When antacids aren’t enough
Heartburn, that almost quintessential American medical malady, now appears to be driving the nation’s fastest-increasing type of cancer. And the antacids used to ease the symptoms could, in some cases, do more harm than good.
The cancer, a type of esophageal disease called adenocarcinoma, is relatively rare. However, incidence has jumped sixfold in the last 30 years. No one knows exactly why esophageal cancer is on the rise, but experts say heartburn is the natural suspect.
About 60 million Americans have occasional symptoms of heartburn -- a burning feeling in the chest, regurgitation and nausea. About 800,000 have chronic heartburn, attacks several times a week over many years -- a condition known as gastroesophageal reflux disease or GERD.
Esophageal adenocarcinoma affects only 23 in 1 million people. But that’s up from fewer than 4 cases in 1 million people in 1975, and doctors think that Americans’ super-sized eating habits are largely to blame.
“This type of cancer is really only common in countries that have a lot of gastroesophageal reflux,” says Dr. Kenneth DeVault, a trustee of the American College of Gastroenterology and a professor of medicine at the Mayo Clinic in Jacksonville, Fla.
About 7,000 Americans are diagnosed each year with esophageal adenocarcinoma, with white men older than 55 at highest risk. Because it’s often detected at a late stage, only 14% of people survive for five years after diagnosis. The usual symptoms are difficulty swallowing and the feeling of food getting stuck in the esophagus. Pain and bleeding can also occur.
“One of the big problems is if you wait until it produces symptoms, it’s almost impossible to cure,” DeVault says. “The idea now is to find the problem early before the patient develops an incurable problem.”
Doctors now are warning people who have had severe gastric esophageal reflux disease for many years that they shouldn’t keep popping Tums and over-the-counter Pepcid instead of seeing a doctor. A physician’s visit is crucial, they say, to make sure sufferers don’t have cancer or a precancerous condition.
The esophagus is the feeding tube that connects the throat to the stomach, where acid and enzymes digest foods. Overeating, eating spicy foods, obesity, pregnancy and other conditions can cause the contents of the stomach to back up into the esophagus, triggering heartburn.
Over time, the reflux of acid and stomach bile can cause cells in the lining of the esophagus to change and resemble the colon more than the esophagus. An estimated 3% to 15% of people with GERD have this condition, which is called Barrett’s esophagus. Adenocarcinoma is usually, but not always, preceded by this condition.
“We think some people develop a mutation because the lower esophagus is trying to adapt to all this acid and injury,” says Dr. William Lyday, a gastroenterologist and assistant clinical professor at Emory University. “It develops a new type of lining that is much more resistant to acid.”
Among people with Barrett’s esophagus, the risk of developing adenocarcinoma esophageal cancer is 30 to 125 times higher than average, according to the National Institute of Diabetes & Digestive & Kidney Diseases. Roughly 2% of people with Barrett’s will develop cancer.
Sometimes the development of Barrett’s -- by changing the lining of the more sensitive esophagus to something more like the colon -- will even cause heartburn symptoms to go away, masking a potentially dangerous condition, Lyday says.
Bill Snell, 64, developed chronic heartburn in his late teens. By the time he was in his 40s, however, the symptoms had stopped. “I thought, OK, I don’t have that anymore.”
Not true. Several years ago, the Westlake Village man was dining in a restaurant when a piece of meat lodged in his throat. After the meat was removed, Snell underwent an endoscopy and learned that he had Barrett’s esophagus. He had the abnormal tissue removed in 2004. “If I hadn’t had an endoscopic procedure, I wouldn’t have known it,” he says.
Because of the deadly nature of esophageal cancer -- and its rising rate in the United States -- experts agree that identifying and treating chronic heartburn and Barrett’s are more important than ever. According to DeVault, anyone older than 50 who has had symptoms of chronic heartburn for 10 years or more should consult a doctor.
It’s not practical to screen every GERD patient for Barrett’s esophagus, because endoscopy requires sedation and costs about $1,000. But those at high risk for Barrett’s are usually advised to undergo endoscopy every few years, in addition to taking medications to control acid reflux. If suspicious cells are found during the endoscopy, a biopsy is performed, DeVault says.
Doctors disagree on how to best treat Barrett’s esophagus. Many recommend continued use of acid blockers and proton pump inhibitors, which cut acid production, along with regular endoscopy and biopsy to monitor the cells so that if cancer occurs it’s caught as early as possible. Some experimental data also suggest that regular aspirin use may help prevent this type of cancer.
“We just don’t know what’s best,” says Dr. Brian Reid, an expert on Barrett’s esophagus at the University of Washington’s Fred Hutchinson Cancer Research Center. “This is why patients are between a rock and a hard spot.”
Abnormal tissue can be removed surgically. And doctors are beginning to use several new technologies to remove the abnormal Barrett’s tissue from the esophagus through an endoscope.
One method, called photodynamic therapy, uses a chemical that is injected into a vein and then activated by a laser light, destroying the tissue.
Another method, called thermal ablation, uses heat to destroy the tissue. Ablation is becoming more popular but lacks long-term studies to show its effectiveness.
Lyday, who uses a newer ablation device called the Halo 360, says: “My feeling is if you should be followed for the rest of your life, why not remove it? It’s logical and it’s low risk.”
DeVault says he recommends ablation only if the cells point to a precancerous condition.
“We would not advocate ablating Barrett’s without the risk of cancer because the majority of these patients are going to live their life out without having cancer,” he says.
Health experts agree on one point: People with long-term GERD should see a doctor, even if the symptoms seem under control or have disappeared. In the last 10 years, several heartburn medications have moved from prescription to over-the-counter status -- including the 2003 approval of Prilosec for frequent heartburn -- which may mean more people self-treat.
“If you have heartburn every once in a while, it’s nothing to worry about,” says DeVault. “But if you keep a bottle of antacid on your desk and take them all day long -- those are the people who need to see their doctor.”