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HEALTH JOURNAL
By TARA PARKER-POPE
Taking Heartburn Seriously: Ailment Can Lead To Deadly Consequences
August 24, 2004; Page D1
An epidemic of heartburn has triggered an alarming rise in a deadly cancer, but many people at risk still aren't being screened for the disease.
Esophageal adenocarcinoma, the most common form of cancer of the esophagus, is strongly linked to chronic heartburn and acid reflux. And it is now the fastest-growing cancer in the country. While the overall number of cases is small -- just 8,000 people were diagnosed last year -- the incidence of the disease has surged fivefold in three decades.
Screening people with a history of chronic heartburn can help can detect a dangerous precancerous condition known as Barrett's esophagus. And it can help diagnose many esophageal cancers far earlier, before symptoms arise and when long-term survival chances are the highest. Overall five-year survival of esophageal cancer is only about 15%, but when the cancer is found early, surgical removal of the esophagus and chemotherapy can improve five-year survival to about 70%.
Even so, screening for the disease remains controversial. It's expensive, costing about $1,000 per test, and many experts feel the cost isn't justified given that the vast majority of people with heartburn won't ever develop esophageal cancer. "It hasn't gotten much attention because it's not a Top 10 cancer," says David Metz, a University of Pennsylvania professor of medicine.
Exactly why esophageal adenocarcinoma is increasing at such a rapid rate isn't clear, but the evidence points to an epidemic of chronic heartburn. Heartburn and reflux occur when stomach acid sloshes up into the esophagus, causing burning pain. It's estimated that 20% of Americans suffer from weekly episodes of heartburn, while 7% suffer bouts every day.
Chronic heartburn, called gastroesophageal reflux disease or GERD, is on the rise for a number of reasons, including greater consumption of fatty foods that can slow the emptying of the stomach. Increased obesity and even moderate weight gain are also factors. Sometimes heredity, bacterial changes in the gut, or general wear and tear on the esophagus can trigger GERD.
The worry about chronic reflux is that years of exposure to stomach acids can trigger changes in the lining of the esophagus, a condition known as Barrett's esophagus, which can eventually lead to cancer.
The most effective treatments for GERD are drugs called proton pump inhibitors -- such as AstraZeneca's Nexium and Tap Pharmaceutical's Prevacid -- which limit the amount of acid the stomach produces. But the drugs are expensive, costing about $120 a month. Many insurance companies won't pay for long-term use, prompting doctors to recommend less-expensive and less-effective over-the-counter remedies such as antacids.
"There's been this trivialization of GERD -- that it's just heartburn, it's not a big problem," says Mark Sostek, a gastroenterologist and AstraZeneca's medical director for Nexium. "If in another five or 10 years this cancer rate continues to rise, people are going to look back and rue the day that we've been undertreating all these patients."
Antireflux surgery to tighten faulty valves or repair hernias at the base of the esophagus can also stop chronic reflux. Symptoms can return over time, however, and nobody really knows whether the drugs or surgery can slow the progression of Barrett's or prevent the onset of esophageal cancer.
As a result, many doctors are calling for stepped-up surveillance of GERD patients to detect Barrett's, followed by regular screening of patients found to be at higher risk. In the absence of such wide screening, most patients only discover they have the cancer when they develop swallowing problems. By then, the disease often has spread to lymph nodes or to other organs.
But there's little agreement on who should be screened and how often. The American College of Gastroenterology suggests screening men over 50 every three years if they have a history of five years or more of chronic reflux and reflux symptoms at least twice a week. Those diagnosed with Barrett's esophagus are checked more often. Screening involves an endoscopy, whereby doctors insert a thin, lighted tube into the throat of a sedated patient to view the esophagus and take biopsy samples. The procedure is simple, but may result in a mild sore throat.
The medical journal Archives of Internal Medicine published a review of the literature last month that supporting screening. But the guidelines miss large numbers of people at risk. One in eight esophageal cancer patients are women. Some GERD patients don't have typical symptoms, suffering from chronic cough rather than typical reflux.
At the same time, the journal Gastroenterology published the findings of a group of experts who concluded there's little medical evidence to support even the current screening, given the cost.
"There's still controversy," says Stuart J. Spechler, professor of medicine at University of Texas Southwestern Medical Center in Dallas and a leading expert on Barrett's. "Most physicians agree it's a good idea to screen, but it doesn't get practiced a lot for financial reasons."
Until more is known, the best advice is to eat healthful foods, manage your weight, and seek treatment for chronic heartburn. Some early studies have shown that daily aspirin use may cut risk of esophageal cancer, and studies are under way looking at whether the anti-inflammatory drugs known as Cox II inhibitors, like Celebrex, may also help treat Barrett's. Other studies have shown that regular consumption of green tea may lower risk for esophageal cancer, but data are far from conclusive.
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STOPPING HEARTBURN
Various methods to stop chronic heartburn, which has been linked to esophageal cancer:
TREATMENT..................COMMENT
Diet changes...............Fatty foods, chocolate can cause symptoms
Weight loss................Can lead to dramatic improvement in some patients
Over-the-counter remedies..Provides only temporary relief
Proton pump inhibitors.....Expensive, long-term use required
Anti-reflux surgery........Benefits don't last, drugs still needed
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• E-mail me at healthjournal@wsj.com.
KJC |
