Advances & Insights: Cancer
May 2, 2006
What the news means for you
Daniel E. Kenady Sr., MD, FACS
Prevention is key in dealing with esophageal cancers
I think this new therapy the Mayo Clinic is testing is very promising. We use radiofrequency ablation quite often now at the University of Kentucky for treatment of liver tumors. Absolutely, if you can get rid of Barrett’s esophagus, that’s the way to go because we know it is premalignant.
"If you can get rid of Barrett's esophagus, that's the way to go because we know it is premalignant."
We are definitely seeing more patients with esophageal cancer. In the last six months I’ve seen 20 or so. Ten years ago it was less that half that number. The age ranges we see are mainly in people over 50, and men are more likely than women to have this disease. It does not seem to be a familial type cancer.
Preventive therapy is the best approach, particularly for esophageal cancer where 85 to 90 percent of the patients die, usually within a couple of years. For those we are able to cure, therapy is extensive—chemotherapy, radiation and surgery. It’s really a tough cancer to treat.
Cancer's link to Barrett's
We know Barrett’s is increasing and that esophageal cancers are changing. They used to be mainly squamous cancers, which are cancers of the native cells. Now they’re mainly adenocarcinomas. Chemical changes from Barrett’s cause the squamous cells to become gland-producing, or the “adeno,” cells.
Barrett’s has become more common because we’re seeing more GERD, which is certainly more prevalent in obese people. We’re setting an obesity epidemic now, particularly in Kentucky. Unfortunately, many people with GERD won’t go to the doctor just for heartburn or regurgitation, so they treat themselves with antacids.
A person with established GERD shouldn’t drink anything with caffeine. We used to think spicy foods were a problem, but that’s really been pretty much negated. Certainly people should stop smoking and limit alcohol intake because those practices are other key risk factors for Barrett’s.
The mainstay for people with Barrett’s now is proton pump inhibitors, a class of drugs that cuts acid production. Using those agents has made a dramatic improvement, although it won’t reverse the damage caused by Barrett’s. Most are prescription drugs like Prevacid and Nexium, although Prilosec is now available over the counter.
People with Barrett’s have at least mild dysplasia, that is abnormal cell development, but we worry more about the severe type because it can progress to cancer. It’s unusual for a person to have symptoms in the early stages of esophageal cancer. It’s often grown quite extensively before a patient has symptoms.
Symptoms of esophageal cancer
The main symptoms of esophageal cancer are chest pain and difficulty swallowing. Early symptoms people should pay attention to are the symptoms of GERD. If you have an episode of heartburn every three to six months, I don’t think that’s cause for alarm, but if it’s something that persists—particularly if you have daily symptoms—it would be worthwhile to see your primary care physician and ultimately a gastroenterologist for an endoscopic exam.
If we find a patient has severe dysplasia, we usually recommend removing the esophagus, because we know that a very high percentage of them will go on to get esophageal cancer. Many already have it; the right place has just not been biopsied yet.
I usually do a transhiatal esophagectomy, which is performed through the neck and abdomen. Once the esophagus is removed, I actually use the stomach, which has a rich blood supply, and take part of this supply and move it into the chest after removing the esophagus. The stomach is then sewn into the remnant of esophagus left in the neck. We do probably 15-20 of these surgeries a year, a moderate amount.
"Radiofrequency ablation therapy is...exciting because it might prevent the need for [removal of the esophagus], which we often employ as a pre-emptive treatment..."
Preventing or reversing Barrett's
There are really no other good options once Barrett’s has developed. That’s one reason the radiofrequency ablation therapy is so exciting because it might prevent the need for such surgery, which we often employ as a pre-emptive treatment in severe dysplasia.
An option for preventing Barrett’s esophagus is an anti-reflux surgery called a Nissen fundoplication, where one wraps the top of the stomach around the esophagus. Many patients lose the sphincter between the esophagus and the stomach that keeps the acid from going up into the esophagus. A lot of them have hiatal hernias, and this could predispose them to Barrett’s or acid reflux. These procedures are done laparoscopically, so they are less complicated. We do a number of them at UK.
What have we learned:
- Barrett’s esophagus, chronic acid reflux, heavy drinking and smoking are the greatest risk factors for esophageal cancer.
- If you have weekly symptoms of acid reflux or heartburn, see your primary care physician to determine whether you have GERD.
- GERD can usually be treated with medication. If the condition doesn’t respond to medication, you need an endoscopy for further evaluation.
- Patients who have this condition and do not treat it are more likely to develop Barrett’s esophagus, a precancerous condition.
- The most effective way to fight esophageal cancer is prevention. Early detection is often impossible, and symptoms may not present until later stages.
- GERD is mainly diagnosed by history. An upper endoscopy gives a clearer picture of whether you have Barrett’s, dysplasia or changes that are consistent with GERD.
Dr. Kenady is a surgical oncologist with the Markey Cancer Center and a professor of surgery at the UK College of Medicine.
New therapy sought to prevent esophageal cancer
In searching for ways to slow the increase of a dangerous form of esophageal cancer, researchers at the Mayo Clinic are testing the effectiveness of a new treatment method for patients with a high-risk condition known as Barrett’s esophagus. According to the American Cancer Society (ACS), in a year’s time one in 200 Barrett’s patients will develop cancer of the esophagus.
A minimally invasive procedure is being studied in Barrett’s esophagus patients to treat this precancerous condition.
Barrett’s esophagus is associated with the fastest growing type of cancer in the nation—esophageal adenocarcinoma. The ACS estimates 14,550 new cases of the disease will be diagnosed in 2006. There is particular urgency to prevent the disease because it is often symptom-free until the advanced stages. As a result, only about 16 percent of esophageal cancer patients survive five years.
Radiofrequency ablation therapy
Dr. V.K. Sharma of the Mayo Clinic in Scottsdale, Ariz., is leading a study examining the use of radiofrequency ablation therapy to remove the damaged tissue in patients with Barrett’s esophagus, allowing the growth of new, healthy tissue. The procedure is done with a new device by Barrx Medical Inc. that was approved last year by the U.S. Food and Drug Administration (FDA).
In March, Barrx began funding a study of 120 patients at Mayo and 15 other medical centers to see how well RF ablation treats Barrett’s patients with precancerous dysplasia. The minimally invasive procedure uses a device mounted on a balloon catheter to deliver controlled ablative energy to the tissue. It takes just under half an hour and is performed in an outpatient setting.
Barrett’s esophagus is believed to be linked with chronic reflux of stomach acid into the esophagus, although not all Barrett’s patients experience the associated symptoms of heartburn. Severe gastroesophageal acid reflux disease, or GERD, can cause the cells lining the esophagus to break down and undergo genetic changes that may set the stage for cancer. Estimates are that 5 to 7 percent of the global population is affected by GERD.
The most common approach to managing Barrett’s esophagus involves regular endoscopic procedures and tissue sampling, monitoring for disease progress and drug therapy to control GERD symptoms and prevent acid-related injury to the esophagus. Lifestyle changes may include losing weight, avoiding foods that aggravate heartburn and stopping smoking.
Other reversal techniques such as photodynamic therapy, which uses a specialized light source to burn away the tissue, are still being evaluated for their long-term effectiveness in preventing cancer.
Some experts believe the esophagus should surgically be removed in patients with Barrett's and high-grade dysplasia.
Some experts believe that esophagectomy should be used for patients with Barrett’s and high-grade dysplasia. This is a high-risk surgery in which the esophagus is removed completely and the stomach pulled into the chest.
Obesity, smoking are factors
People who are overweight or obese are at increased risk for developing acid reflux disease or Barrett’s. According to the Kentucky Long Term Policy Research Center in Frankfort, one in four Kentuckians is obese, and one in 32 is more than 100 pounds overweight, as compared to one in 40 nationally. The U.S. Department of Health and Human Services has set a national goal of reducing obesity in adults to 15 percent or less of the population in all states by the year 2010. Kentucky also has the highest smoking rate in the nation, another major risk factor for esophageal cancer.
For more information, see:
Barrett’s esophagus, National Digestive Diseases Information Clearinghouse
Esophageal cancer, Health Information, UK HealthCare
Marty Driesler Cancer Project Fact Sheet , UK HealthCare
Esophageal cancer, National Cancer Institute
Chronic heartburn can increase risk of esophagus cancer, study shows, New York Times, March 18, 1999
UK HealthCare Cancer Services - Markey Cancer Center
For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at (800) 333-8874.