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Tag Archives: Barrett’s Esophagus

More On Screening: Barrett’s Esophagus

18 Wednesday Apr 2012

Posted by @JustOncology in Uncategorized

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Barrett’s Esophagus, cancer, CME, epatients, GERD, medical education, medicine, oncology, participatory medicine, patients, physicians, research

By Richard Just, MD

Recently, a friend of mine asked me for medical advice concerning his condition, Barrett’s esophagus.  When the diagnosis was initially made, he was advised he would require annual screening endoscopies with random biopsies.  But, on his last visit, my friend was told he didn’t need another procedure for 5 years, with no explanation.  “What’s up?”  Since he had a copy of the biopsy report (not with him, but at home), I advised he read it and look for the word dysplasia.  Wikipedia defines dysplasia as

maturation abnormality.

So far, I haven’t heard back.  But this stimulated me to review current recommendations on the subject.

Between 2-3 decades ago, there was a sudden increase of adenocarcinomas (“glandular cancers”) of the lower esophagus usually in Caucasian males.  This event was noticeable in that the usual esophageal cancers were a different cell type, squamous cell carcinomas, that tended to occur in Black males.  Adenocarcinomas appeared to be correlated with gastroesophageal reflux disease (GERD), while squamous cell carcinomas (SCC) are associated with smoking and alcohol consumption.  These are tends, not absolutes.  GERD causes irritation of the cells of the lower esophagus resulting in conversion of the cell type (metaplasia) from squamous cells to columnar cells, the definition of Barrett’s esophagus.  Barrett’s, in turn, can progress to low grade dysplasia, high grade dysplasia, and adenocarcinoma.  Thus, it has been proposed that patients with at least weekly GERD symptoms (heartburn, regurgitation, and dysphagia, meaning difficulty swallowing) that have been present for at least 5 years, and who have multiple risk factors for esophageal adenocarcinoma including white ethnicity, male sex, older age, obesity and long duration of GERD undergo screening for Barrett’s esophagus.

Management of Barrett’s esophagus involves 3 major components:

  1. Treatment of GERD:  Recommended to be initiated prior to surveillance endoscopies to minimize confusion caused by inflammation in diagnosing dysplasia.  Not thought to reduce incidence of esophageal adenocarcinomas.
  2. Endoscopic surveillance:  If no dysplasia found, next scope in 3-5 years.  Follow up for low grade dysplasia is 6-12 months  For intensive endoscopic surveillance of high grade dysplasia, scope every 3 months.
  3. Treatment of high-grade dysplasia:  Recommendations can include esophagectomy, endoscopic ablative therapies, and endoscopic mucosal resection in addition to intensive endoscopic surveillance.

Since the above recommendations were updated in 2011, my assumption is that no dysplasia was discovered on any of the 3 studies and risk of progression to cancer is low.  For the general population of patients with Barrett’s esophagus, the risk of esophageal adenocarcinoma is 0.5% per year.  Contrast this with 5-8% per year in patients with high grade dysplasia.  The risk for low grade dysplasia falls somewhere between these 2 extremes.

I’ve written previously about the limitations and risks of mass screening techniques, e.g., mammography for breast cancer, PSA testing for prostate cancer and PAP smears for cervical cancer.  The same applies to screening endoscopies for Barrett’s esophagus.  The procedure carries with it risks, including perforation and bleeding.  It’s also not very comfortable to have a hose snaked down your throat so that pre-anesthetics are sometimes necessary, creating more risk.  Random biopsies are performed because it’s sometimes difficult for the endoscopist to identify areas of dysplasia from just metaplastic cells, leading to falsely negative results.  In his new book “The Creative Destruction of Medicine”, Dr. Eric Topal opines “We’re not very good at detecting and fighting cancer.  The mass screening model, as with mammography or prostate specific antigen (PSA) testing……..is enormously expensive and leads to an untold number of false positive results and more unnecessary biopsy procedures.  Doing serial sensitive scans like PET or CT would likely make this problem worse, both by increasing the false positives and incidental findings and by exposing individuals to ionizing radiation that itself causes cancer.”  The use of innovative technologies such as circulating tumor cells (CTC), genomics (circulating DNA and RNA) and wireless sensors including implanted nanosensors are described.  Obviously, hope runs high that at least some of these techniques will be validated so that the ultimate goal, prevention, is achieved.

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The ‘incident’

My life was essentially on autopilot. My oncology practice was very successful; in fact, too successful. All my time and energy was devoted to keeping pace with the increasing demands of the profession. Other pursuits, be they personal or professional, always seemed to take a back seat. My main unfulfilled passion was writing.

On January 7, 2011, everything changed. I had a new bovine aortic valve and three new coronary artery grafts. A life altering event, to say the least. Fortunately my recovery has been uneventful, and I had no evidence of muscle injury. So I’m extremely grateful for the pre-emptive surgery, and since I’m back to work on a part time basis, I now can devote some of my attention to writing.

For the past several years, a colleague, trusted advisor and friend of mine, Gregg Masters, had been prodding me to “just do it”, i.e., just start blogging, podcasting and life streaming my experiences in Medicine. He pointed out the value of my 36 years in clinical practice of hematology and medical oncology as 'elder wisdom' currency in relative short supply. In truth, there is certainly a lot to write about as the clinical knowledge base has grown enormously, to the point where management of all this information requires computers. Fortunately, technology has developed at a rapid rate also so that we can not only mine all this data to obtain meaningful information, but better disseminate it to each other, health plans (including government) and especially our patients. With the advent of social media including Twitter, Facebook and You Tube, this flow of information becomes a two way street allowing physicians to listen as well as talk. On a personal note, my wife published daily status updates during my surgery and through the post-operative period on a website called Caringbridge. She posted pictures as well as narrative. Colleagues, relatives, friends and patients had a window opened to them as to how I was doing, and they in turn wrote back notes of encouragement that touched me deeply.

When Gregg and I thought about it, his background not only in 'web 2.0' (social media) but perhaps more significantly his considerable experience in the business aspects of medicine brings value into the conversation as well. In today’s environment, physicians are constantly reminded that we not only are responsible for all aspects of caring for patients, but we are running a business as well. Years ago, I remember reading an excellent book called “The E-Myth Physician” by Michael Gerber. One of the chapters was devoted to the subject of “Money”. So Gregg’s knowledge complements my clinical background resulting in the birth of JustOncology.com.

Certainly there is no shortage of topics to discuss. Utilizing a variety of media: blogging (which addresses my passion for writing), audio and visual interviews with as many of the stakeholders in cancer care as possible, we hope to provide a forum for discussion of problems facing us. From these interactions, the desired outcome is to identify solutions that can only come from a collaborative effort.

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About

JustOncology.com is a joint publication of Richard Just, MD, aka @chemosabe1 on Twitter and Gregg Masters, MPH, aka @2healthguru on Twitter.

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