| ObjectivesIn order to settle the problem of starting age, refine and standardize of the strategy of early detection and early treatment in esophageal cancer in China, the age tendencies of the incidence and mortality of esophageal cancer were described and analyzed. Meanwhile, the health economic and epidemiologic methods were used to analyze the effectiveness of different starting age of esophageal endoscopy screening in high risk areas in rural China. The study could not only provide scientific evidence for extending endoscopic screening technology, but also provide experience and reference of screening and early detection and early treatment for other high-risk areas.Meterial and MethodsThe national cancer registry data and the data registered in Cixian county, Hebei province from 2005 to 2009 were compared to describe the burden of esophageal cancer by age variation. The age-specific esophageal cancer incidence and mortality data in a Cixian endoscopy screening cohort were used to analyze the age tendencies and explore the age tendency join points of esophageal cancer incidence and mortality.The incidence and mortality of esophageal cancer in endoscopy screening cohort in Cixian Hebei province were used to evaluate the risks of esophageal cancer incidence and mortality of different age groups. The esophageal cancer burden of each screening starting age group was evaluated by calculating of the cumulative mortality rates in screening group with different starting age and control group. The realistic screening effect was evaluated by mortality reduction and life-years gained.A Markov model was constructed based on the parameters collected from literature review and practically basic data to evaluatethe effectiveness of endoscopy screening once-in-a-lifetime by different starting age. The Markov model was simulated in the esophageal cancer screening and early detection and early treatment cohort by endoscopy with Lugol’s iodine staining and biopsy.Results1. The age tendency of esophageal cancer:According to the national registry data, the incidence and mortality of esophageal cancer was much low before 40 years old but ascendingwith ages. In high-risk rural areas, the burden of esophageal cancer increased rapidly after 50 years. The 80-84 year old group had the most severe cancer burden. The cohort study showed that the incidence and mortality rates of esophageal cancer were highest in 60-69 year old group, following by 50-59 years. The relatively lower incidence and mortality was shown in 40-49 year old group (<5‰). No significant ascending trend of incidence and mortality was shown during 2000-2013 in each age group.2. The epidemiologic evaluation results:The cumulative incidence of cohort population was 5.68%(388/6825) and the cumulative mortality rates was 4.76%(325/6825). The risk of incidence and mortality for ESCC increased as age:the risks of incidence for ESCC were 1 in 41 for a person at age 40 years,1 in 14 at age 50 years, and 1 in 8 at age 60 years respectively. The risks of mortality for ESCC were 1 in 55 for a person at age 40 years,1 in 17 at age 50 years, and 1 in 9 at age 60 years respectively. The results of Log-rank test indicated that there was statistical significance of esophageal cumulative mortality rates between the age 40 years(x2=4.5393,p=0.0331)and age 50 years(x2=7.7611,p=0.0053). Compared with control group, the relative risk (RR) of cumulative mortality rates in screening group with screening starting age 40 years was 0.60 (95%CI=0.37-0.97) and the NNS to prevent 1 ESCC death was 104 (95%CI=51-1520). The RR of cumulative mortality rates in screening group with screening starting age 50 years was 0.59 (95%CI=0.40-0.86)and the NNS to prevent 1 ESCC death was 34 (95%CI=20-114). The Log-rank test indicated that there was no statistical significance of cumulative mortality rates of age 60 years(x2=0.1694,p=0.6806) and the RR of cumulative mortality rates was 0.94(95%CI=0.67-1.31).3. The health economics evaluation results:Compared with control group, the strategy starting at 45 year-old saved the maximum life years.All strategies were cost-effective and starting at 40 year-old cost the most per life year saved. The strategy of 55 year-old cost less than control group per life year saved. Among all alternatives, strategies starting age at 45 year-old and 50 year-old were incremental cost-effective and 50 year-old was relative lower than 45 year-old.ConclusionsThe high mortality of esophageal cancer indicates that it is still one of the main cancer burden in China. Before 50 years old, the incidence and mortality rates of esophageal cancer is relatively lower, however, the rates ascend with ages. In high-risk rural areas of China, though the cancer burden in 40 years old group increases, the incidence is relatively low(<5‰).50 years old and other older groups are the main esophageal cancer population because of the higher cancer burden than younger age group.The endoscopic screening and early detection and early treatment could decrease the incidence and mortality of esophageal cancer. The strategy starting at 40 year-old implemented at present and other strategies were cost-effective in high-risk areas of rural China. Compared with starting age at 50 years, the additional benefits gained by 40 years old group is lower. More health resources and more screening will be required when screening started at age 40 years versus age 50 years.Comprehensively considering of the lacking resources in rural China, screening starting age at 50 years is recommended. Screening once-lifetime at age of 50 years can obtain the optimal screening effectiveness. The strategy of starting age at 40 year-old which could obtain the most screening effects would be preferable in wealthy regions. |
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