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Heartburn's Dangerous Cousin

Timely treatment can help prevent Barrett's Esophagus from becoming cancer.

Why are men twice as likely as women to develop Barrett’s esophagus, a precursor of possible cancer? Science doesn’t know the answer to that one yet, any more than it knows why Caucasian men are at greater risk than others. But medicine does have new tools for diagnosing and treating the esophageal condition itself.

To understand Barrett’s esophagus, first consider gastroesophageal reflux— alias acid reflux, a condition you may have had from time to time. In reflux, the tight sphincter muscle that connects the stomach and the esophagus—normally keeping the stomach’s acids in place—relaxes and allows those acids to move out of the stomach and up into the esophagus. That stomach acid burns, creating the sensation of heartburn. If the reflux becomes chronic and intense, that’s called gastroesophageal reflux disease (GER D), which in turn can lead to Barrett’s esophagus (especially if you smoke or are obese).

With chronic acid exposure, the lining of the esophagus—the muscular tube that carries food and liquids from the mouth to the stomach—turns into a precancerous tissue that is called Barrett’s esophagus, explains Shireen Pais, M.D., a gastroenterologist who is Chief of Endoscopic Ultrasound at Westchester Medical Center. This happens in 5 to 10 percent of patients with chronic acid reflux.

People with Barrett’s esophagus are at increased risk for progression of the abnormal precancerous cells into esophageal cancer. This happens in 1 in 200 patients with Barrett’s esophagus per year. This type of cancer has a poor prognosis and outcome; hence it is important to prevent Barrett’s esophagus or treat it if it develops.

Barrett’s esophagus is often treated first with acid-suppressing medications called proton pump inhibitors, which are used to prevent further damage to the esophagus and, in some cases, to heal existing damage.

Typically, before esophageal cancer develops, the Barrett’s cells become more abnormal, which is called dysplasia. This means that the risk of progression to cancer is higher and more imminent, reaching rates as high as 10 to 30 out of 100 patients. Dysplasia may be present for years before cancer develops. A periodic upper gastrointestinal endoscopy with biopsy (that is, an internal exam via a lighted tube with a video camera, and the taking of a tissue sample) is often used to monitor people with Barrett’s esophagus and watch for signs of cancer.

There are several new modalities to manage patients with Barrett’s esophagus who develop dysplasia. Radiofrequency ablation is one such technique that uses radio waves to kill precancerous and cancerous cells. Here an electrode mounted on a balloon catheter or a thin, flexible tube (an endoscope) delivers heat that is generated by radio waves. “This is a safe and effective way to treat the dysplastic cells,” says Dr. Pais. “It has the fewest side effects, and there are good long-term data showing low recurrence rates.”

Another modality is endoscopic ultrasound, which uses sound waves to take pictures inside the body. This procedure can determine how many layers of tissue are involved, and it can assess if the abnormal cells have spread beyond the esophagus into nearby lymph nodes. If a biopsy is required, an ultrasound- guided biopsy that allows more accurate sampling can be obtained.

Narrow-band imaging is another cancer-spotting technology where different wavelengths of light allow highdefinition visualization of the esophagus tissue and can more easily detect abnormal appearing cells. “This permits the endoscopist to biopsy areas that look abnormal rather than doing random biopsies throughout the esophagus and is more effective in finding cancer if it’s there,” Dr. Pais explains.

If Dr. Pais locates nodules, small masses or areas of suspicious cells, she can remove these areas with a procedure called “endoscopic mucosal resection,” which is sent for testing to determine how advanced the disease or cancer is. These findings can guide decisions about surgery if needed. Westchester Medical Center is the only facility in the county to offer all of these new technologies to prevent and treat Barrett’s esophagus and esophageal cancer.

The bottom line for men? If you suffer from GERD, you should be monitored regularly by a specialist for possible changes in the cells that line the esophagus—to stop possible cancer before it starts.

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