Saturday, May 26

Management of Barrett's esophagus

Only 10% of patients with GERD have Barrett's esophagus. Some physicians have suggested that all patients with GERD should be screened with endoscopy for the presence of Barrett's. Then, if they have Barrett's, they can undergo regular endoscopic surveillance for the development of cancer. For most physicians, however, screening all patients with GERD seems unreasonable since it would require a tremendous increase in the cost of care for patients with GERD. One study suggested that cancer of the esophagus develops more often in patients who have had heartburn more frequently and/or for a longer period of time. Accordingly, perhaps screening for Barrett's esophagus is realistic only for those GERD patients with frequent and long-standing heartburn. However, studies have yet to demonstrate the value of this approach.

Periodic surveillance for cancer is recommended in patients with Barrett's esophagus. Yet, there also may be a role for other treatments. For example, since reflux is believed to be the cause of Barrett's esophagus, it is possible that early and aggressive treatment of GERD (elimination of virtually all reflux) will prevent the progression of Barrett's esophagus to cancer. Additionally, newer experimental techniques that destroy the Barrett's cells (e.g., laser or electrocautery) also may prevent the progression to cancer. Studies are needed in Barrett's to evaluate both the aggressive therapy of GERD and the destructive therapy of Barrett's for the prevention of esophageal cancer.

Although Barrett's esophagus clearly is a pre-cancerous condition, only a minority of patients with Barrett's esophagus will develop cancer. Moreover, periodic endoscopic surveillance for cancer is expensive and each endoscopy puts a patient at a slight risk for complications of endoscopy. Thus, investigators are seeking better ways of determining which patients with Barrett's are more likely to develop cancer and need more frequent endoscopic surveillance and which patients need infrequent surveillance or, perhaps, no surveillance. Accordingly, they are evaluating newer techniques (for example, analysis of the cells' DNA) to examine in more detail the altered cells in the esophagus of patients with Barrett's. In this way, the investigators are trying to identify cellular changes that can predict the later development of cancer.

The standard treatment for early cancers in Barrett's esophagus is surgical removal of a portion of the esophagus (esophagectomy). This is major surgery. However, several experimental procedures that do not require surgery are being evaluated for treating early cancers. For example, photodynamic therapy is a procedure in which the cancers are destroyed with light after they have been sensitized to the light by the intravenous injection of light-sensitizing chemicals.

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