GERD Is the Word Treating Esophageal Cancer

If the fiery feeling of heartburn affects you more than twice a week, you may be at risk for more serious health issues. Frequent or long-standing heartburn is a symptom of gastroesophageal reflux disease (GERD), which can lead to esophageal cancer.

Feeling the Burn: How Acid Reflux Changes the Esophagus

This common condition occurs when acid from your stomach backs up (or refluxes) into your esophagus (or the foodpipe). Typically, our stomach produces about 1.5–2 litres of acidic fluid on a daily basis, and that same acid causes heartburn when it backs up into the esophagus. The reflux then leads to severe inflammation of the inner lining of the esophagus and transforms it, a process that is termed metaplasia. Eventually, the cell transformation can progress into low-grade, and later high-grade dysplasia, or Barrett’s esophagus, which can then lead to cancer of the esophagus, if left untreated.

Although there are different types of cancer of the esophagus, it’s typically the adenocarcinoma variety that we associate with acid reflux. This used to be a disease of 60- and 70-year-olds. But unfortunately, we now see it even in younger patients—in their 20s and 30s—primarily because of obesity, increased BMI, and poor eating habits, all of which affect our lower esophageal sphincter and relax it.

Surprisingly Common Symptoms

The symptoms of gastroesophageal reflux disease are very common. Some people don’t even realize that they have reflux disease and, while others do, they ignore it because they associate it with stress or certain meals. And because they get immediate relief from Tums®, they continue to just “fight through it."

Common alarming symptoms to watch out for include:

• Heartburn
• Waking up with a sour taste in your mouth
• Persistent cough
• Constant hoarseness
• Frequent throat clearing

Be Aware of Risk Factors

Many patients diagnosed with cancer of the esophagus have a history of risk factors for the disease, including:

• Hiatal hernia or para-esophageal hernia
• Long-standing acid reflux
• Smoking cigarettes
• Alcohol abuse/routine alcohol use
• Obesity
• Collagen vascular diseases such as rheumatoid arthritis or scleroderma
• Multiple pregnancies
• Consistently drinking burning hot coffee or tea
• Exposure to nitrosamines, a probable carcinogen found in tobacco products, processed foods, cured meat (cold cuts and bacon), and beer

And some patients have no risk factors. In a fraction of the patients on whom we operate for cancer of the esophagus, we actually find no evidence of reflux. Research still has not figured out why patients who are male, nonsmokers, nondrinkers, and without a history of reflux or hernia still get the disease. Unfortunately, we are miles away from identifying why this group of patients develop esophageal cancer.

Stopping Heartburn Does Not Stop the Progression

When people are diagnosed with long-standing acid reflux or believe they’re having heartburn, they typically will take an antacid and dismiss the symptom because they have instant relief.

But we must remember that the reflux is coming from something. It could be a structural defect, like a lax lower esophageal sphincter (a ring of muscles connecting the esophagus to the stomach).

If a patient feels less burning by simply taking the medicine, he or she may just be fooling themselves into thinking their reflux is gone, yet the mechanism could still be there. These patients should ideally be on antacid therapy for their lifetime or until the acid reflux is well-controlled. And they should see their doctor for regular evaluation, so it doesn’t lead to Barrett’s esophagus.

About Barrett's Esophagus

Barrett's esophagus is essentially a change in the type of cells within the lining of the esophagus. The cells transform from a normal to an abnormal type of cell. When this change happens, you’re at risk of the condition progressing to cancer of the esophagus.

We currently recommend that those patients undergo some sort of treatment after a thorough evaluation with endoscopy. If you have Barrett’s, your gastroenterologist will first biopsy you to prove it and then either treat you with medicines or other endoscopic modalities, such as radiofrequency ablation, a minimally invasive treatment that treats the diseased tissue.

Extremely Aggressive

People suffering from frequent heartburn should be aware of two facts about esophageal cancer:

• It is extremely aggressive
• It has no cure

About 20 years ago, the five-year survival rate for esophageal cancer was 18%. Currently, the five-year survival rate is 19.5%. So, we have hardly made any progress in detecting it early or treating patients appropriately.

Stages of Esophageal Cancer

Cancer of the esophagus is quite complex, and so are the various ways we can classify it. Each patient and situation is different, so it’s best to talk with your doctor if you or a loved one is diagnosed with the disease. In general, though, we can classify this cancer into these stages:

• Stage 1—a lesion in the lining of the esophageal wall Treatment: Removal of the lesion through minimally invasive surgery.

• Stages 2 or 3—a deeper tumor and/or involvement of lymph nodes Treatment: Chemotherapy and radiation, followed by an esophagectomy, surgery to remove 70% to 80% of the esophagus, leaving a little piece to connect to the stomach. We perform the surgery only if the tumor has responded well to the chemotherapy and radiation. If the tumor has progressed, as far as the size or number of involved lymph nodes, or it has spread to other parts of the body, the patient will no longer be a candidate for surgery.

• Stage 4—the tumor has spread Treatment: Anti-cancer drugs that reach all parts of the body and/or palliative care to improve the patient’s quality of life.

No Routine Screening Guidelines

Unfortunately, there are no standard screening guidelines for cancer of the esophagus. If it could be diagnosed at an early stage through endoscopy, we could take action before it gets worse. But, because we don't screen for it on a routine basis, we tend not to diagnose patients at an early stage.

I hope that increased awareness will encourage patients to think, “Okay, I’ve got persistent symptoms. Something could be wrong. I should go see a doctor.”

Prevention Is the Best Medicine To Care for Your Esophagus

I highly encourage people, if you've had symptoms of GERD for more than 5 years, to get an endoscopy to make sure you don't have any long-term effects of acid reflux, Barrett’s esophagus, dysplasia, or early-stage nodules that might be malignant. You don't want to wait until you have food getting stuck in your throat or you've got a large mass—the earlier you see your doctor about your heartburn or other symptoms, the better the outcome may be.

• Recognize the symptoms. We all think we are invincible. When you're in your 30s and 40s and you have acid reflux, you may not be concerned about your symptoms. When the effects of the risk factors finally hit you in your 60s and 70s, significant damage may exist. Many patients can benefit from awareness of the effects of acid reflux on their esophagus, earlier surveillance, and monitoring their symptoms.
• Be your own advocate. If you think you're having reflux and you have had it for a long time, ask your primary care doctor for a referral to a gastroenterologist, who may perform an endoscopy and, if you have reflux, see that you get appropriate treatment. If the treatment is not working, ask your doctor to be referred to a surgeon because you may need anti-reflux surgery. And if an endoscopy finds damage to your esophagus, you may need other work done.
• Stay vigilant. It’s important to remain aware and take care of your own health. Ensure you are under the care of a good doctor who keeps current with your symptoms, to avoid potentially being diagnosed with a form of cancer in its later stages.

Here at MedStar Washington Hospital Center, our specialists will make sure that your symptoms get addressed and you get started on the right treatment in time.