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 were classified as squamous cell carcinoma. These tumors typically occur in the upper part of the esophagus and are more common in African American men, pipe or cigar smokers, alcoholics, and in people who have suffered either a thermal or chemical injury of the esophagus. At the time of my report the remaining 5% of cancers consisted of what are called adenocarcinoma. These occur in the lower part of the esophagus, down near the stomach, and are commonly associated with chronic acid reflux.
Over the last 30 years things have changed significantly. The incidence of adenocarcinoma 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 unlike squamous cell cancers these tumors are more common in caucasian men who have chronic symptoms of acid reflux. Repeated acid injury is well known to be associated with the development of a condition known as Barrett’s esophagus, where the esophageal lining changes into tissue that looks more like the lining of the stomach. These abnormal areas of mucosa are at further 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 this type of cancer.
The presence of Barrett’s changes 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 then recommended. There are some promising new endoscopic treatments available to treat Barrett’s, but in general the primary way to manage the problem is to aggressively control 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 between the stomach and esophagus.
Unfortunately, esophageal cancer has few if any early symptoms, but as it progresses patients typically complain of increasing difficulty swallowing. These malignancies are extremely difficult to treat successfully unless they are diagnosed very early, long before there are any symptoms. The most effective treatment is often the surgical removal of the esophagus, 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 esophagus. 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. 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. If you have any questions about Barrett’s or esophageal cancer consult your doctor.