E NDOSCOPIC O NCOLOGY
E NDOSCOPIC O NCOLOGY
Gastrointestinal Endoscopy and Cancer Management
Edited by
D OUGLAS O. F AIGEL , MD , FACG , FASGE
Associate Professor of Medicine, Director of Endoscopy Oregon Health and Science University, Portland, OR
M ICHAEL L. K OCHMAN , MD , FACP , FASGE
Professor of Medicine and Surgery, Co-Director Gastrointestinal Oncology,
Hospital of the University of Pennsylvania, Philadelphia, PA
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Cover illustration: From Fig. 5B in Chapter 3, "Image Enhancement Endoscopy," by Stephan M. Wildi and Michael B. Wallace;Fig. 2 in Chapter 13, "Diagnosis and Management of Gastrointestinal Lymphoma," by John G. Kuldau, Peter R. Holman, and Thomas J. Savides; and Fig. 1A in Chapter 15, "Carcinoid Tumors,"
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Library of Congress Cataloging-in-Publication Data
Endoscopic oncology : gastrointestinal endoscopy and cancer management / edited by Douglas O. Faigel, Michael L. Kochman.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58829-532-X (alk. paper)
1. Endoscopy. 2. Gastrointestinal system--Cancer--Endoscopic surgery. 3. Gastrointestinal system--Diseases--Diagnosis.
[DNLM: 1. Neoplasms--therapy. 2. Endoscopy, Gastrointestinal--methods. QZ 268 E556 2006] I. Faigel, Douglas O. II. Kochman, Michael L.
RC804.E6E53 2006 616.99'407545--dc22
2005036564
v
Preface
Cancer is the second most common cause of death in Americans (see www.cdc.gov). Colorectal cancer kills more Americans than any other malignancy except for lung cancer.
The incidences and mortalities of the major gastrointestinal (GI) malignancies are shown in Table 1. Taken as a group, the five most common GI malignancies account for more cancers and more cancer deaths than for any other site.
Flexible endoscopy has given physicians unprecedented access to the GI tract. The ability to endoscopically visu- alize, biopsy, and apply therapy has had implications for the management of all the major GI malignancies. Accepted applications of endoscopy range from detection of malig- nant and premalignant lesions (e.g., colonoscopy for colon cancer screening), prevention of cancers through removal of precursor lesions (e.g., polypectomy), surveillance of premalignant conditions (e.g., Barrett’s esophagus), pal- liation of symptoms (e.g., placement of stents for biliary or esophageal obstruction) or staging of cancers to allow stage directed therapy (e.g., endoscopic ultrasound), and, in selected circumstances, definitive therapy for early stage neoplasms (e.g., endoscopic mucosal resection). This par- tial list of applications demonstrates the central role that endoscopy plays in management for those at risk for or with a GI malignancy. The wide variety of endoscopic techniques applied suggests a new subspecialty of endos- copy: “endoscopic oncology.” This is similar to “surgical oncology,” as it concerns itself with the subset of endo- scopic procedures directly applied for the management of neoplastic and precancerous conditions.
It becomes apparent that a substantial proportion of endoscopies are performed for a cancer-related indication.
To determine what proportion of endoscopic procedures are done out of a concern for cancer or a premalignant condition, a large national database of endoscopic reports (Clinical Outcomes Research Initiative [CORI]) was que- ried. Indications related to cancer were defined by conven- ing an expert panel (Table 2).* We then queried the CORI database to determine the proportion of endoscopies done for these indications. The CORI database encompassed 105 practice sites in 28 states and had data on 245,971 patients.
The results demonstrated that the majority of endo- scopic procedures (63.5%) in these practices were per- formed owing to a primary concern for cancer (Fig. 1). In fact, only for EGD were the majority not done for a cancer- related indication (32.7%). The great majority of colonoscopy (84.4%), ERCP (59.9%), and EUS (98.7%) procedures are
done for cancer-related indications. For colonoscopy, the major cancer-related indications are surveillance of patients with prior polyps (21.3% of cancer-related indications), evaluation of hematochezia (26.2%), follow-up of a posi- tive hemoccult test (15.6%), or surveillance in a patient with a family history of colorectal cancer (17.8%). For EGD, dysphagia was the most common cancer-related indication (62.4%) followed by anemia (23%) and Barrett’s screening/surveillance (12.2%). For ERCP, 98%
of the cancer-related indications are related to bile duct obstruction. For EUS, the primary indications related to cancer are FNA of a mass (26%), stage a known cancer (23%), or evaluate a pancreas lesion (23%).
Table 1
Incidence and Mortality of the Five Most Common Gastrointestinal Malignancies
Site Incidence
aMortality
aColorectum 53.9 21.6
Pancreas 11.1 10.6
Stomach 9.1 4.9
Liver/intrahepatic bile ducts 6.2 4.4
Esophagus 4.5 4.3
Data from SEER database 1992–2002 (www.seer.cancer.gov).
a
