Up to 80 million people suffer from acid reflux or heartburn every day--and the esophagus can suffer. The esophagus is that tube connecting the throat to the stomach. Smoking makes it worse, but so does poor eating habits and stress--making a potentially dangerous problem a common problem.
Cyndy Hayward is in her early 50's, in shape, and on the move.
“I’ve moved to the beach and just opened a bookstore and a coffee shop,” she says.
When you see Cyndy she doesn’t look like someone who’s just overcome esophageal cancer.
“When I was diagnosed with cancer, it came out of the blue for me. I've had acid reflux and heartburn for years, and years and years and years,” she says.
For quite a while Cyndy says over the counter and heartburn and acid reflux drugs did help, but 5 years ago, she started having problems swallowing.
“With french fries, or chicken or certain foods I realized I needed a lot of water to get down.”
Dr. Donald Low is a thoracic surgeon at Virginia Mason Medical Center and a leading expert in esophageal cancer.
In a procedure to treat esophageal cancer, Low and a team of experts remove the entire esophagus and create a new one by pulling part of the stomach, up through the body, and attaching it to the throat.
“Cyndy is the classic example,” says Low, “she thought for 15 years that she was just someone who had standard heartburn disease.”
But doctors believe a small percentage of those who have chronic acid reflux or heartburn... will develop what's called Barrett's esophagus where the cells in the lining of the esophagus change, and that, for some people, can eventually turn into cancer.
“This cancer is one of the fastest growing cancers in the United States at the present time,” says Low, “and historically it is very difficult to treat.”
Up to 20% of those diagnosed with esophageal cancer will die, though at Virginia Mason, the odds are much better, thanks to a specialized, well-practiced team.
“We put together a plan that is specifically tailored to that individual patient,” says Low.
“What saved my life is we got it early,” says Cyndy.
Still: the numbers of those at risk are growing and Cyndy admits not only good doctors, but a bit of luck saved her life.
”The gift of the illness was to give me an opportunity to look at my life, what's left in my life and what I want to do with my life and that's a big gift.”
Web Extra: Symptoms and Resources for Esophageal Cancer and Barrett’s Esophagus
Esophageal Cancer: Virginia Mason
Dr. Donald Low: Virginia Mason
Esophageal Cancer: Mayo Clinic
Definition of Barrett’s Esophagus:
Barrett's esophagus is a condition in which the color and composition of the cells lining your lower esophagus change because of repeated exposure to stomach acid. This exposure to stomach acid is most often a result of long-term gastroesophageal reflux disease (GERD) - a chronic regurgitation of acid from your stomach into your lower esophagus.
Barrett's esophagus is uncommon. Only a small percentage of people with GERD develop Barrett's esophagus. But once Barrett's esophagus is diagnosed, there's a greater risk of developing esophageal cancer. Although increased, the absolute risk of esophageal cancer for someone with Barrett's esophagus is small - less than 1 percent a year.
You can eliminate or reduce the frequency of stomach acids flowing up into the lower end of your esophagus - and your chance of developing Barrett's esophagus - by making lifestyle changes.
Barrett's esophagus itself isn't associated with specific symptoms. But, heartburn and acid reflux - the sensation of bad-tasting liquid that may enter your mouth from your throat - are common indicators of GERD. And having GERD can lead to Barrett's esophagus.
A telltale sign of Barrett's esophagus - which your doctor can notice using a lighted instrument -occurs when the color of the tissue lining the lower esophagus changes from its normal pink to a salmon color. This cellular change, called metaplasia, is caused by repeated and long-term exposure to stomach acid.
Other signs and symptoms that may suggest a complication of GERD or Barrett's esophagus, including the development of esophageal cancer, include:
Trouble swallowing. Often, a narrowing of the esophagus (esophageal stricture) leads to difficulty swallowing (dysphagia).
Bleeding. You may vomit red blood or blood that looks like coffee grounds, or your stools may be black, tarry or bloody.
Weight loss and loss of appetite. You may experience an unexpected drop in weight.
The exact cause of Barrett's esophagus is not known, but the condition usually develops in people who have GERD. Heartburn and acid reflux are the most common symptoms of GERD and result from stomach contents washing back into the esophagus.
The ring of muscle at the junction of the esophagus and stomach (sphincter) normally keeps acid in your stomach by closing tight. GERD usually results from a weakened sphincter, and it can be aggravated by a protrusion of the upper stomach through the diaphragm (hiatal hernia).
Left untreated, GERD can lead to more-serious complications. Severe heartburn with inflamed esophageal tissue (esophagitis) can cause chest pain intense enough to resemble a heart attack. Other complications of GERD may include esophageal stricture - in which scarring causes narrowing of the esophagus - bleeding, Barrett's esophagus and esophageal cancer.
Risk factors for Barrett's esophagus include:
Chronic heartburn and acid reflux or GERD. These put you at risk of Barrett's esophagus because the esophagus is designed to carry food and liquid only one way - from your mouth to your stomach. The esophageal lining is sensitive to acid and unable to handle it.
Your stomach, however, has a lining designed to withstand acid-containing stomach (gastric) contents.
Stomach acid is damaging to esophageal tissue. Repeated and long-term exposure to stomach acid can lead to the transformation of esophageal tissue into the salmon-colored tissue characteristic of Barrett's esophagus, which is actually an acid-resistant lining of cells similar to the cells lining your small intestine.
Being a man. Men are two to threes times more likely to develop Barrett's esophagus.
Being white or Hispanic. White and Hispanic people are at greater risk of the disease than are blacks and Asians.
Being an older adult. Although Barrett's esophagus can affect people of all ages, the condition is more common in older adults.
When to seek medical advice:
See your doctor if you've had long-term trouble with heartburn and acid reflux. Talk to your doctor as soon as possible if you:
*Have difficulty swallowing
*Are vomiting red blood or blood that looks like coffee grounds
*Are passing black, tarry or bloody stools
*Experience an unexpected weight loss
Tests & Diagnosis:
Diagnosing Barrett's esophagus is difficult because it often doesn't exhibit specific symptoms. Experiencing the frequent and severe acid reflux of GERD may be the best indication that you either have Barrett's esophagus or may be at risk of the disease.
If you have severe acid reflux or have had acid reflux for many years, your doctor may discover Barrett's esophagus by examining your esophagus through endoscopy. Endoscopy involves inserting a lighted, flexible tube (endoscope) with a camera on its tip through your mouth and into your esophagus and stomach. Usually, you'll receive a local anesthetic, and you may be sedated for this procedure.
What your doctor looks for
The procedure allows your doctor to search for abnormalities such as precancerous cell changes (dysplasia) or an abnormal junction between your stomach and esophagus. In a healthy esophagus, the stomach-esophagus mucosal junction is at the lower end of the esophagus. In Barrett's esophagus, this junction is displaced upward. If Barrett's esophagus is suspected, your doctor also looks for evidence of cancer or precancerous changes.
During endoscopy, your doctor may remove tissue samples (biopsies) of potentially abnormal areas to be examined under a microscope. If specimens reveal intestinal goblet-shaped cells not usually seen in the esophagus, your doctor may make a diagnosis of Barrett's esophagus.
Following your diagnosis, your doctor may recommend endoscopies at regular intervals to screen for cell changes that could indicate progression to cancer. This usually means a repeat endoscopy one year after your diagnosis, followed by endoscopies every three years if no dysplasia is present. If a tissue sample shows dysplasia, you may need screenings at shorter intervals — at least annually and in some cases, as often as every three months.
Treatments & Drugs:The primary goal of Barrett's esophagus treatment is to prevent the development of esophageal cancer. It's not too late to treat dysplasia in Barrett's esophagus if it hasn't yet advanced to cancer.
Treatment for Barrett's esophagus may start with controlling GERD by making a number of lifestyle changes and taking self-care steps. These actions include losing weight, avoiding foods that aggravate heartburn, stopping smoking if you smoke, taking antacids or stronger acid-blocking medications, and elevating the head of your bed to prevent reflux during sleep.
People with severe GERD and Barrett's esophagus usually need aggressive treatment, which may include medications, other nonsurgical medical procedures or even surgery.
Medications to treat GERD and Barrett's esophagus include:
Proton pump inhibitors (PPIs). These medications — such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix) and esomeprazole (Nexium) — block production of acid and relieve irritated tissue.
H-2-receptor blockers. Doctors sometimes prescribe this class of drugs to treat GERD and Barrett's esophagus. They're less expensive, although weaker than PPIs. Prescription H-2-receptor blockers such as famotidine (Pepcid AC), cimetidine (Tagamet), nizatidine (Axid AR) and ranitidine (Zantac 75) are also available over-the-counter in doses less than prescription strength.
Although these medications often are quite effective for GERD, once Barrett's metaplasia is present these drugs won't reliably reverse the condition, and the risk of cancer remains even if your GERD symptoms go away with treatment.
Anti-reflux surgery (laparoscopic Nissen fundoplication) offers an alternative to long-term use of medication for GERD. The procedure tightens the sphincter by wrapping part of the stomach around the lower esophagus to prevent acid reflux. Laparoscopic surgery involves inserting special instruments through small incisions — less than an inch. The procedure leaves only tiny scars. You can expect to stay in the hospital for one or two days after this surgery. Although surgery can be effective for GERD, once Barrett's metaplasia is present surgery won't reliably reverse the condition, and the risk of cancer remains.
If you have esophageal cancer, or if you have Barrett's esophagus and high-grade dysplasia, your doctor may recommend you undergo a major surgical procedure in which the esophagus is removed completely and the stomach is pulled into the chest (esophagectomy). You may need to spend about two weeks recovering in the hospital after surgery. Although this treatment is effective, it is associated with significant health risks. Up to 50 percent of people who undergo esophagectomy experience at least one serious complication, including pneumonia, heart attack and infections at the surgical site.
The surgical treatment of people with high-grade dysplasia is controversial. Some experts believe that esophagectomy should be used as a measure to protect against cancer. Other experts believe that it's sufficient to schedule screening endoscopies every three to six months and perform an esophagectomy only if cancer develops. Doctors generally don't recommend surgery for people with declining health or for those who are too weak to withstand this major procedure.
Alternatives to medications and surgery
Removal (ablation) of dysplasia makes possible the reversal of Barrett's esophagus, and it may prevent esophageal cancer. Combined with PPIs, ablation may be appropriate especially if you're not a good candidate for an esophagectomy. Ablation procedures include:
Photodynamic therapy (PDT). First, you'll be injected with a drug called porfimer sodium (Photofrin) that makes the Barrett's cells sensitive to light. Then, your doctor inserts a specialized light source into your esophagus. The light causes a reaction with the Photofrin that destroys Barrett's cells.
Electrocautery. Your doctor inserts an electric wire into your esophagus to burn away dysplasia.
Laser therapy. Your doctor uses a hot beam of light (laser) inserted into your esophagus to burn away Barrett's cells.
Argon plasma coagulation. Your doctor releases a jet of argon gas into your esophagus along with an electric current to burn away dysplasia.
Endoscopic mucosal resection. Using an endoscope, your doctor injects a saline solution under the area of your esophagus that contains dysplasia. A blister forms under these abnormal cells, allowing your doctor to cut or suction the abnormal area away from the underlying tissue without damaging the rest of your esophagus. Your doctor may recommend following this procedure with photodynamic therapy.
Radiofrequency ablation. During this procedure, your doctor guides a tiny camera and a small balloon down your esophagus. The balloon and camera help your doctor measure the size of your esophagus and the length of the area that needs treatment. Then, your doctor inserts a second balloon, specifically sized to fit the area requiring treatment. The second balloon delivers a short burst of energy that burns out (ablates) the dysplasia.
Radiofrequency ablation is a fairly new procedure that is still being studied. However, research shows that more than 70 percent of those treated are free of dysplasia up to 12 months after treatment. Complications can include esophageal perforation (rupture) and strictures (narrowing).
The long-term effectiveness of ablation procedures in preventing cancer is still being studied.
Lifestyle & Home Remedies:
You may eliminate or reduce the frequency of stomach acids flowing up into the lower end of your esophagus by making the following lifestyle changes:
Control your weight. Being overweight is one of the strongest risk factors for heartburn. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus.
Eat smaller, more frequent meals. Three meals a day, with small snacks in between, will help you stop overeating. Continual overeating leads to excess weight, which aggravates heartburn.
Loosen your belt. Clothes that fit tightly around your waist put pressure on your abdomen, aggravating reflux.
Eliminate heartburn triggers. Everyone has specific triggers. Common triggers such as fatty or fried foods, alcohol, chocolate, peppermint, garlic, onion, caffeine and nicotine may make heartburn worse.
Avoid stooping or bending. Tying your shoes is OK. Bending over for a long time to weed your garden may not be, especially soon after eating.
Don't lie down after eating. Wait at least three to four hours after eating to lie down or go to bed.
Raise the head of your bed. An elevation of six to nine inches puts gravity to work for you. Or you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head by using only pillows isn't a good alternative.
Don't smoke. Smoking may increase stomach acid. The swallowing of air during smoking also may aggravate belching and acid reflux. In addition, smoking and alcohol increase your risk of esophageal cancer.