Virginia Mason to Study Breath Test for Detecting Esophageal Cancer

Research is beginning at Virginia Mason Medical Center that will evaluate the accuracy of a breath test for detecting esophageal cancer, one of the fastest growing and deadliest cancers in the United States.

The project, supported by a grant from the Salgi Esophageal Cancer Research Foundation, is led by Donald Low, MD, who specializes in esophageal and thoracic surgery at Virginia Mason, and George Hanna, PhD, of St. Mary’s Hospital in London (Imperial College Healthcare), who is the co-investigator.

At Virginia Mason, the project will involve as many as 50 patients over the next 12 to 18 months. The research will attempt to build on findings from recent research into a potential breath test for esophageal cancer conducted in England. See article in JAMA Oncology.

The ultimate goal is to develop a noninvasive test for the detection of esophageal cancer that is based on the unique signature of volatile organic compounds in exhaled breath.

“There are currently no standard screenings for the early detection of esophageal cancer, and symptoms often present only after the illness is advanced and difficult to treat,” Dr. Low said. “We hope to change this. Research in London demonstrated the potential for breath analysis to provide an indication when early esophageal cancer has occurred. The purpose of our study is to assess the diagnostic accuracy of a breath test.”

Virginia Mason researchers will examine the reliability of such a test “longitudinally,” Dr. Low added, explaining that patients enrolled in the study will provide sputum and urine samples, in addition to exhaled breaths, that will be evaluated for common markers at three separate points in their treatment journey. The ultimate goal is to develop a noninvasive test for the detection of esophageal cancer that is based on the unique signature of volatile organic compounds in exhaled breath.

In 2019, an estimated 16,000 people will die from esophageal cancer in the United States, while less than 20 percent of those diagnosed with the disease will survive more than five years, according to the National Cancer Institute.

Gastroesophageal reflux disease (GERD), also called acid reflux disease and heartburn, can lead to Barrett’s Esophagus, a primary risk factor for esophageal cancer.

“One of the reasons for conducting research is that you never know what you will discover,” said Dr. Low. “It’s exciting to imagine a day, not far in the future, when a person will breathe into a special device that can provide reliable information, based on the breath, indicating whether the individual has early-stage esophageal cancer. This would be a marvelous advancement for medicine and patients. My colleagues and I are proud to be involved in the assessment of this new diagnostic approach.”

Low,Donald02colorDonald Low, MD, FACS, is Program Director of the Esophageal Center of Excellence, providing comprehensive, multidisciplinary care for a range of esophageal and gastrointestinal issues. If you have questions or are experiencing symptoms, please call (206) 223-2319.

What Your Gut Should Tell You: Esophageal Health Requires an Experienced Team

Reflux and other esophageal issues require prompt diagnosis and treatment to prevent more serious health concerns, including chronic indigestion or rarely, cancer. The Esophageal Center of Excellence at Virginia Mason brings a multidisciplinary approach to treatment that includes experts in interventional radiology, oncology, nursing and pathology.

“Multidisciplinary care allows us to provide the treatment that is most appropriate and most effective,” says gastroenterologist Andrew Ross, MD.

stomachePublished outcomes show that innovative care at the Esophageal Center results in shorter hospital stays, better cancer survival rates and a better quality of life after surgery. “Our excellent outcomes are attributable to our commitment to clinical research and publication,” says Donald Low, MD, director, Esophageal Center of Excellence. “We are always on the forefront of research that allows us to use the newest and best treatments.”

Virginia Mason has the highest volume of esophageal resections in the Pacific Northwest, with 75 percent of patients traveling 150 miles or more to receive care. Esophageal specialists also developed the only anti-reflux procedure originating in North America.

GERD and Acid Reflux

The Esophageal Center is known for its innovative and successful treatment of the related conditions of acid reflux and gastrointestinal reflux disease (GERD), a chronic condition frequently caused by inappropriate relaxation of the lower esophageal sphincter.

GERD requires prompt treatment to avoid additional health problems that include esophageal ulcers, chronic cough, irritation of the esophagus and other serious conditions. Smoking, obesity, pregnancy and certain medications may predispose a person to experience GERD.

Symptoms of GERD include the sensation of a lump behind the breastbone, nausea after eating and heartburn. GERD is treatable in the overwhelming majority of patients with dietary and lifestyle changes, medications and/or surgical intervention.

Medications generally work by making the stomach juices less acidic. They do not fix the underlying reason for GERD, which leads to a recurrence in symptoms once medications are stopped.

There have been some controversial studies regarding the safety of long-term use of some medications to treat GERD. It is best for patients to rely on the lowest possible dose that results in control of symptoms. Concerns regarding calcium metabolism and osteoporosis mean that patients using these medications for longer periods may need to have their bone density monitored, and should check with their physician to see if tests are indicated.

Long-term GERD can, in rare cases, lead to the development of esophageal cancer. Patients with long-term (greater than 5-10 years) of symptoms, especially middle-aged white men, should ask their doctor about undergoing an endoscopy to evaluate for pre-cancerous changes of the esophagus. Patients who develop difficulty swallowing, weight loss, blood in the stool or anemia should see their doctor immediately.

Barrett’s Esophagus

Barrett’s Esophagus is a condition of GERD that occurs when the tissue in the esophagus begins to take on the characteristics of the tissue in the intestines. Although this is considered a pre-cancerous condition of the esophagus, most patients with Barrett’s esophagus will never develop esophageal cancer in their lifetime. In patients with Barrett’s esophagus, routine exams of the esophagus and upper digestive systems may help ensure that any cancerous or pre-cancerous cells are found and treated early.

Esophageal Cancer

Esophageal cancer patients who have undergone surgery at Virginia Mason have some of the best reported outcomes in the world. An analysis of one 20-year period (1991-2011) showed a postoperative mortality rate of less than 0.5 percent compared to the national rate of 8.9 percent.

In addition, recent data from the National Cancer Data Base demonstrate that patients at Virginia Mason have better esophageal cancer survival rates at every stage of the disease. Physicians from around the world have visited Virginia Mason to study the clinical pathways that have led to the best possible management of esophageal cancer.

This management includes regular multidisciplinary cancer conferences and support groups that benefit patients, physicians and staff, who gain better insight into and understanding of specific esophageal disorders. At Virginia Mason, care supported by an esophageal cancer nurse navigator and continuous communication help ensure the best results, and ultimately the best quality of life for patients.

The Esophageal Center of Excellence provides comprehensive care for a range of esophageal and gastrointestinal issues. If you have questions or are experiencing symptoms, please call us at
(206) 223-2319.

GERD, Barrett’s Esophagus and the Risk for Esophageal Cancer

**By Donald E. Low, MD, FACS**


Kathi Brunson and her husband Tom

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.

Cancer screenings

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

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.