 Cancer Mortality in Northern Ireland, 2007
  3.  ISD Online, 2009 Cancer Mortality in Scotland, 2007

Oesophageal Cancer survival statistics

  1.  Office for National Statistics. Office for National Statistics
  2.  Gilbert FJ, Thompson, A.M., (eds), Scottish Audit of Gastric and Oesophageal Cancer. Report 1997-2000. A prospective audit. 2002, Scottish Audit of Gastric and Oesophageal Cancer Steering Group: Edinburgh.
  3.  Coleman, M.P., et al., Cancer Survival Trends in England & Wales, 1971-1995 Deprivation & NHS Region. 1999: The Stationery Office.

Oesophageal Cancer Risk Factors

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