Authored by Thiago Mamôru Sakae*
Abstract
Background: Esophageal cancer (EC) is one of the most common malignant tumors in the world and is associated with a late diagnosis and poor prognosis in most cases, with an average 5-year survival ranging from 15 to 20%. The main risk factors are smoking, alcoholism and gastroesophageal reflux disease. Worldwide, epidemiological disparities of the disease were observed according to geographic location.
Objective
1) To analyze the temporal trend of esophageal cancer morbidity and mortality in Santa Catarina in the period 2009-2018.
2) To define the sociodemographic profile of affected patients, according to sex, age group, ethnicity and macro-region of occurrence.
3) To analyze the temporal trend of risk rates for hospitalizations and deaths.
4) To determine the proportion of hospitalizations in ICU beds, the proportion of diagnostic, clinical and surgical procedures, and the average length of stay.
5) To detail the proportional distribution of cases of hospitalization for the neoplasm, according to its topographic location.
6) To evaluate clinical variables and the outcome of patients with esophageal cancer undergoing treatment in Santa Catarina.
7) To correlate the time series of hospital morbidity of hospitalizations for esophageal cancer with those of mortality for this group of neoplasms.
Methods: Observational study of ecological type with quantitative approach and time series analysis. It studied the population resident in Santa Catarina with 20 years of age or older who was hospitalized for esophageal cancer in the period 2009–2018 in hospitals in the state of Santa Catarina (SC), whose procedures were financed by SUS, and the population residing in Santa Catarina with 20 years of age or older who died having esophageal cancer as the basic cause, according to the death certificates issued in the period 2009– 2018 in the state.
Results: During the study period, 8,920 hospitalizations and 3,644 deaths from esophageal cancer were registered. The average hospitalization rate for males (30.48/100,000 inhab) was 4 times higher than for females (7.57). The highest average rates of hospitalizations occurred in the 60 to 79 age group (66.43) and in the macro-regions of the Grande Oeste (37.05), the Meio Oeste e Serra Catarinense (23.66). The average length of stay for hospitalizations was 6.82 days in the period studied. The average mortality rate was higher for the population aged 80 years or older (44.85). The majority of deaths were registered in the population with white skin color (n = 3,202; 87.87%), and the average lethality rate of non-whites (48.95%) was approximately 22.55% higher than the found in the population with white skin (39.94%).
Conclusion: The results showed that the sociodemographic profile of patients suffering from esophageal cancer in Santa Catarina in the period 2009-2018, according to available variables, was men, aged between 60 and 79 years, of white ethnicity, and residents of the Grande Oeste macroregion. There was a temporal trend of stability in the hospitalization rates, proportion of intensive care and clinical and surgical procedures. There was a temporal trend of reduction in mortality, lethality rates and average length of stay.
Headings: Esophageal cancer; Morbidity and mortality; Temporal trend
Introduction
Esophageal cancer (EC) is one of the most common malignant tumors and one of the main causes of cancer death worldwide [1]. The first description of esophageal cancer probably occurred in Egypt more than 5,000 years ago [2]. Due to its anatomical and histopathological particularities, EC is associated with a late diagnosis and in advanced stages, requiring extensive treatments, a decrease in quality of life and poor prognosis in most cases. The five-year survival of the EC varies from 15 to 20% [3-6]. The GLOBOCAN study, which estimated incidence and mortality from 36 types of cancer in 185 countries, pointed out that in 2018 there were 572,034 new diagnosed cases and 508,585 deaths from EC, which placed EC as the 7th most frequently diagnosed cancer, and the sixth leading cause of cancer death in the world, representing 5.3% of cancer deaths in the same year. Approximately 70% of EC cases occur in men [1]. In the world, some African countries have the highest incidences, around 24 cases per 100,000 inhabitants [7]. In South America, the regions with the highest incidence are Uruguay and Southern Brazil [8].
In Brazil, Rio Grande do Sul is the state with the highest incidence, and the gross rate in 2018, according to the Brazilian National Cancer Institute (INCA), it was 20.15 and 6.91 per 100,000 for males and for females, respectively, about 2 times that of the state of São Paulo. The INCA incidence estimates for EC in 2018 in the state of Santa Catarina were 15.08 and 3.44 per 100.000 inhabitants for males and females, respectively.
Squamous cell carcinoma (SCC) and adenocarcinoma (AC) represent approximately 90% of esophageal malignancies [9]. Smoking and alcohol consumption, two carcinogenic agents when in contact with the esophageal mucosa, especially if combined, are the main risk factors for esophageal SCC. In addition, mechanical injuries to the esophagus (for example: achalasia, radiotherapy and swallowing hot drinks or sodium hydroxide (caustic soda) increase the susceptibility of esophageal cells to carcinogenic agents [10]. According to the study by Chen et al, in a 2015 metaanalysis, an association between consumption of drinks and food at high temperatures and SCC type EC was significant in the Asian and South American population (OR: 2.06; 95% CI: 1, 62-2.61 and OR: 1.52; 95% CI: 1.25-1.85, respectively), but it was not significant in the European population (OR: 0.95; 95% CI: 0.68- 1.34) [11]. Dietary factors such as the consumption of fruits and vegetables are protective, while the consumption of red meat or processed meat may be associated with increased risk, but the association shown in some studies was weak [12,13]. Genetic factors are also involved in susceptibility to EC [14]. The control of smoking and drinking are the most effective primary prevention measures to date [15,16]. As for adenocarcinoma, obesity and gastroesophageal reflux disease were thought of as the most relevant risk factors for esophageal AC [17,18]. Helicobacter Pylori infection, and possibly the use of nonsteroidal anti-inflammatory drugs, are protective factors [19,20].
The economic impact of esophageal cancer for public and private health organs and institutions is high in most cases, mainly due to the anatomical, epidemiological and pathophysiological characteristics of the disease. Affected patients often need hospitalization, enteral or parenteral nutritional therapy, medications for symptomatic control, invasive surgical approaches with the need for trained multidisciplinary teams, radiotherapy and / or chemotherapeutic approach depending on the stage of tumor evolution, treatment of possible metastases and interventions in possible associated diseases in smoking and/or alcoholic patients [21]. In addition, patients in advanced stages may be dependent on admission to the intensive care unit (ICU) for long periods.
In addition to health care expenses, the economic impact is even greater if we consider that a significant part of the patients is part of the economically active population, resulting in increased indirect economic costs. The study by Tramotano et al. calculated the direct cost of treating patients with EC in the United States according to the stage of esophageal cancer of types SCC and AC, separately. The results were converted to 2018 US dollar amounts and pointed to an average total monthly cost in AC ranging from $ 70,280 in stage I to $ 55,328 in stage IV, and in SCC ranging from $ 84,538 in stage I to US $ 43,992 in stage IV [22]. Thus, esophageal cancer proves to be a serious disease, currently without public policies for population screening in Brazil, and with an important economic impact for the Brazilian Unified National Health System (SUS), showing that it is of public interest to analyze the temporal trend of morbidity and mortality due to esophageal cancer in the state of Santa Catarina, giving visibility to this problem and stimulating discussions in the scientific and health fields about new public health policies for the disease, optimization of expenses and integral treatment for affected patients. This study aimed to analyze the temporal trend of morbidity and mortality from esophageal cancer in Santa Catarina in the period 2009-2018 and, based on that, to define the sociodemographic profile of affected patients, the clinical evolution according to the macroregion of occurrence, in addition to determine the proportion of procedures performed, the proportional distribution of cases according to the topographic location and the average length of hospital stay.
Methods
Observational study of ecological type with quantitative approach and time series analysis. It studied the population resident in Santa Catarina with 20 years of age or older who was hospitalized for esophageal cancer (group C15 by the International Classification of Diseases-ICD 10) in the period 2009–2018 in hospitals in the state of Santa Catarina (SC), whose procedures were financed by SUS, and the population residing in Santa Catarina with 20 years of age or older who died having esophageal cancer as the basic cause (C15 by - ICD 10), according to the death certificates issued in the period 2009– 2018 in the state.
For the analysis of the time series of the rates, hospitalization for EC according to sex (female and male), age (20 to 39 years; 40 to 59 years; 60 to 79 years and 80 years or more), the macro-region of residence (Sul, Grande Florianópolis, Vale do Itajaí, Foz do Itajaí, Nordeste, Planalto Norte, Serra Catarinense, Meio Oeste e Grande Oeste), the need for hospitalization in intensive care unit beds (yes and no), diagnostic, clinical and surgical procedures (yes and no), length of stay (full days), ethnicity (white and non-white), deaths (frequency) and the population of Santa Catarina according to the same categories of gender, age groups, ethnicity and macro-region of residence were defined as dependent variables of the study. As an independent variable, the study period (2009 to 2018) was established.
Data collection was performed through access to public databases of the Unified Health System (SUS), being them: Hospital Information System (SIH) and Mortality Information System (SIM), both managed by DATASUS. The utility data for the study were obtained with the aid of the TABWIN software, which was installed on the researcher’s computer together with the definition files for reading the morbidity and mortality data. 120 files of reduced information of Hospitalization Authorizations (AIH) were used, and 10 files related to the annual death certificates (DO) corresponding to the state of SC. After being extracted and tabulated, the data were exported to the MS-Excel program, which was used to organize the data in spreadsheets, as well as to perform calculations, adjustments and to represent the results in the form of tables. For the calculation of rates and proportions, the ratio between the frequency of studied events (morbidities, mortality, type of procedure, etc.) by the population subject to the risk of occurrence of events was used, and the result was multiplied by the constant of 100,000 for rates, or 100 for proportions. The results were analyzed using the IBM - Statistical Package for the Social Sciences (SPSS). Version 18.0 program.
For temporal analysis, Spearman’s correlation coefficient (value 1 was considered a perfect correlation, values ≥ 0.800 and <1 a very strong correlation, values ≥ 0.645 and <0.800 a strong correlation, values ≥ 0.500 and <0.645 moderate correlation and <0.500 weak correlation), the coefficient of determination (R2), by simple linear regression (which percentually indicates the alignment of the studied rates in relation to the evolution of years in the period studied) and the p-Value from analysis of variance (ANOVA) were used. Values of p <0.05 were considered significant. As the present study is of the ecological type, based on secondary data in the public domain, without identification of the participants and used population aggregates as the unit of analysis, it was not necessary to assess the project by the Research Ethics Committee Involving Human Beings, in accordance with the terms of CNS Resolution 510/2016 (Article 1 Items II, III and V).
Results
During the period studied (2009-2018), a total of 4,371,365 hospitalizations were performed in the state of Santa Catarina, with 299,037 hospitalizations (6.84% of the total) corresponding to hospitalizations for neoplasms and, of these, 8,920 hospitalizations (0.20% of the total) corresponded to hospitalizations whose main cause was group C 15 - Malignant Esophageal Neoplasm, according to the ICD-10th Revision.
In the same period, using the Mortality Information System (SIM), 348,253 deaths were recorded in SC, 75,959 deaths from neoplasms (21.8% of the total), and of these, 3,644 deaths (1.0% of the total) by EC, representing 4.79% of deaths due to neoplasms that occurred in that period in the state. The average mortality rate for all types of cancer in the state in the period studied was 161.52 / 100,000 inhabitants, and the EC contributed with 7.75 deaths/100,000 inhabitants. Considering the hospitalization rate approximating the cancer incidence rate, the average mortality rate for cancer in the state in the period studied was 9.27%, while the average mortality rate for EC was 40.85%.
The proportional distribution of cases of hospitalization for esophageal neoplasms in Santa Catarina, in the studied period, according to their topographic location, was as follows: invasive esophageal lesion, 6,528 cases (73.2%); cervical portion of the esophagus, 1,002 cases (11.2%); thoracic portion of the esophagus, 741 cases (8.3%); abdominal portion of the esophagus, 649 cases (7.3%). (Table 1) shows the rates of hospitalization for esophageal cancer according to the year, sex and age group that occurred in Santa Catarina in the period 2009-2018. During the studied period, there was no correlation of hospitalization rates by sex (Spearman = 0.370 for males, and 0.248 for females). The average hospitalization rate for males was 4.02 times higher than for females. There was a moderate correlation in the evolution of hospitalization rates for EC in the age group from 40 to 59 years old (Spearman = -0.552). There was a strong correlation in the evolution of hospitalization rates due to EC in the age group of 80 years or more (Spearman = 0.661). The average hospitalization rate by age group was higher between 60-79 years old. (Table 2) shows the rates of hospitalization for EC according to the year of occurrence and macroregion occurred in SC in the period 2009-2018.
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