Barrett’s esophagus and early stage esophageal cancer
Anish Sheth, MD
Since the mid 1970’s, the incidence of esophageal adenocarcinoma has increased more rapidly than any other cancer in the United States. Most commonly found in the lower third of the esophagus, esophageal cancer can cause bleeding and difficulty swallowing. Risk factors include male sex, alcohol and tobacco use, obesity, and longstanding gastroesophageal reflux disease (GERD).
GERD exposes the esophagus to acid, bile, and other noxious substances that over time cause changes in the esophageal lining. Normal esophageal cells change into “intestinal” cells, a transformation known as Barrett’s esophagus. Barrett’s esophagus is the precursor lesion to esophageal adenocarcinoma. Accurate diagnosis and management of this condition is crucial to preventing cancer development.
Individuals with a history of GERD, especially with a family history of esophageal cancer, should undergo a screening upper endoscopy to detect the presence of Barrett’s esophagus. Biopsy samples from abnormal appearing tissue are needed to confirm and stage Barrett’s esophagus.
Barrett’s esophagus at its most basic stage is called intestinal metaplasia. Progression from this early stage to esophageal cancer is low (approximately 0.2% per year). Periodic endoscopy is needed to detect cellular changes which increase the risk of esophageal cancer. These changes, called dysplasia, can range in severity from low to high grade and carry an increased risk of cancer development.
Treatment for early stage intestinal metaplasia consists of acid suppression with medications along with lifestyle changes (i.e weight loss, tobacco cessation). If periodic endoscopic monitoring reveals dysplasia changes, more aggressive therapy is required to prevent development of esophageal cancer.
Endoscopic radiofrequency ablation (RFA) was approved in 2007 for treatment of Barrett’s esophagus and has been shown to prevent the development of esophageal adenocarcinoma in patients who have developed esophageal dysplasia.
This outpatient endoscopic procedure utilizes thermal energy to destroy abnormal esophageal cells. As part of the healing process, precancerous cells are then replaced by normal esophageal cells. A landmark 2009 study of 127 patients published in the New England Journal of Medicine demonstrated the efficacy of RFA in eradicating dysplasia as well as preventing cancer. It has now become the standard of care for managing patients with Barrett’s esophagus and dysplasia.
Endoscopic Mucosal Resection
Advances in endoscopic techniques, combined with RFA, have led to the nonsurgical management of early esophageal cancer. Early stage esophageal cancer is limited to the most superficial esophageal layers and can often by treated endoscopically with a technique called endoscopic mucosal resection (EMR). EMR allows removal of small cancer nodules in the esophagus by utilizing devices which can be passed through an endoscope. Once this focus of cancer has been removed, the background Barrett’s esophagus is treated using RFA as described above. Many patients with early esophageal cancer who would have required surgery in the past can now be managed with a series of outpatient procedures.
Early follow-up data regarding patients who have undergone RFA and EMR treatment are promising. Over 90% of patients will be free of Barrett’s esophagus and dysplasia after 5 years. Still, continued endoscopic observation is needed to detect recurrent disease. Disease detected through regular surveillance is typically found at an early stage and, thus, more amenable to treatment.