Trial Title:
Efficacy of Endoscopy Screening on Esophageal Cancer in China (ESECC)
NCT ID:
NCT01688908
Condition:
Esophageal Squamous Cell Carcinoma
Dysplasia
Conditions: Official terms:
Carcinoma, Squamous Cell
Esophageal Neoplasms
Esophageal Squamous Cell Carcinoma
Conditions: Keywords:
Esophageal Squamous Cell Carcinoma
Endoscopic Screening
Efficacy
Cost-utility
High risk region
China
Study type:
Interventional
Study phase:
N/A
Overall status:
Active, not recruiting
Study design:
Allocation:
Randomized
Intervention model:
Parallel Assignment
Primary purpose:
Screening
Masking:
Single (Outcomes Assessor)
Intervention:
Intervention type:
Procedure
Intervention name:
Endoscopic Screening
Description:
1. Upper G.I. endoscopic examination with Lugols Iodine in esophagus
2. Biopsy at the visually abnormal sites
3. Pathologic examination of all biopsy tissue specimens
4. Subsequent re-examination and further medical services among individuals who already
have high-grade lesions found at screening.
5. Advises of endoscopic or surgical treatment will be given to participants who are
diagnosed of high grade upper G.I. lesions.
Arm group label:
Screening Arm
Summary:
To evaluate the efficacy of endoscopic screening on esophageal cancer (EC) and determine
the most cost-effective strategy of endoscopic screening in high risk population in
China, 668 villages of Hua county, a high risk area of esophageal cancer, were randomized
into screening arm and control arm in a ratio of 1:1 and the total sample size is over
32,000 (~16,000 per group). Participants in the screening arm will accept standard
chromoendoscopy examination to detect early esophageal cancer and no screening were
designed in the control arm. The incidence of advanced EC, EC-specific mortality and
all-cause mortality will be compared within the two groups to test the hypothesis that
endoscopic screening would alter the natural history of lesions in esophagus and the
incidence of advanced stage EC, EC-specific mortality and all-cause mortality in the
screening arm will be lower than the control group. Cost-effectiveness analysis will also
be conducted to find the most cost-effective strategy of endoscopic screening in rural
China.
Detailed description:
BACKGROUND Esophageal cancer (EC) is one of the most common cancers in the world, and is
a leading cause of cancer death, with more than 450,000 new cases and 400,000 deaths in
2012.Nearly half of the new cases of EC worldwide are found in China, and esophageal
squamous cell carcinoma (ESCC) is the predominant histologic type. A series of etiologic
factors for ESCC have been proposed in previous studies conducted in high prevalence
regions of China, including age, family history of ESCC, poor nutritional status, smoking
and drinking, chemical carcinogen exposure, and human papillomavirus (HPV) infection. But
the main etiologic factors have not been definitively identified.
Because there are typically no symptoms in the early stages of ESCC, the vast majority of
cases are clinically diagnosed at an advanced stage. The overall five-year survival is
about 20% in China, and is even lower in less developed countries. However, if the
disease is found at an early stage, the five-year survival may be 80% or greater. This
profound improvement in survival indicates there is clearly a need for effective early
detection strategies to enable earlier diagnosis and curative treatment. Esophageal
squamous dysplasia (ESD) is considered to be the premalignant precursor lesion for ESCC,
and harbors a high risk for progression into invasive cancer. ESD as well as early-stage
malignant lesions (carcinoma in situ, CIS) are therefore screening targets for ESCC.
Various screening methods have been tested, and endoscopy with iodine staining is the
gold standard technique for the diagnosis of ESCC and its precursor lesions. Endoscopic
screening has therefore been widely accepted as an optimal strategy in the secondary
prevention of ESCC. However, taking the high cost and invasive nature of endoscopy into
consideration, the efficacy and cost-effectiveness of such screening, must be evaluated
prior to introduction of a population-wide screening program. Evidence regarding the
efficacy of endoscopic screening for ESCC has been based predominantly on observational
studies in high risk regions. There has been only one non-randomized controlled trial
which reported that endoscopy plays a positive role in reducing mortality. No randomized
controlled trials (RCTs) evaluating endoscopic screening have been reported to date.
Observational studies and trials which are not randomized are limited in determining the
true benefits of screening on reducing mortality due to potential lead-time bias,
length-time bias and confounding bias. Hence, one-step large-scale population-based RCT
are needed to determine the efficacy of endoscopic screening for ESCC.
In January 2012, we initiated the ESECC (Endoscopic Screening for Esophageal Cancer in
China) trial in rural Hua County of Henan Province, which is a high-risk region in
northern central China. This is the first population-based RCT aiming to evaluate the
efficacy and cost-effectiveness of endoscopic screening for ESCC worldwide.
STUDY DESIGN Setting and participants This ESECC trial was undertaken in rural Hua
County, which is an agricultural region in the northern part of Henan Province, Peoples
Republic of China with a rural population of 1.1 million. The mortality for ESCC in this
area is among the highest in the world.
Participants were eligible for the study if they meet the following criteria: 1)
permanent residency in a target village; 2) age 45-69 (>5 years of life expectancy), and
no history of endoscopic examination within 5 years prior to the initial interview; 3) no
history of cancer or mental disorder; 4) negative for hepatitis B virus (HBV), hepatitis
C virus (HCV) and human immunodeficiency virus (HIV); 5) voluntary participation and
agreement to complete all phases of the examination.
Randomization This ESECC trial was designed as a cluster RCT. There are a total of 968
villages in rural Hua County, and 668 target villages were randomly selected from the 846
villages with population sizes ranging from 500 to 3,000 in Hua County. These 668 target
villages were randomly allocated into the screening arm of the study or the control arm
at a ratio of 1:1 (334 villages in each arm), using a blocked randomization procedure
based on the total population size of each village for balancing the sample sizes between
the two study arms.
Sample size According to the New Rural Cooperative Medical Scheme (NCMS) registration
system of Hua County, the combined incidence rate of advanced esophageal cancer and
cancer of the gastric cardia in the targeted population (age 45-69) was estimated to be
184.07/100,000 in 2011. Calculation of required sample size was based on the following
assumptions: the average period of progression from severe dysplasia to EC is 5 years,
and the accrual time is 5 years; the study period was set at 10 years, and 5% of the
participants would be lost to follow-up per year; 5% of the participants in the control
arm would seek endoscopic examination independently during the study period. Finally,
with a total of 32,337 participants enrolled (1:1 between arms, ~20% of all eligible
residents in target villages), statistical power of 86% at a one-sided 0.025 significance
level can be achieved, even if only 30% of advanced EC cases were protected by screening.
The number of participants enrolled in each target village was determined by the weight
of the population size of the very village in the total population of the whole arm.
Intervention An informed consent was obtained from each study participant. Basic
information including name, gender, date of birth, address and phone number was then
collected and managed using a custom-designed database system. All participants received
a physical examination which included measurement of height, weight and blood pressure.
Blood samples were collected to screen for HBV, HCV and HIV, and participants with any of
these infections were excluded. A computer aided one-on-one questionnaire investigation
was conducted for all participants by trained interviewers to collect data on potential
risk factors for esophageal cancer. EQ-5D-3L, a standardized generic instrument, was used
in this ESECC trial to assess health related quality of life (HRQOL).Standardized
explanations regarding the items in the questionnaire were provided if the participant
was unable to understand the questions or respond appropriately.
In the screening arm, standard upper gastrointestinal endoscopy (UGE) with iodine
staining was performed by physicians experienced in endoscopic examination. The entire
esophagus and stomach were visually examined and biopsies were taken from all focal
lesions. Standard sites in the esophagus (28 and 33 centimeters distal to the incisors in
the 6 o'clock position) were biopsied if no visually identifiable abnormalities were
found elsewhere. Biopsy specimens were fixed in 10% formaldehyde, embedded in paraffin,
sectioned at 5μm, and stained with hematoxylin and eosin. The biopsy slides were reviewed
by pathologists at Anyang Cancer Hospital without knowledge of the endoscopic findings.
Diagnoses of ESD (mild, moderate and severe), CIS and squamous cell carcinoma were
independently confirmed by two pathologists and discrepancies in their histologic
diagnoses were adjudicated by consultation. To reflect the situation in real
population-level screening as much as possible, participants who were diagnosed with
severe squamous dysplasia, CIS or squamous cell carcinoma in the esophagus or malignant
lesions in other sites were only informed of the diagnosis and provided with appropriate
medical advice, rather than arranging directly for their further clinical treatment.
In the control arm, no endoscopic screening was performed and an abdominal ultrasound
scan which had no association with the diagnosis of esophageal cancer was used.
Follow-up and outcomes The primary endpoint of the trial was EC-specific mortality, and
the secondary endpoints included mortality from all causes, incidence of advanced EC and
cost per quality-adjusted-life-year (QALY) gained. Two sources of follow-up data were
used to identify outcome events in this study, namely door-to-door interviews, and
electronic registry data. A record of vital events, including the experience of UGE,
onset of cancer and death, will continue to be collected through annual door-to-door
interviews with all cohort members. Data regarding cancer occurrence and death were also
collected from the New Rural Cooperative Medical Scheme (NCMS) of Hua County, which is a
government-run health insurance program in rural China with a nearly 100% participation
rate which has been proved to be an ideal data source regarding cancer occurrence,
diagnosis and treatment, and from the Death Registry of National Centers for Disease
Control and Prevention (DR-CCDC) respectively.
Ethics statement This trial was approved by the Institutional Review Board of the Peking
University School of Oncology, China. Informed consent was obtained from each
participants.
Criteria for eligibility:
Criteria:
Participants were eligible for the study if they meet the following criteria: 1)
permanent residency in a target village; 2) age 45-69 (>5 years of life expectancy), and
no history of endoscopic examination within 5 years prior to the initial interview; 3) no
history of cancer or mental disorder; 4) negative for hepatitis B virus (HBV), hepatitis
C virus (HCV) and human immunodeficiency virus (HIV); 5) voluntary participation and
agreement to complete all phases of the examination.
Gender:
All
Minimum age:
45 Years
Maximum age:
69 Years
Healthy volunteers:
Accepts Healthy Volunteers
Locations:
Facility:
Name:
Laboratory of genetics, Peking University cancer Hospital and institute
Address:
City:
Beijing
Zip:
100142
Country:
China
Start date:
January 1, 2012
Completion date:
December 31, 2027
Lead sponsor:
Agency:
Peking University
Agency class:
Other
Source:
Peking University
Record processing date:
ClinicalTrials.gov processed this data on November 12, 2024
Source: ClinicalTrials.gov page:
https://clinicaltrials.gov/ct2/show/NCT01688908
https://www.ncbi.nlm.nih.gov/pubmed/29306867
