Category: Medicine Hat News

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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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PSA and Prostate Cancer

Dear Dr. B: Recent reports on PSA and prostate cancer have really confused me. Can you please tell me about the tests required for early detection of prostate cancer and where does PSA fit in?

Dear Reader: You are not the only one who is confused. PSA-based screening for prostate cancer has always been confusing and controversial. Even doctors are confused!

I am into my seventh year of writing these columns. And looking back I have written at least five columns on PSA and prostate cancer. And we haven’t heard the last word on it.

Let us look at the recent media attention given to PSA and prostate cancer. An article published in the New England Journal of Medicine (NEJM) asks: What is the prevalence of prostate cancer among men with low prostate-specific antigen (PSA) levels?

Currently, the cut off point for PSA level is 4 ug/L. If the PSA level is 4 ug/L or more then the patient is referred for a biopsy of the prostate gland to check for cancer.

Some experts have argued that this cut off point is high and we may be missing lot of cancers in patient whose levels are lower than 4 ug/L.

The NEJM article reports on the results of PSA levels and prostate biopsy done on 2950 men who completed the seven-year-trial. The study found that the risk of cancer increased with increasing PSA level, from 6.6 per cent for levels of 0.5 ug/L or less to 26.9 per cent for level of 3.1 to 4.0 ug/L.

It has been estimated that by using the current cutoff point at 4 ug/L we will miss up to 82 per cent of cancers in younger men and 65 per cent of those in older men. This finding is the most recent reminder that that PSA measurement is not a good screening test for early detection of prostate cancer.

Is there anything better? Unfortunately, no! It is suggested that monitoring the rate of rise of PSA levels over time may help. For example, if your baseline PSA is 1.0 ug/L and over a period of time it gradually increases then there may be an indication for prostate biopsy. This hypothesis has not yet been validated.

Prostate cancer is the most frequent cancer and the second leading cause of death from cancer in men, exceeded only by lung cancer. In our region, 80 to 90 new cases of prostate cancers are diagnosed each year. And each year 10 to 15 patients die of the disease.

Every man, who lives long enough, will develop prostate cancer. The risk of getting prostate cancer increases rapidly after the age of 50. In fact, by age 75, the risk of getting prostate cancer is 30 times higher than age 50.

So, for early detection tests, what we have is better than nothing. The current tests are digital rectal examination and PSA blood test and they are still available. How often one should undergo these tests also remains controversial. But the best thing is to discuss your risk factors with your doctor and he or she can advise you accordingly.

Thought for the week:

“Success is that old A B C – ability, breaks, and courage.”

-Charles Luckman

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Interesting Medical Stories

Medical science has many interesting stories. To day, let me share with you three stories which were published recently.

Which twin is the father?

Answer to this question is expected to come from Mr. Justice Paul Jolin of the Quebec superior court. It involves a Montreal man claiming paternity of his former girlfriend’s five-year-old child.

The woman has acknowledged that she had an affair with the man. But she was also having sex with his twin brother at the time of conception – a tripartite relationship!

So, who is the father? Can DNA answer the question?

Identical twins have similar DNA. That means it may be impossible to determine who the father is. The judge has ordered the man seeking paternity to undergo DNA test to see if his claim has some relevance. If there is some relevance then the brothers may have to undergo DNA testing to see if they are identical twins.

The court does not cover the cost of DNA testing. And it looks like there is no legal precedent for this unusual court case. A Montreal lab charges $645 for legal paternity testing. It also charges $195 to establish if siblings are identical or fraternal twins, says a report in the Globe and Mail.

Well, King Solomon, where are you?

India finds creative uses of condoms.

A report in the Medical Post says that condoms earmarked for an AIDS prevention program in India are being snapped up by businesses to build roads, waterproof roofs and to polish gold-embroidered garments.

India’s auditor general says that only one-quarter of the condoms in India are being used for birth control and protection against sexual diseases. India manufactures 1.5 billion condoms annually.

The report says that contractors add condoms to concrete and tar to make roads. The latex in the condoms helps make the roads smooth and resistant to cracks.

Roofers spread an underlayer of condoms that melt and form a seal. India’s military has covered gun and tank barrels with condoms as protection against dust.

Weavers use lubricated condoms to maintain their looms and to polish the gold in sari material. People in rural areas also use them as portable water containers while in the field.

History of condoms is interesting. An internet site says that early condoms were made of linen or pig or sheep’s gut, tied at the end with ribbon. After sex, they were rinsed out and reused!

In England, condoms are known as ‘French Letters’. In Italy, they used to be called ‘English Overcoats’

Well, now you know, there is more to condoms than sex!

Thought for the week:

Raquel Welch, the sexy 62-year-old actress says her secret of youthful beauty is -exercise, diet and attitude. She says, “If you are feeling great, you look better.” Well then let us all keep smiling!

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Trans-fats

Dear Dr. B: What are trans-fats? Why all the fuss about them?

Before we discuss trans-fats we need to understand something about fat and fatty acids.

Fat is an important component of our diet. It is made up of two main groups of fatty acids – saturated and unsaturated fatty acids. Unsaturated fatty acids are further subdivided into mono and poly-unsaturated fatty acids.

Experts say that our diet should contain less than 30 percent of fat. But who on earth would be able to calculate what percentage of fat he or she eats in a day? I have never been able to figure out how much fat is in my diet.

What I try to remember is that anything I eat that is oily, greasy or fatty immediately gets converted into fat and goes to my storage areas in my waist and butts. Eating fat hardens my arteries and raises my cholesterol level. And eating fat makes me fat. So, no surprises there!

Some fatty acids are good for us. But we should know which ones to eat so we can make the right choice. We should avoid foods containing saturated fatty acids and trans fatty acids. They are not good for our arteries and heart. We should eat food containing unsaturated fatty acids (both mono and poly) and Omega-3 fatty acids.

Red meat, poultry, most dairy products (butter, cream, cheese, and full-fat milk), coconut oil, palm and palm kernel oil contains saturated fatty acids. But some of the stuff listed here tastes so good that it is hard to not to eat this! But we have to be careful. We should minimize saturated fat in our diet.

The dreaded trans-fats are artificially produced. They have the properties of saturated fats. They are also known as hydrogenated fats. Hydrogenation is a process where by liquid oils are made more solid i.e. unsaturated fat is processed to become more saturated which helps to increase the shelf life of processed foods.

Trans-fats are found in bakery products (crackers, cookies, and cakes), fried foods (chips, french fries), other commercial snack foods, and margarine made with partially hydrogenated vegetable oil or shortening.

Now, who can resist the temptation of freshly baked cookies and cakes? I guess we have to if we want to stay healthy. Trans-fat is very popular with food manufacturers. They increase the shelf life of their products, and often improves the texture of the food as well. That improves sales and profit margin!

When it comes to trans-fats and saturated fatty acids, the best thing is to eat leaner meats and low-fat dairy products. And avoid commercial foods that contain partially hydrogenated vegetable oil or shortening. Read the labels when you buy cookies, crackers, microwaved popcorn, vegetable shortening and some margarine.

Unsaturated fatty acids help reduce blood cholesterol and Omega-3 reduces the risk of heart disease. Olive, canola and peanut oils, sesame, soy, corn, sunflower oils, non-hydrogenated margarines and nuts and seeds are good. And eat lots of fish – two to three times a week for Omega-3 fatty acids.

Well, I am getting hungry. I wonder if my favorite peanut butter chocolate chip cookie from Tim Horton’s has trans-fats. Well, do I really want to know?

Thought for the week:

“There is one way to be born, but a million and one ways to die.”

-Newsweek.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!