Heartburn, Barrett’s Esophagus, and Cancer

Dear Dr. B: I have chronic heartburn. I have been told I have Barrett’s esophagus. I believe this is a pre-malignant condition. Should I be having scope tests every year as a method for surveillance and early detection of cancer of the esophagus?

Dear reader: Answer to this question depends on the type of changes seen in the esophagus. There are many unresolved controversies regarding the surveillance and management of this condition. Let us briefly look at the whole subject of Barrett’s esophagus and the current recommendations.

All experts agree that Barrett’s esophagus is a complication of long lasting and usually severe gastro-esophageal reflux disease (GERD) – commonly known as heartburn. This may or may not be associated with a hiatus hernia.

The condition was first described in 1950 by Sir Norman Barrett. His original description has been revised few times. Currently, Barrett’s esophagus implies change in the lining of the esophagus (of any length) from a squamous type to columnar type. This change is only recognized at the time of endoscopy and confirmed by biopsy.

Barrett’s esophagus affects mainly white men, with an average age of 55 years. It occurs in only a small percentage of people with GERD – approximately five to15 percent of patients with inflamed esophagus due to reflux. There is a small but definite increased risk of cancer of the esophagus in people with Barrett’s esophagus.

About 10 percent of patients with Barrett’s esophagus at the time of the initial endoscopic examination have coexistent esophageal cancer. Unfortunately, the 5 year survival rate for patients with esophageal cancer is only 11 percent.

Is it possible to do something to prevent Barrett’s esophagus from turning into esophageal cancer?

Regular endoscopic surveillance and biopsy is recommended for patients with Barrett’s esophagus despite the high cost and inconvenience and the lack of proof that it prolongs survival. Biopsies are done to look for dysplasia.

Dysplasia is a cellular process that occurs in the lining of the Barrett’s esophagus. Presence of dysplasia indicates increased risk of cancer. It is not a foregone conclusion that patients with dysplasia will develop cancer but dysplasia remains the best indicator of cancer risk.

How often one should have scope tests and biopsies? It depends on the presence of dysplasia in the Barrett’s esophagus:
If the patient has no dysplasia: The frequency for endoscopic biopsy surveillance is annually twice, and then, if no dysplasia is found, every 3 to 5 years. Risk of subsequently developing cancer is quite low.
If the patient has low grade dysplasia: A surveillance endoscopy with biopsies at six months, one year, and then yearly is recommended.
If the patient has high grade dysplasia: The management of high grade dysplasia involves repeating the biopsies right after the high grade is discovered to rule out an accompanying cancer. Esophagectomy (surgical removal of the esophagus) is the gold standard of therapy for high grade dysplasia and cancer, but experimental procedures are available.

The treatment for Barrett’s esophagus is, in general, essentially the same as for GERD and heartburn. It is either medical (acid-suppression drugs) or surgical (fundoplication). There is no guarantee that either treatment will result in the disappearance of Barrett’s esophagus or in a reduced cancer risk.

Thought for the week:
“Nothing can be created out of nothing.”
-Lucretius 99-95 BC

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