Barrett's Esophagus May Be Less Risky Than Thought
Study Questions Need for Invasive Screening in Patients With Barrett's Esophagus
Questions About Cancer Screening continued...
But the debate over screening for cancer of the esophagus may be even more pitched because the cancer is so lethal and it's on the rise in the U.S.
"If you get the cancer, you don't survive, by and large," says Peter J. Kahrilas, MD, a gastroenterologist at Northwestern Memorial Hospital and a professor in the department of medicine at the Feinberg School of Medicine at Northwestern University in Chicago.
"The only strategy for surviving the cancer, and this is the irony of the whole thing, is early detection," says Kahrilas, who was not involved in the research but wrote an editorial on the study.
To many doctors, that means a diagnosis of Barrett's, one of the few established risk factors for cancer of the esophagus, shouldn't be ignored.
"As an esophageal surgeon who deals with esophageal cancer and who has to at times tell people, 'I'm sorry, this is now metastatic [the cancer has spread], I can't operate on you,' I have a hard time reconciling inside of myself telling someone with Barrett's, 'You have Barrett's. Don't worry about it. You don't need any further examination.' That makes me very, very nervous," says Christian G. Peyre, MD, an assistant professor of surgery at the University of Rochester Medical Center in New York. Peyre was not involved in the study.
The better question in Peyre's mind is how often people with Barrett's need to be checked.
Guidelines suggest doing a test called an endoscopy with a biopsy every two to five years in people who have Barrett's esophagus or even persistent heartburn.
The endoscopy test involves inserting a lighted tube through the mouth into the esophagus. A biopsy of the esophagus can be performed during the procedure. The test should be repeated more frequently if precancerous cells are found.
Indeed, the study found evidence that cancer was more likely in people who had Barrett's esophagus with precancerous cells, called dysplasia.
"I think that all patients with new GERD [acid reflux] symptoms should undergo endoscopy," says study researcher Peter Funch-Jensen, MD, a researcher in the department of clinical medicine at Aarhus University in Denmark, in an email.
Still, the diagnosis of dysplasia is subjective, since it relies on the judgment of the doctor. The American Gastroenterological Association recommends that a diagnosis of dysplasia be confirmed by at least one additional pathologist.
Routine Surveillance of Barrett's Esophagus?
If no dysplasia is found, "no routine surveillance is probably indicated," Funch-Jensen says.
"The second people get told they have a cancer or a risk for cancer, they start to not sleep at night very well, so it becomes a big issue," says Brian Reid, MD, PhD, member of the human biology division at Fred Hutchinson Cancer Research Center in Seattle. Reid is also principal investigator of the Seattle Barrett's Esophagus Research Program.
"The fundamental difficulty that we have is that there's widespread screening for Barrett's, yet probably only 5% or so will go on to develop a cancer during their lifetime. The remaining 95% will die of something else," Reid says.
Experts say the quandary will likely only be solved by the discovery of new indicators for cancer of the esophagus and better tests.
"We have to come up with a better way of screening," says Kahrilas. "We have to come up with a way of screening that is inexpensive, unobtrusive, and cost-effective."