Heartburn is a common symptom and about one in five Australians suffer from it. However, not many will be aware that it can cause oesophageal cancer.
By Professor Krish Ragunath, Gastroenterologist, Hollywood and Royal Perth Hospital
Chronic heartburn resulting in reflux of acid and gastric contents leads to the condition called Barrett’s oesophagus (BO). Australian surgeon Norman Barrett, working in London in the 1950s, first described this condition as a congenitally short oesophagus when he observed gastric type columnar epithelium in the distal oesophagus.
Subsequent research has recognised this as an acquired condition due to chronic gastro-oesophageal reflux wherein the distal oesophageal squamous epithelium is replaced by the pre-malignant metaplastic columnar epithelium with intestinal metaplasia.
About 10-15% patients with reflux symptoms undergoing endoscopy get diagnosed with BO and predisposed to adenocarcinoma, which is the predominant type of oesophageal cancer in the Western population. Whereas squamous cell carcinoma is more common in the Asian population.
Globally there is an increasing incidence of oesophageal adenocarcinoma (OAC) in the Western world. Barrett’s oesophagus is the only identifiable pre-malignant condition that could account for the increasing incidence of OAC.
It is estimated that 1742 Australians were diagnosed with oesophageal cancer in 2023 and 1419 died of it. The majority of these cancers were OAC. The overall five-year survival rate is only about 23%, making this a killer disease. It is more common in men, with males more than twice as likely as females to be diagnosed with the disease and die from it.
Key messages
- Heartburn is a common symptom that should not be ignored due to its association with oesophageal cancer.
- Screen with endoscopy for BO in those with persistent heartburn requiring long-term acid reduction therapy.
- Screening followed by regular surveillance is the most effective way to combat OAC.
Regular surveillance endoscopy is recommended by national societies including the Australian Cancer Council to monitor and detect dysplasia and early cancer. Surveillance detected cancers are usually at early stage and potentially curable by modern endoscopic treatments or minimally invasive surgery.
While endoscopy is increasingly being performed nationally, with corresponding increase in the diagnosis of Barrett’s oesophagus, the incidence of OAC has not fallen. Less than 10% of patients diagnosed with OAC have a pre-existing diagnosis of BO.
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It is evident that patients at risk of developing OAC are not diagnosed with BO to undergo regular surveillance. This could partly be explained by the fact that up to 40% of patients with BO do not have ongoing heartburn symptoms and thus go undiagnosed in the community.
The public awareness to seek prompt medical attention is lacking as well with easy access to over-the-counter antacids to ease heartburn symptoms. Proton pump inhibitors (PPI) effectively cure reflux and heartburn symptoms.
It is important that patients with persistent heartburns and reflux symptoms requiring long-term treatment with PPI undergo endoscopy to screen for BO.
The annual incidence of OAC arising from BO is quite small, around 0.1-0.5%. However, the development of low or high-grade dysplasia increases the risk and are currently managed by endoscopic treatments.
There is an urgent need to identify risk stratification tools and biomarkers that can identify patients at risk of cancer progression and an effective screening test to identify asymptomatic or minimally symptomatic individuals.
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Screening followed by surveillance is the most effective approach to address the increasing incidence of OAC. Currently there are no cost-effective proven screening tests in routine clinical practice. However, there are several non- endoscopic approaches to screening that are being researched.
Cytosponge is one such tool that looks promising and multiple studies have been conducted in the UK. Other options include exhaled volatile compounds, oral microbiome alterations and blood-based biomarkers which are in early phase studies.
Artificial intelligence-based risk stratification tools are also under development to identify BO individuals at higher risk of progression to OAC.
Author competing interests – nil
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