NEW YORK (Reuters Health) - Use of rigid esophagoscopy (RE) for screening patients in North America with head and neck cancer for additional primary esophageal malignancies is of limited value because such malignancies are rare, according to a retrospective study.
"Performing rigid esophagoscopy to screen for synchronous esophageal malignancy in patients with head and neck cancer, while safe, is unnecessary in most patients and should be limited to patients who are high-risk," Dr. Mark J. Jameson told Reuters Health via email.
Many institutions routinely perform screening endoscopy for individuals with head and neck squamous cell carcinoma (HNSCC) because of historically high rates of synchronous esophageal malignancy in such patients, explained Dr. Jameson, of the University of Virginia Health System, in Charlottesville.
He said that he and his colleagues decided to study RE screening for synchronous esophageal malignancies because "we questioned the value of this practice in the face of our clinical observation that it rarely changed the management of our patients, given the low prevalence of significant findings."
The study involved a review of medical records of 582 patients with HNSCC (mean age 60 years, 78% men) at the University of Virginia Medical Center who had undergone RE for staging from 2004 to 2012. During this period, standard staging of HNSCC included RE; flexible esophagoscopy was not performed.
Of a total of 601 staging REs, 551 were completed. There were no abnormal findings in 95% of patients, and none of the pathological findings included synchronous primary esophageal malignancies or any other malignancies, the researchers note in a report online December 3 in JAMA Otolaryngology-Head & Neck Surgery.
There were nine complications (1.5%), including one esophageal perforation.
Another part of the study, a search of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, showed that the incidence of synchronous primary esophageal malignancies had consistently decreased in North America from 1980 to 2010, from 0.36% in the 1980s to 0.19% in the 2000s.
A literature search with data on synchronous primary esophageal neoplasms detected by rigid or flexible screening esophagoscopy found a similar trend, the researchers said. In North American studies, the detection rates in the late 1970s and early 1980s ranged from 1% to 8%, decreasing to 0% in the last decade.
In contrast, the rate of synchronous esophageal malignancy in patients with HNSCC is still relatively high in Asia and South America. Studies have found rates as high as 14% in Tokyo and 23% in New Tapei City, Taiwan.
"We were surprised by the distinction between the incidence of synchronous esophageal malignancy in North America and in other parts of the world," noted Dr. Jameson.
This reduction in incidence of esophageal squamous cell carcinoma in the United States is "probably because of a decrease in tobacco and alcohol use combined with an increased intake of fresh fruits and vegetables," the authors noted.
"The study has it right; we rarely find a second primary" malignancy in patients with head and neck cancer, Dr. Kerstin M. Stenson told Reuters Health.
The findings from the authors' institution and from the literature indicate that use of screening RE "really doesn't impact" care in patients who are not at high risk for a synchronous malignancy, noted Dr. Stenson, director of Rush University Medical Center's head and neck cancer program, in Chicago.
"So why put the patients at undue risk?" said Dr. Stenson, who was not involved in the study. "Even though it's a very low-morbidity procedure, it's extra time in the OR, and there's always the chance that you could hurt the patient."
Dr. Jameson noted that it's still important to perform an esophageal evaluation, generally using rigid esophagoscopy, standard flexible esophagoscopy, or transnasal esophagoscopy, in certain patients with head and neck cancer who are at high risk for synchronous esophageal malignancy. This subset of high-risk patients includes those with esophageal symptoms, hypopharyngeal primary tumor, and East Asian ethnicity.
People who have oral cavity cancers, especially those with heavy alcohol and cigarette use, also are at higher risk for esophageal cancer, Dr. Stenson noted.
RE in the setting of esophageal screening does have some limited advantages, specifically "larger biopsies and the option to debulk a tumor - but only when a tumor is found, which is rare," Dr. Jameson said.
The technique also remains an important skill for otolaryngologist-head and neck surgeons to learn - perhaps with the help of simulators, given the decreasing use in screening esophagoscopy - "as it is especially useful for esophageal dilation and retrieval of esophageal foreign bodies," he said.
The study had no commercial funding and the authors reported no conflict-of-interest disclosures.
SOURCE: http://bit.ly/1TZus89
JAMA Otolaryngol Head Neck Surg 2015.
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