The esophagus transports food from the mouth to the stomach approximately 600 times a day. This is usually a one-way route, but sometimes gastric acid escapes the stomach and returns. This damages cells in the inner wall of the esophagus, prompting them to grow again due to genetic errors.
In the United States, approximately 22,370 such mistakes end up in cancer each year.
If esophageal cancer is discovered and treated before it penetrates into or spreads to other organs, it can be cured. But this rarely happens.
“It’s often the case that patients have reflux symptoms for years, they take Tums or other medications, and then suddenly have trouble swallowing, so they come to the emergency room,” said Dr. Allon Kahn, the emergency room director. Gastroenterologist and associate professor of medicine at the Mayo Clinic in Arizona. That’s when doctors discovered that the tumor had grown into the esophagus wall and possibly beyond.
“By then,” Kahn said,”it will be incurable.”
That’s why only about 20% of Americans with esophageal cancer are still alive five years after diagnosis. Doctors say they don’t necessarily need better drugs to improve that number. What they need is to find better ways while the cancer is still in its early, highly treatable stage.
To do this, they need to make breakthroughs in disease screening.
“The concept of screening is to detect dangerous things before they happen,” said Dr. Daniel Bofa, chairman of thoracic surgery at Yale University.
It is suitable for diseases such as breast cancer, lung cancer and colon cancer. In these cases, there is an obvious progressive step that leads to cancer-and only cancer.
But this does not seem to be the case with esophageal cancer.
“We really don’t know who to screen, how often to screen, and what we can see will tell us ‘this person is going to have dangerous cancer,'”Bofa said.
He likened the situation to the difficulty of predicting tornadoes.
“Most tornadoes occur when conditions are favorable for tornadoes,” he said. “But most of the time, conditions are favorable for tornadoes to occur, but in fact no tornadoes occur. And many times, tornadoes occur outside of these conditions.”
Another complicating factor is the low number of esophageal cancer cases, accounting for about 1% of all cancers diagnosed in the United States.
Imagine 100,000 college football fans pouring into Michigan Stadium in Ann Arbor on game day, said Dr. Joel Rubenstein. He is a research scientist at Lieutenant Colonel Charles S. Kettles Veterans Medical Center three miles away and a gastroenterologist at the university. Michigan. Then imagine having to figure out which four of these fans will develop esophageal cancer this year.
Screening someone for esophageal cancer is not a simple process.
The standard method is to insert an endoscope (a flexible tube with a camera on one end) into the patient’s throat and then pass it through the stomach. The camera allows doctors to examine the esophagus up close and check for abnormal cells that may become cancerous.
The tube also serves as a conduit for tools to collect tissue samples that can be sent to a pathology laboratory for diagnostic analysis. If doctors find that the tumor looks like early-stage cancer, they can remove it on the spot.
It sounds simple, but patients must be sedated during surgery, which means they lose a day’s work. Endoscopy is also expensive and there is a lack of doctors who can perform it.
“We can only find 7% of cancers through endoscopy,” Kahn said. “We have to find a way to increase that number.”
In the United States, the most common cancer begins at the bottom of the esophagus. These cells cannot withstand the effects of gastric acid, so for people with chronic acid reflux, they sometimes adapt by becoming more like intestinal tissue. The condition is called Barrett’s esophagus, and approximately 5% of American adults suffer from it.
“If that was all we would say,’That’s great,'”Kahn said. “But unfortunately, when cell types change, genetic changes occur that make patients susceptible to cancer.”
Dr. Sachin Wani, a gastroenterologist and professor at the University of Colorado School of Medicine, said approximately 0.3% of patients with Barrett’s esophagus develop esophageal cancer each year. They are about nine times more likely to die of esophageal cancer than people without Barrett’s disease.
This means screening for Barrett’s disease is equivalent to screening for esophageal cancer.
Doctors generally agree on a set of core risk factors, including chronic gastroesophageal reflux disease, smoking and excessive abdominal weight. Other risk factors include age at least 50 years old, male, white, and a family history of Barrett or esophageal cancer.
There is no consensus on how many risk factors a person must have to justify screening.
According to recommendations from the American College of Gastroenterology, more than 31 million people are eligible for screening. Dr. Gary Falk, a gastroenterologist and emeritus professor of medicine at the University of Pennsylvania’s Pereman College, said the American Society of Gastroenteroscopy guidelines increase this number to 52 million, and the American Society of Gastroenterology recommends expanding this number to 120 million.
All of these suggestions leave room for improvement. Dr. Prasad Iyer, director of gastroenterology at the Mayo Clinic in Arizona, said only 50 to 60 percent of people who meet screening requirements actually have Barrett’s disease.
“The screening criteria are not accurate enough,” he said.
In fact, at least 90 percent of people with risk factors for Barrett’s disease do not actually have the disease, Iyer said. This includes the vast majority of people who suffer from acid reflux.
As a result, doctors are turning to artificial intelligence to identify other characteristics, improving their ability to identify people most likely to have Barrett and esophageal cancer.
“Everyone in the medical community is focusing on artificial intelligence,” Falk said. “We think this will completely change everything.”
Ayer and his colleagues are developing an artificial intelligence tool that can search the electronic medical records of Mayo Clinic patients to find those who should be screened for Barrett’s disease. The tool considers more than 7,500 different data points, including past medical procedures, laboratory test results, prescriptions, and more. (Surprisingly: Patients ‘triglycerides and electrolytes have predictive value.)
“This may be something that humans cannot do effectively,” Ayer said.
In testing, the overall accuracy rate of these two tools was 84%. Iyer said that while these are substantial improvements, the team hopes to increase them to 90% before rolling them out to clinics.
Rubinstein and his colleagues in Michigan have created something similar, using machine learning technology to analyze the health records of patients in the National Department of Veterans Affairs. Their tool also performed better than the Medical Association’s official guidelines, with an accuracy rate of 77%. Now, the team is working to increase the screening threshold by increasing cost-effectiveness.
Once put into use, such tools could reduce the burden on overburdened primary care doctors who are not necessarily aware of the latest screening guidelines, and fewer than half of eligible patients referred are tested.
“It flags a patient and says,’This patient should be screened,’ or ‘This patient should not be screened,'”Ayer said. “This is what the future really needs.”
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Original text:https://medicalxpress.com/news/2024-09-ai-esophageal-cancer-deadly.html
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