"Medicalization," Barrett's Esophagus and the Numbers Problem
The word medicalize, means "to use medical methods or concepts in dealing with nonmedical problems..." Thus, the latest healthcare growth industry "medicalization,” has come to describe various ways used to convert healthy people into anxious patients. The latest ploy when doing a colonoscopy is to follow it with an upper endoscopy or EGD on the same visit, or vice versa, something which happened to a doctor friend's wife recently. It is called a "flip" procedure since it merely involves flipping the patient over to do another 10 or fifteen minute procedure and collect an additional hefty fee, the latest medical version of the phrase, "in one end and out the other." Gastroenterologists justify it since most patients have occult blood in their stool (especially when they are not prepared with a meatless diet for three days) and it is "always necessary" to rule out an upper GI lesion so why not do it while the patient is still sedated and save time and money? In a small survey I conducted among local physicians, I learned that flip procedures involving colonoscopy or EGD (start at either end) are becoming more and more frequent.
What is GERD and How Common is It?
Heartburn is a burning sensation felt behind the breast bone and sometimes in the neck and throat. It is caused by stomach acid refluxing or splashing up into the lower end of the esophagus, and is called simply GE reflux, or gastroesophageal reflux disease (sic!), nicknamed GERD. Although the above patient had no symptoms of GERD she was informed that she had Barrett's esophagus, a possible precancerous condition, would need to be on a proton pump inhibitor, such as Prilosec for a year, and undergo periodic upper endoscopy (EGD) every 6-12 months. The prevalence of reflux in the U.S. population has been estimated at 70 million. There are an estimated 10-20 million chronic GERD sufferers in the U.S. with symptoms three or more times a week. Note 20 million-70 million with a Disease named GERD! In 2004, more than $4 billion was spent in the U.S. on over the counter drugs, and $6 billion-$8 billion for prescription drugs to treat heartburn.
Normally, there is an area at the end of the esophagus that marks the border between the cells of the esophagus and those of the stomach. Barrett's esophagus is the growth of intestinal-type cells above this border into the esophagus. "Since the cells lining the stomach are protected from contact with acid, their growth into the esophagus may actually be a defense mechanism to protect the normal tissue in the esophagus against further damage by reflux or GERD. This may explain why the symptoms of GERD seem to lessen in some patients with Barrett's esophagus."
On exceedingly rare occasions these tissue changes may be a forerunner of abnormal changes called dysplasia, which itself, in rare cases, may progress through various cell stages to cancer of the lower esophagus, a type known as adenocarcinoma. The more common cancer of the mid and upper esophagus (squamous cell cancer) is usually related to alcohol, smoking, and other risk factors. This type of cancer appears to be decreasing in the population, while the rate of adenocarcinoma is increasing, especially in white males. Adenocarcinoma, however, takes several years to develop, and is said to occur in less than 0.5% of patients with Barrett's, a figure which is inconsistent with the small number of those who develop dysplasia, said to be 0.4%! What is the true risk of this particular esophageal cancer developing in a patient with Barrett's?
Many observers assume that the most severe reflux problems are likely to have Barrett's, some say, as many as 10% of the 20 million GERD sufferers. Yet up to 25%-35% of patients with Barrett's have no symptoms, i.e. do not have reflux. This suggests that there may indeed be 3 million or more patients with Barrett's. Out of this estimated population of 3 million people, an unknown number, certainly less than 8,000 in the U.S. annually get the type of cancer associated with the condition. Another way of looking at this is that less than 1 in 375 patients per year with Barrett's will develop adenocarcinoma of the esophagus. A physician would have to evaluate almost 40 patients with known Barrett's for 10 years each to have a chance of finding a single cancer.
The American College of Gastroenterology states that "...patients with chronic symptoms of GERD are those most likely to have Barrett's esophagus and should undergo upper endoscopy." Yet, only 5 percent of patients who had surgery for esophageal adenocarcinoma were known to have Barrett's esophagus before operation, highlighting the fact that current screening techniques are relatively ineffective.
Other authorities state there is no need for routine treatment for Barrett's esophagus. "Most people who have Barrett's esophagus have heartburn or other symptoms of acid reflux and take antacids or some type of medication to suppress the production of stomach acid. These medications provide relief from reflux symptoms but don't have any important effects on the Barrett's mucosa. As far as we can tell, there is no easy way to cause the Barrett's mucosa to disappear, nor is there any easy way to prevent the development of cancer in a patient with Barrett's mucosa." (my italics). Low-grade or mild dysplasia requires no specific therapy, but unlike most cases of Barrett's does require surveillance endoscopy. According to this article, "Given the high prevalence of GERD, it is physically and financially impossible to screen all patients with GERD symptoms for the development of Barrett's." Clearly, a patient with alarm symptoms of esophageal cancer, such as difficulty or pain on swallowing, bleeding, or weight loss should be promptly referred for barium studies and, if necessary, endoscopy. The authors add that "...currently, there is little evidence that screening for Barrett's esophagus decreases the rate of mortality from adenocarcinoma."
Finally, "Despite the rapidly increasing incidence rate of esophageal adenocarcinoma, the vast majority of patients with Barrett's esophagus will never go on to develop this cancer. Furthermore, esophageal adenocarcinoma is a rare cause of death in Barrett's esophagus patients, and most of these patients die from other causes..." Some studies demonstrate that the overall survival of patients with Barrett's esophagus is no different than that of the general population..."
The good news is that estimated new cases of cancer of the esophagus in 2006 is 14,550, only 1% of all cancers in the U.S. The bad news is that 13,770 will die of the disease this year, 2.5% of all cancer patients.
The bottom line at present seems to be:
- 95% of patients operated on for lower esophageal cancer were not diagnosed as having Barrett's preoperatively, even though patients with chronic GERD are most like to have Barrett's. This strongly suggests that screening the average patient with mild to moderate reflux (40-million-50 million Americans) is useless and impossible. Patients, however, with long-standing and severe GERD should probably be screened once with EGD, despite the extreme unlikelihood of their ever developing esophageal cancer.
- Treating asymptomatic patients with evidence of Barrett's does not seem justified.
- There is no good evidence that treatment of GERD prevents the development of esophageal cancer, even if it provides relief of symptoms.
- How often patients with Barrett's and dysplasia should be endoscoped is not clear and may depend on the degree of dysplasia.
- Patients with Barrett's but without dysplasia are probably at such low risk for esophageal cancer that whether they should have repeat endoscopy every few years is debatable.
Martin F. Sturman, MD, FACP
Copyright 2006, Mathemedics, Inc.
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