For the estimated seven million people in the United States suffering from gastroesophageal reflux disease (GERD), the uncomfortable burning sensation caused by the disease is normally their primary concern. However, another condition, called Barrett's esophagus, may be lurking. While causing no immediate symptoms, Barrett's puts you at an increased risk of esophageal cancer.
How serious is this risk? Dr. Phil Katz, chairman of the division of gastroenterology at Albert Einstein Medical Center in Philadelphia, helps make sense of this condition.
What is Barrett's esophagus?
It is a change in the lining of the esophagus—the swallowing tube—from what normally is tissue that looks a little bit like skin. It's transformed to a salmon-colored, glandular type of tissue that looks like the stomach or intestine.
What causes these changes?
We're not 100 percent sure of all of the reasons why someone may get Barrett's. However, it is a problem that is associated with having acid reflux disease for a long time.
What is the risk of cancer from Barrett's?
One of the difficulties is that even though the incidence of esophageal cancer is higher in those with Barrett's than in the population without Barrett's, the number of cancers is still remarkably low. The main point is, this is a problem that does have risk, but it's not clear whether we can easily impact that risk with treatment.
Who is at risk for Barrett's esophagus?
In general, Barrett's is a disease that develops over time. If someone has had reflux for only several months to a year or two, we don't worry about Barrett's. But many people who have had minor symptoms of reflux are not asked about it. As a result, the length of the reflux is often underestimated.
How common is the condition?
In the group of people with heartburn more than two or three times a week, the prevalence is somewhere between 5 and 15 percent. If we look at the general population as a whole, it is estimated somewhere around 1 in 100.
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How do you determine how long someone has had reflux?
If a gentleman in his early 50s said that he really had just started experiencing reflux over the last six months, I would be concerned that he had some heartburn occasionally for a long time and never paid attention to it. In this case, I would be a little more assertive in my questioning, because Barrett's is more commonly seen in people over the age of 50. I would ask him more questions about the reflux than if a female in her early 20s started having reflux.
Is Barrett's more common in men than women?
Barrett's is a disease—or a condition, if you would—that is more common in men, more common in Caucasians, and it is more common in people who have had reflux for more than five to ten years or in those who started refluxing before the age of 35.
Are there any symptoms of Barrett's esophagus?
The unfortunate part of the process is that the symptom presentation is no different than someone with simple reflux disease. In fact, the Barrett's tissue itself is, to some degree, less acid-sensitive. So, one of the reasons we see people who develop cancer from Barrett's late in the disease is that the symptoms are milder because the tissue doesn't sense acid as easily.
If the tissue doesn't sense acid, does that make people think their condition is getting better?
Yes. One of things that I try to teach my trainees is that if, in the course of following someone, a patient talks about their heartburn decreasing in frequency, they should be concerned that either Barrett's had developed or that some other complication had occurred. Typically, reflux doesn't spontaneously go away.
How is a diagnosis of Barrett's esophagus made?
If a gastroenterologist decides to look for Barrett's, the only effective screening modality is an endoscopy. And the endoscopist is looking for is a change in the appearance of the esophageal mucosa, or lining, to look like the tissue found in the stomach.
Are there any treatments for Barrett's esophagus?
The guidelines that we follow are that patients with Barrett's are treated similar to patients with reflux disease; we make every effort to make them symptom-free.
There is no evidence that higher doses of medication will actually cause a reduction in Barrett's tissue. Surgery also hasn't been proven to decrease the risk of cancer. So my bias is, if you had Barrett's, I would offer you aggressive treatment for reflux. That is, I would make sure that your acid was controlled, and then I would tell you what other treatments were possible to consider and let you make your own choice.
How often would a patient with Barrett's be screened for esophageal cancer?
What we try to do is a systematic biopsy soon after diagnosis. There, we take extensive tissue samples to determine whether someone has any cellular changes, called dysplasia, which is the first step in a cell becoming cancerous.
We then do two endoscopies, approximately a year apart. After that, if there is no dysplasia or abnormality beyond the Barrett's, then the patient at this point would have endoscopy every two or three years. Now, if you have dysplasia or abnormal cells, I think it's sufficient to say that you should be surveyed more frequently to be ahead of the game, so to speak, if the dysplasia is going to progress.
Are there any additional treatments if dysplasia is found?
At that point, it is important for the physician to have another discussion with the patient about investigational therapies. And I say "investigational" because we have the capability of removing this tissue using either thermal therapy, laser therapy and now we even have the capability to endoscopically remove tissue.
The problem is that it is hard to prove that you can remove all the tissue. Since even a little bit could be bad, we've kind of hesitated to make a blanket recommendation that if you have dysplasia you should attempt to have it removed. But it's an important discussion to have with patients because, as you can guess, people don't like to sit there with it.
Does someone with minor reflux need to be worried about getting Barrett's?
One of the overall problems with reflux is that people don't stop refluxing simply because they're on a drug like Nexium or Prevacid. Even with these drugs, they're still refluxing material that is not as damaging, so they aren't getting symptoms. And even with surgery you don't completely eliminate reflux.
I think anyone who has a long-term need to take medication for heartburn or who is given a diagnosis of reflux would do well to consult a care provider to understand what their risks are.
Certainly, if you are in the typical Barrett's age group—over the age of 50—and you have an endoscopy that does not show any Barrett's, I would be very comfortable telling you that you didn't need another screening.
What advice do you have for someone with reflux disease?
Anyone with reflux disease should learn about Barrett's so that they can be informed as to their potential risk. This is an evolving field, and we're learning enough about the disease that going forward, our technologies are going to evolve to a point where if we can make an impact in treating Barrett's esophagus, it's going to be early on in the disease.
