Large-scale esophageal cancer screening through noncontrast computed tomography and artificial intelligence

The absence of accurate, noninvasive, scalable screening tools keeps early esophageal cancer (EC) detection a global health challenge. Although noncontrast computed tomography (NC CT) is widely accessible, the esophagus is a hollow tubular structure prone to collapse and motion artifacts, making small early malignant lesions difficult to distinguish from normal tissue. Here we developed the Esophageal AI-Guided malignant Lesion Evaluation (EAGLE) model to detect precancerous lesions and cancer from chest NC CT, a task historically considered impossible. EAGLE was trained on 6,813 patients from two centers and validated across 12 centers in three countries involving 80,612 patients in opportunistic and population-based screening settings. For opportunistic screening on existing CT scans, multicenter external test cohorts (eight centers, n = 11,466) achieved 98.5% specificity, with 90.0% sensitivity for cancer and 52.5% for precancerous lesions; low-dose CT (LDCT) validation (two centers, n = 1,607) showed comparable performance, supporting EC screening through lung-cancer screening programs. Calibration in a real-world cohort (three centers, n = 35,402) reduced false positives by 72.7% while preserving sensitivity; prospective hospital validation (n = 17,446) achieved a 42.2% PPV, and real-world low-dose screening (n = 10,959) reached 99.94% specificity. EAGLE also detected precancerous lesions-in paired CT-endoscopy cohorts (two centers, n = 702), sensitivities were 65.0% for precancerous lesions and 78.4% for stage I EC at a higher-sensitivity operating point. Exploratory analyses of a prospectively enrolled cohort suggest that referring high-risk individuals for endoscopy could improve screening efficiency. In conclusion, EAGLE has the potential to serve as a scalable tool for early EC screening. Chictr.org.cn identifier: ChiCTR2300074806 .