Endoscopy Overused in Heartburn Patients
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Scoping for Dollars
Fear of a malpractice lawsuit over a missed cancer, financial incentives, and expectations on the part of GERD patients and their primary care providers, who refer them to gastroenterologists for evaluation, are among the factors behind the overuse of upper endoscopy, the authors write. “We have always equated better care with more care,” Shaheen says. "That’s just the American way.”
But GERD symptoms alone are a poor predictor of esophageal adenocarcinoma risk, according to the paper. For one, 40% of people diagnosed with the cancer have no heartburn. For another, 80% of cases of esophageal adenocarcinoma occur in men, possibly because they’re more likely to carry their excess weight in their belly, where it can do more harm than in other parts of the body.
In other words, the authors write, a woman with GERD is as likely to develop esophageal adenocarcinoma as a man is to develop breast cancer. Men don’t routinely get mammograms, so women with GERD shouldn’t routinely get upper endoscopy, Shaheen says.
When to Scope
Upper endoscopy should be performed only in these groups of GERD patients, according to the advice paper:
- People with “alarm symptoms” such as bleeding, anemia, weight loss, difficulty swallowing, and recurrent vomiting. Men and women whose GERD symptoms persist after taking a proton pump inhibitor (PPI) drug twice daily for one to two months. These drugs decrease the production of stomach acid; they include drugs such as Nexium, Prevacid, Prilosec, and Protonix.
- People with severe, erosive inflammation of the esophagus after a two-month course of PPI treatment, or those with a history of narrowing of the esophagus with recurrent swallowing problems.
- Men older than 50 with chronic GERD symptoms for more than five years and who have additional risk factors, such as obesity and nighttime symptoms.
Patients found to have Barrett's esophagus shouldn’t be screened more often than every three to five years, unless they also have the presence of abnormal cells indicating a greater risk for developing into cancer, according to the paper.
The paper also notes that unnecessary endoscopy exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary costs.