Center of Exellence

Barrett’s Esophagus Institute

AT FLORIDA DIGESTIVE HEALTH SPECIALISTS

• Am I at risk for esophageal cancer?

  One type of esophageal cancer, adenocarcinoma of the esophagus, can occur in people with gastroesophageal reflux disease (GERD). This is intestinal type cancer occurring in the esophagus, and in general is more difficult to treat than other forms of esophageal cancer. In fact, esophageal adenocarcinoma is regarded as having the worst prognosis of any human malignancy with approximately an 8-15% survival after 5 years, and less than 1% 5-year survival if not surgically resectable, making this worse than even pancreatic cancer. A common symptom of GERD is heartburn, which many adults experience. While the vast majority of them will never develop esophageal cancer, a small portion of patients with GERD will develop a condition called Barrett’s Esophagus. Barrett’s esophagus is the only known precursor of esophageal adenocarcinoma. Barrett’s esophagus is twice as common in men as women. It is most often found in middle-aged Caucasian men who have had heartburn for many years.

• What is Barrett’s Esophagus?

  Barrett’s Esophagus is a condition in which the esophageal lining changes and becomes similar to the tissue lining the intestine. Barrett’s is more likely to occur in patients who either experienced GERD first at a young age or have had symptoms for an extended period of time. Dysplasia, a precancerous change in the tissue, can develop in any Barrett’s tissue.

• What is dysplasia?

  “Barrett’s is a protective mechanism gone bad. Barrett cells are actually more tolerant of acid, and when they form on a person’s esophagus, their symptoms will often improve, giving a false sense of security. But it is the genetic changes in these cells that allowed them to form that ultimately predispose a person to cancer.”

  – Dr. Scott Corbett, board-certified Gastroenterologist with a specialty in Barrett’s Esophagus.

  • Dysplasia describes the progression of precancerous changes in the cells. Dysplasia levels indicate the extensiveness of these changes. The higher the stage of dysplasia, the higher the risk that Barrett’s esophagus will become esophageal cancer.
  • Non-dysplastic Barrett’s esophagus indicates the first change in cancer sequence. Non-dysplastic Barrett’s is still considered pre-cancerous, as this tissue may carry several pre-cancerous genetic changes prior to the development of overt dysplasia.
  • The average patient with non-dysplastic Barrett’s has a risk of developing cancer at a rate of 0.5% per patient per year, or 1/200 every year. That indicates that there is a 5% risk in 10 years, and a 10% risk over 20 years.
  • Several factors influence the above risk and may cause it to be greater or less. These include, but are not limited to: Caucasian race, male gender, age over 50, Barrett’s segment 3cm or more (with risk increasing for every cm over 3cm), having any circumferential Barrett’s, obesity (with risk 1.5x for BMI over 30), family history of Barrett’s or esophageal cancer, presence of a hiatal hernia, smoking history  and disease duration over 10 years. The presence of dysplasia substantially increases risk.
  • “No Dysplasia” means the Barrett’s esophagus cells show no precancerous changes.
  • “Low-Grade Dysplasia” means the cells show early characteristics of cancer.
  • “High-Grade Dysplasia” means that the cells show more advanced changes toward cancer.
  • “Intramucosal cancer” means cancer confined to just the thin surface layer without invading the deeper tissue layers.
  • “Invasive cancer” refers to cancer cells having invaded into the deeper tissue layers and beyond the stage that is considered curative by endoscopic methods alone.

• What treatment is available?

  “We now have several minimally invasive methods documented in a multitude of peer reviewed studies for treating Barrett’s by removing the pre-cancerous tissue and minimizing the risk of esophageal cancer safely and effectively with cost-effectiveness and durability. Watching this through endoscopic surveillance is no longer our only option.”

  – Dr. Scott Corbett, board-certified Gastroenterologist with a specialty in Barrett’s Esophagus.

  Radiofrequency Ablation (RFA)

  • Radiofrequency Ablation (RFA) is an FDA-approved, minimally invasive procedure that uses heat to destroy precancerous tissue in the esophagus.
  • RFA was first approved by the FDA to treat Barrett’s esophagus in 2001 and numerous clinical studies support its effectiveness for treating the disease. It is generally performed on an outpatient basis with the patient under moderate sedation.
  • FDHS gastroenterologists have performed thousands of RFA procedures.
  • The patient will be asked not to eat or drink anything after midnight the night before the procedure, except for small sips to take daily medication (please talk to your gastroenterologist about specific instructions).
  • Generally, RFA procedures take about 30 minutes and patients are discharged after 30 minutes of monitoring in the post-operation area. A prescribed oral pain medication and/or an oral numbing solution may be used for several days following the treatment.
  • Most patients return back to normal activities the day after the procedure, with a modified diet to allow time for healing.
  • For most patients, one to three RFA treatment sessions are needed to remove all traces of cancerous cells. The longer the Barrett’s segment, the more sessions are typically needed to remove all the tissue at risk for cancer. A follow-up endoscopy a few months later is necessary to check on the healing process and determine if additional treatment is needed.
  • Regular surveillance endoscopies are recommended for all Barrett’s patients. Your gastroenterologist will determine frequency.

  Endoscopic mucosal resection (EMR)

  • Endoscopic mucosal resection (EMR) may be needed for raised or focal defects to be determined by the endoscopist.
  • Raised and nodular areas are usually too thick to be amenable to RFA alone. EMR goes more deeply into the tissue and may more reliably remove dysplasia and early cancer, but at the cost of incurring more scar tissue and risks of bleeding and strictures.

  Cryo-balloon ablation

  • Cryo-balloon ablation is an emerging method using tissue freezing instead of heat. It may cause less discomfort and penetrate more deeply. APC (argon plasma cautery) has also been tested. Neither of these methods has been studied as extensively as RFA or EMR.

  Photo-dynamic therapy

  • PDT (photo-dynamic therapy) is an older, laser-based method now reserved mainly for palliation of more advanced disease not responding to chemotherapy or radiation in non-surgical candidates. It may result in significant scar tissue that is difficult to treat.
  • Eradication of non-dysplastic Barrett’s has been shown to be over 98% effective with a recurrence rate of only 8% at 5 years, 100% of which has been amenable to touch-up.
  • Regular surveillance endoscopies are recommended for all Barrett’s patients. Your gastroenterologist will determine frequency.

• Who should be screened for Barrett’s Esophagus?

  Even in patients with heartburn, Barrett’s Esophagus is uncommon and esophageal cancer is rare. Although there isn’t a universal recommendation, many doctors screen patients older than 50 who have significant heartburn or need regular medications to control heartburn.

• What are the risk factors?

  • Chronic heartburn
  • Obesity
  • Caucasian ethnicity
  • Family history of Barrett’s or esophageal adenocarcinoma
  • Male gender
  • Age over 50 (especially in a white male)
  • History of achalasia
  • Hiatal hernia
  • Smoking history over 20 pack-years

• What are the symptoms?

  Commons symptoms include:

  • Chronic heartburn
  • Difficulty swallowing
  • Nausea
  • Chest pain
  • Regurgitation of food or stomach contents
  • Prior history of significant or frequent heartburn that has resolved without specific therapy

• How does my doctor test for Barrett’s esophagus?

  You will need to see a board-certified gastroenterologist, who will ask you in-depth questions about your symptoms. However, Barrett’s cannot be diagnosed by evaluating symptoms only. If your gastroenterologist believes you may have Barrett’s, an upper endoscopy will be necessary. Barrett’s tissue has a different appearance than the normal lining of the esophagus and usually visible during endoscopy. Biopsies from the esophagus confirm the diagnosis and can show any precancerous change. The gastroenterologists at FDHS and their Barrett’s specialists employ both advanced imaging techniques, as well as advanced biopsy and tissue analysis not typically available in most clinical practices or hospitals. These methods optimize the detection of Barrett’s and dysplasia.

• What if I have acid reflux, but test negative for Barrett’s esophagus?

  If patients have reflux but do not have Barrett’s, it is crucial to keep symptoms in check with acid suppressive medication prescribed by your gastroenterologist. This is intended to prevent Barrett’s esophagus and esophageal cancer from forming. Your gastroenterologists will most likely recommend regular check-ins and monitoring of symptoms.

• What if I don’t have any symptoms, but I have other risk factors?

  Oddly, and unfortunately, 53.4% of patient’s who are diagnosed with esophageal adenocarcinoma never recall having had any reflux symptoms. This is because Barrett’s tissue is more tolerant of acid reflux. When Barrett’s develops, symptoms such as heartburn may go away, giving a false sense of security. Consequently, we are only evaluating 4-5% of the population at risk. If you have no symptoms, but do have risk factors, your FDHS gastroenterologist may suggest a simple non-invasive test such as Cytosponge. This is a test in the office where a patient can swallow a small dissolvable capsule with a cytology sponge inside attached to a string. After seven minutes, the sponge opens in the stomach and can be pulled up the esophagus by the string, picking up any Barrett’s or pre-cancerous cells. The sponge is then sent to the pathology lab for analysis. If positive, an endoscopy will be recommended.