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Rare cancer on the rise

DMS, VA physicians call for more research

The marked increase in cancer of the esophagus over the last 25 years represents a real disease burden in the United States that is as yet unexplained, according to researchers from Dartmouth Medical School and the Veterans Administration (VA) Outcomes Group based at the VA Medical Center in White River Junction, Vt.

In the January issue of the Journal of the National Cancer Institute, VA physician Heiko Pohl and DMS physician H. Gilbert Welch reported that two potential causes of apparent increase in disease incidence-over-diagnosis and reclassification-do not account for the rise in the number of cases of one type of esophageal cancer.

"Our results strongly indicate that the increase ... represents a true increase in disease burden," the authors wrote. "In fact, this cancer constitutes the fastest rising malignancy in the United States." They also emphasized, however, that esophageal cancer is still relatively rare and much less common than cancers of the lung, colon and breast.

The authors noted that approximately 14,000 Americans were diagnosed with esophageal cancer in 2004. Of these, more than half had esophageal adenocarcinoma, a cancer affecting the glands in the lower third of the esophagus. While rates of other types of esophageal cancer have actually fallen during the time period of the study, Pohl and Welch report that deaths from this type have risen from 2.5 to 20 deaths per million since 1975.

The study, based on data from the Surveillance, Epidemiology and End Results (SEER) database, was designed to determine if the dramatic rise in adenocarcinoma esophageal cancer could be attributed to increased screening-from procedures such as diagnostic endoscopy-and resultant over-diagnosis of conditions that would not otherwise have produced signs or symptoms before death, or because of reclassification-a change in how diagnostic terminology is applied.

Using data from 1975-2001, the researchers found, however, that despite increased diagnostic intensity, there was only a small increase in the proportion of early cancers at diagnosis during that period. Logical reclassifications were also ruled out as an explanation based on their analysis.

"The rate of increase in esophageal adenocarcinoma is greater than that of any other major malignancy in the United States," wrote Pohl and Welch. "Dramatic increases in disease incidence need to be explained." Pohl and Welch concluded that identifying the risk factor responsible for the increase must be a priority.

H. Gilbert Welch is Professor of Medicine and Community and Family Medicine at Dartmouth Medical School, a member of the Center for the Evaluative Clinical Sciences at DMS, and Co-director of the VA Outcomes Group. Heiko Pohl is a member of the VA Outcomes Group and was supported in this research by a Veterans Affairs Special Fellowship in Outcomes Research.


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Last Updated: 12/17/08