Prospective evaluation of high-risk assessment strategy for esophageal cancer: a community-based cancer screening cohort in rural China

Abstract Objective To evaluate a questionnaire-based strategy for risk stratification in population-based esophageal cancer(EC) screening in China. Methods 120,488 residents from four cancer screening centers in Shandong Province were enrolled in a prospective cohort between 2013 and 2018. Participants were followed prospectively for the incidence EC, gastric cancer(GC), and upper gastrointestinal cancers(UGI). Cumulative incidence was estimated using the Kaplan–Meier method. Associations between high-risk classification and cancer incidence were evaluated using Cox proportional hazards models. Results were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). Propensity score matching (PSM) was performed to minimize potential confounding. Results During a median follow-up of 8.32 years (IQR, 6.76–9.93), 593 EC, 374 GC and 967 UGI cases were identified, corresponding to incidence densities of 58.91, 37.16, and 96.07 per 100,000 person-years, respectively. High-risk participants had significantly higher cumulative incidences of all outcomes compared with non–high-risk participants (log-rank test, P < 0.05). High-risk classification remained significantly associated with increased risks of EC (HR, 1.74;95%CI, 1.47–2.06), GC (HR, 1.29;95%CI, 1.05–1.58), and UGI (HR, 1.55;95%CI, 1.36–1.76). Conclusions The questionnaire-based high-risk assessment strategy effectively identifies asymptomatic individuals at elevated risk of EC, GC, and UGI who may benefit from prioritized endoscopic examination. This strategy is an efficient, scalable tool for primary risk stratification in population-based screening programs.