**By Donald E. Low, MD, FACS**
Ellensburg resident Kathleen (Kathi) Brunson is lucky and she knows it. Her good fortune – namely in the form of better health – is something she’s thankful for every day.
The 75-year-old Japanese-American, who was a legal secretary in Ellensburg for almost 30 years, was diagnosed with advanced esophageal cancer in 2006. Kathi’s primary care physician insisted on further testing after Kathi mentioned trouble swallowing during an annual checkup.
That simple mention eventually lead to the discovery of a cancerous mass in her esophagus and a referral to Virginia Mason. After many weeks of chemotherapy and radiation at Virginia Mason Memorial’s North Star Lodge in Yakima, I performed Mrs. Brunson’s surgery in Seattle.
Now, 10 years later, she is healthy and cherishing every minute with her husband, two married daughters and four grandchildren.
Although Mrs. Brunson periodically wonders what might have caused her cancer, especially since she didn’t have any of the typical risk factors and has eaten a vegetable-rich diet most of her life, she tells people all the time to listen to their bodies and be their own health advocates.
As Mrs. Brunson can attest, education, awareness and being proactive are critical to helping put people in the best position to successfully battle cancer.
If you’ve ever been affected by a cancer diagnosis, a screening exam is common.
Cancer screening exams are important medical tests performed when people are at risk but don’t have symptoms. They help detect cancer at its earliest stage, when the chances for successful treatment are highest. Unfortunately, to date no standardized screening tests have been shown to improve esophageal cancer outcomes.
Esophageal cancer risk factors
Anything that increases your chance of getting esophageal cancer is a risk factor.
If you experience frequent heartburn, talk with your doctor about tests that may help find esophageal cancer early. Long-term heartburn or reflux is a factor in half of esophageal cancers.
Other risk factors for esophageal cancer include:
- Long-term history of smoking
- History of other squamous cell cancers related to tobacco use
- Drinking too much alcohol, especially if you smoke
- Age: Most esophageal cancers occur in people over 55
- Gender: Men are three times more likely to develop esophageal cancer
- Achalasia: A disease in which the muscle at the bottom of the esophagus fails to open and move food into the stomach
- Tylosis: A rare, inherited disorder that causes excess skin to grow on the soles of the feet and palms. It has an almost 100 percent chance of developing into esophageal cancer
- Esophageal webs: Flaps of tissue that protrude into the esophagus, making swallowing difficult
- Lye ingestion or being around dry-cleaning chemicals
- Diet and weight: Risk is higher if you’re overweight, tend to overeat or don’t eat a healthy diet
Not everyone with risk factors gets esophageal cancer. However, if you have risk factors, you should discuss them with your physician.
At risk for esophageal cancer?
There are two main types of esophageal cancer: squamous cell cancer and adenocarcinoma of the esophagus.
Squamous cell cancer occurs most often in African Americans, as well as people who smoke cigarettes and drink alcohol excessively. Fortunately, this type of cancer is not increasing in frequency.
Adenocarcinoma of the esophagus occurs most commonly in Caucasians, as well as people with gastroesophageal reflux disease (GERD). Unfortunately, this cancer is increasing in frequency.
The most common symptom of GERD is heartburn, a condition that 20 percent of American adults experience at least twice a week. Although these individuals are at increased risk of developing esophageal cancer, most will never develop it. But in a few patients with GERD (estimated at 10 to 15 percent), a change in the esophageal lining develops, which is a condition called Barrett’s esophagus. Experts believe most cases of adenocarcinoma of the esophagus begin in Barrett’s tissue.
It is very important for everyone who has had a continuing issue with dysphagia, which is the impression of food sticking in the chest, to see their physician and have it looked at immediately.
What is Barrett’s esophagus?
Barrett’s esophagus is a condition where the esophageal lining changes, becoming similar to tissue that lines the intestine. A complication of GERD, Barrett’s is more likely to occur in patients who either first experienced GERD at a young age or have had symptoms for a while. The frequency and or severity of GERD does not affect the likelihood that Barrett’s may have formed. Dysplasia, a precancerous change in the tissue, can develop in any Barrett’s tissue. Barrett’s tissue is visible during endoscopy, although a diagnosis by endoscopic appearance alone is not enough. A definitive diagnosis of Barrett’s esophagus requires confirmation through a biopsy.
How do you test for Barrett’s esophagus?
A gastroenterologist will first perform an upper endoscopy using a thin, flexible scope with a light and camera on the tip to diagnose Barrett’s esophagus. Barrett’s tissue has a different appearance than the normal lining of the esophagus and is visible during endoscopy. Although this exam is very accurate, your doctor will take biopsies from the esophagus to confirm the diagnosis as well as look for the precancerous change of dysplasia that can’t be seen with the endoscopic appearance alone. Taking biopsies from the esophagus through an endoscope only slightly lengthens the procedure time, doesn’t cause discomfort and rarely creates complications. Your doctor can usually tell you the results of your endoscopy after the procedure, but you will have to wait a few days for biopsy results.
Who should be screened?
Barrett’s esophagus is twice as common in men as women. It tends to occur in middle-aged Caucasian men who have had heartburn for many years. There is no agreement among experts on who should be screened. Even in patients with heartburn, Barrett’s esophagus is uncommon and esophageal cancer is very rare. One recommendation is to screen patients older than 50 who have had significant heartburn or required regular medication use to control heartburn for several years. If the first screening for Barrett’s tissue is negative, there is no need to repeat it.
How is Barrett’s esophagus treated?
Medicines and or surgery can effectively control the symptoms of GERD. However, neither medications nor surgery can reverse the presence of Barrett’s esophagus or eliminate the risk of cancer. There are some experimental treatments through which the Barrett’s tissue can be destroyed using the endoscope. These treatments are becoming more common, but should only be considered in patients with Barrett’s, dysplasia or the earliest form of esophageal cancer.
What is dysplasia?
Dysplasia is a precancerous condition that doctors can only diagnose by examining biopsy specimens under a microscope. Doctors subdivide the condition into high-grade, low-grade or indefinite. If dysplasia is found on your biopsy, your doctor might recommend more frequent endoscopies, attempts to destroy the Barrett’s tissue, or esophageal surgery. Your doctor will recommend an option based on the degree of the dysplasia and your overall medical condition.
If I have Barrett’s esophagus, how often should I have an endoscopy to check for dysplasia?
The risk of esophageal cancer in patients with Barrett’s esophagus is quite low, about 0.5 percent per year or one out of 200. For this reason, a Barrett’s esophagus diagnosis should not be reason for alarm. It is, however, reason for periodic endoscopies. If your initial biopsies do not show dysplasia, endoscopy with biopsy should be repeated about every three years. If your biopsy shows dysplasia, your doctor will make additional recommendations.
A version of this article was originally posted on LocalHealthGuide.com.
Donald E. Low, MD, FACS, is board certified in General and Thoracic Surgery. He practices at Virginia Mason Hospital and Seattle Medical Center. His specialties include esophageal cancer, thoracic surgery, esophageal diseases, esophageal surgery, gastrointestinal cancer, lung cancer, lung surgery, and minimally invasive surgery.