Is it Really Just Heartburn?
In 1977, as a young surgical resident, I was given an assignment to deliver a formal presentation to our entire faculty and all my fellow residents. My topic was cancer of the esophagus, which at that time was a relatively uncommon malignancy. In the course of my review of the literature, I discovered that for the decades prior to the 1970’s about 95% of all esophageal cancers occurred in the upper part of the esophagus and were more common in African American men, pipe or cigar smokers, alcoholics, and in people who had suffered either a thermal or chemical injury of the esophagus. At the time of my report only about 5% of cancers were associated with chronic acid reflux, which occur in the lower part of the esophagus, down near the stomach.
Over the last 30 years things have changed significantly. The incidence of adenocarcinoma of the lower esophagus has been rising steadily, to the point where today this type of cancer now accounts for the majority of esophageal malignancies. A number of theories have been suggested as to why this dramatic change has occurred, but there is no proof as to the actual cause. We know that this type of esophageal cancer is more common in caucasian men who have chronic symptoms of acid reflux. Repeated acid injury is associated with the development of a condition known as Barrett’s esophagus, where the tissues that line the lower esophagus undergo a change, looking more like the lining of the stomach. These areas are at risk for undergoing additional changes that can culminate in adenocarcinoma. Although the incidence of Barrett’s esophagus is still relatively low in the population in general, it has been steadily rising and along with it the risk of esophageal cancer. In fact, in the United States the incidence of esophageal cancer is rising faster than any other malignancy.
The presence of Barrett’s can only be determined by inspecting the inside of the esophagus with an endoscope. This procedure is commonly referred to by one of several different name: upper GI endoscopy, esophagogastroduodenoscopy, EGD, or sometimes just a scope. During the procedure biopsies can be taken of any suspicious appearing tissues, and if Barrett’s is confirmed appropriate treatment is recommended. There are some promising new treatments available for Barrett’s, but in general the primary way it is managed is by aggressively controlling the reflux of acid from the stomach up into the esophagus. This can be accomplished either with daily medications that suppress stomach acid production, or by performing a surgical procedure to improve the function of the failed anti-reflux barrier.
Unfortunately, esophageal cancer has few if any early symptoms, but as it progresses it usually causes an increasing difficulty with swallowing. These malignancies are extremely difficult to treat successfully unless they are diagnosed very early, long before there are any symptoms. Treatment may include the surgical removal of the esophagus, which is an extremely challenging and potentially disabling procedure. Radiation and chemotherapy can also be used to treat patients with esophageal cancers, but once again, a successful outcome depends largely on making an early diagnosis.
So what’s the bottom-line? If you suffer from chronic heartburn, even if its reasonably well controlled with either prescription medications or over the counter drugs, you should, at some point, have an endoscopic examination to check for Barrett’s changes. This is especially true if you are a caucasian man over the age of 50, but actually anyone who has chronic reflux is at risk.
There is an exciting new screening test for Barrett’s esophagus called Transnasal esophagoscopy or TNE. This procedure provides a direct inspection of the esophagus and stomach and can be performed in the doctor’s office without the need for sedation or general anesthesia. It only takes about 30 minutes and can provide patients who are at risk for Barrett’s the peace of mind of knowing the actual health of their esophagus.
Esophageal cancer is largely preventable, and controlling your acid reflux is the single most important thing you can do to protect yourself. As you’ve heard on countless television ads for the various acid reflux medications, it could be something more than just a little heartburn. So if you have any questions about Barrett’s or esophageal cancer consult with your doctor or check out My Heartburn is Gone.
by Robert Sewell, MD. FACS