01:59pm Friday 17 January 2020

Esophageal Cancer and Barrett's Esophagus

In a small percentage of those patients, a complication called Barrett’s esophagus can lead to cancer.  While that percentage is small, around one percent, it can be very deadly. 

Steven Edmundowicz, MD, chief of endoscopy in the division of gastroenterology at Washington University and Barnes-Jewish Hospital explains the risks as well as a new procedure for Barrett’s in this Q&A.

What is Barrett’s esophagus?


It’s a change in the lining of the esophagus that occurs we think in patients who have long standing gastroesophogeal reflux or heartburn where acid is coming up into the esophagus and irritating those cells.  And like in many other sites of the body where there is chronic irritation, there can be cell turnover and this can lead into dysplasia and cancer.


The risk of Barrett’s developing into cancer is quite low, correct?


There is a risk of cancer, but the risk of cancer development in Barrett’s esophagus is quite low when you look at individuals with Barrett’s.  Probably less than one or two percent.


Although the percentage is low, how deadly can it be?


Unfortunately, cancer of the esophagus is a very significant disease and can be very deadly depending on the stage you detect it. If you detect it early it’s 90% curable.  If you catch it late once it’s spread it’s five percent curable.


Why is it important to catch it so early?


In the early stage of cancer you don’t have many symptoms so you don’t know something is going on there.  That’s one of the advantages for patients with Barrett’s esophagus is because we’ve identified a pre-cancerous condition and we can look with flexible endoscopes in the esophagus.


You have a minimally invasive treatment for Barrett’s.  What is it?


Our initial data shows you can treat this disease very effectively and make the pre-malignant cells go away without doing a major surgical therapy to remove the actual esophagus.  The advantage of that is it can be done as an outpatient.  It can be done over a course of time and it can give you very good results as opposed to a surgical resection.  Not that a surgical resection isn’t a very effective therapy to remove early cancer, but there are risks and complications associated with an aggressive surgery where you’re actually removing the esophagus from a patient


What are the advantages of this versus an open surgery?


Surgical resection has a couple of advantages.  One is that it removes all of the cells of the esophagus and if there is a superficial cancer there or even a small lymph node that may have cancer in it, it’s removed at the time of surgery.  The surgical therapy has been the gold standard over the years and it’s a very effective way to treat esophageal cancer.  The disadvantage of the surgical therapy is because it’s a medical intervention, there are complications related to anesthesia, there can be leaks, there can be infections.  Plus, patients have to adapt to eating without their esophagus in place.  Many people have difficulty afterwards in terms of regurgitation and swallowing.


The endoscopic therapy or radiofrequency ablation eliminates many of those problems because the esophagus stays in place.  You merely take out the lining of the esophagus that is the problem and you leave the muscle layers there.  And the body has a way to regrow the lining of the esophagus as long as we control the acid reflux that was causing the Barrett’s esophagus in the first place.  So this was really a therapy that involves life long medication to reduce acid in the esophagus.  Plus the heat energy that causes the bad lining of the esophagus to sluff off if you will.


Have you done any research into this?


We were part of a multicenter study that looked at the use of this technology particularly in patients that already had dysplasia in their Barrett’s segment and dysplasia is a step towards cancer.  Not cancer, but a step towards cancer.  That can be identified by biopsies of the esophagus.  And what we found was in using this technology, we can effectively reduce or eliminate the amount of dysplastic cells in the esophagus and in over 80 percent of the patients we could eliminate all the dysplastic cells.  In a smaller number of patients with high grade dysplasia, we could also eliminate the number of cells and we could reduce the transmission from dysplasia to cancer in the patients we treated when we compared them to patients who had those findings but were kept just on the medicines to control acid reflux. 


I should clarify this is a preliminary report and this is only one year data and we’re really looking at 3-5 year period for patients with this disease but we’re very encouraged by our early findings and we do believe this is a very effective alternative to other therapies for Barrett’s esophagus.


What’s the overall message you want patients to know about Barrett’s esophagus and esophageal cancer?


I think there’s a couple of messages.  One is for those of you who have Barrett’s esophagus you should first be assured that while it’s being followed by physicians and under surveillance, your chance for developing a problem with Barrett’s esophagus going on to cancer is very, very low.  The second message is if you’re having symptoms of difficulty swallowing, food sticking in your esophagus, you’re losing weight those are signs you may have a more advanced problem and you may have to talk with your doctor.


Third thing is if you have a history of cancer in the esophagus, if you’ve had other relatives who’ve had Barrett’s esophagus who’ve gone on to cancer, you should discuss that with your doctor because those patients may be at a higher risk of developing Barrett’s esophagus and if we can identify it and catch it at an early stage then we can actually have an effective way to maintain those patients without developing cancer.


The last thing is if you have chronic heartburn or if you have chronic symptoms that are requiring you to take Tums or antacids on a daily basis and you find yourself not getting relief from those medications or getting partial relief, you really need to discuss that with your doctor because that’s one of the signs of ongoing reflux disease and that can lead to development of Barrett’s esophagus.


Jason Merrill



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