Barrett's esophagus to esophageal adenocarcinoma: Are you at risk?
Since the 1970s, esophageal adenocarcinoma has been the neoplasm with the fastest-growing incidence of any cancer in the Western world. Maria Perno Goldie, RDH, MS, points out why it is best to prevent the progression of esophageal adenocarcinoma from its premalignant lesion, Barrett’s esophagus, in order to improve survivability.
Esophageal cancer is a cancerous (malignant) tumor of the esophagus, the muscular tube that moves food from the mouth to the stomach. Esophageal cancer is not very common in the United States. It occurs most often in men over 50 years old. Two main types of esophageal cancer exist: squamous cell carcinoma and adenocarcinoma. These two types look different from each other under the microscope.(1)
“Once a rare cancer representing only 5 percent of all esophageal cancers in the United States, esophageal adenocarcinoma is the cancer with the fastest-rising incidence — six-fold increase in the past three decades — and currently comprises more than 80 % of all new esophageal cancer cases in this country,” said Xifeng Wu, M.D., chair of the Department of Epidemiology, Division of Cancer Prevention and Population Sciences at The University of Texas MD Anderson Cancer Center, in Houston. “To reduce the mortality of esophageal adenocarcinoma, the best hope in the near term is to detect it at its early stage, or even better, to prevent the progression of esophageal adenocarcinoma from its premalignant lesion, which is called Barrett’s esophagus.”(2)
To improve survivability, it is best to prevent the progression of esophageal adenocarcinoma from its premalignant lesion, Barrett's esophagus. In a recent study, researchers compared hundreds of microRNAs in normal esophageal epithelia and in Barrett's esophagus and esophageal adenocarcinoma tissues of different histological grades with distinct progression risks. As a result, they were able to identify a number of differentially expressed microRNAs at each histological stage.(3)
The expression of microRNAs in Barrett's esophagus and esophageal adenocarcinoma tissues were similar, indicating that the microRNA aberrations were early events in the development of Barrett's esophagus, the researchers reported.
The researchers also identified a small number of microRNAs that were significantly different between Barrett's esophagus and esophageal adenocarcinoma. Patients with Barrett's esophagus with low levels of miR-375 and/or high levels of the other five microRNAs who are upregulated in esophageal adenocarcinoma are at increased risk for malignant progression and should be under intensive surveillance, screening, and treatment of their Barrett's esophagus.
Defining the protein-coding genes targeted by the differentially expressed microRNAs may provide significant biological insights into the development of esophageal adenocarcinoma, they found. The genes may become promising biomarkers to predict Barrett's esophagus progression and potential preventive and therapeutic targets, according to the study authors.
Specific mutations in the epidermal growth factor (EGF) gene appear to increase the risk for esophageal cancer in patients with gastroesophageal reflux disease (GERD), according to research presented here at the 2009 Gastrointestinal Cancers Symposium.(4) New guidelines on the diagnosis and management of gastroesophageal reflux disease appear in the American Journal of Gastroenterology.(5)
Among the strong recommendations with the highest level of evidence:
• Don't use barium radiographs to diagnose the condition.
• Use an 8-week course of proton-pump inhibitors (PPIs) for symptom relief and healing of erosive esophagitis.
• The various PPIs show the same level of efficacy.
• There is not an increased risk for adverse cardiovascular events among PPI users taking clopidogrel.
The risk of esophageal cancer in patients with Barrett’s esophagus is quite low, approximately 0.5 percent per year (or 1 out of 200). Therefore, the diagnosis of Barrett’s esophagus should not be a reason for alarm. It is, however, a reason for periodic endoscopies. If your initial biopsies don’t show dysplasia, endoscopy with biopsy should be repeated about every 3 years. If your biopsy shows dysplasia, your doctor will make further recommendations.
Esophageal cancer is the seventh leading cause of all deaths from cancer worldwide, with an estimated 14,000 deaths from this cancer in the United States alone in 2006. Since the 1970s, esophageal adenocarcinoma has been the neoplasm with the fastest-growing incidence of any cancer in the Western world.
This rising incidence implies a need for improvement in identifying those at risk for the disease and in both intervention and prevention. In the past, there has been a lack of consensus among experts regarding the diagnosis and management of Barrett's esophagus. Hopefully the new guidelines will assist practitioners in both prevention and intervention messages and strategies.
1. MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/000283.htm.
2. AACR in the News. Newly Identified Biomarkers May Help Predict Progression of Barrett's Esophagus to Esophageal Adenocarcinoma. Press release March 6, 2013. http://www.aacr.org/home/public--media/aacr-in-the-news.aspx?d=3028.
3. Wu X, Ajani JA, Gu1 J, Chang DW, Tan W, Hildebrandt MAT, Huang M, Wang KK, and Hawk E. MicroRNA Expression Signatures during Malignant Progression from Barrett's Esophagus to Esophageal Adenocarcinoma. Cancer Prev Res March 2013, 6; 196. doi: 10.1158/1940-6207.CAPR-12-0276.
4. 2009 Gastrointestinal Cancers Symposium (GICS): Abstract 2. Presented January 15, 2009.
5. Katz PO, Gerson LB, and Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013; 108:308 – 328; doi: 10.1038/ajg.2012.444; published online 19 February 2013.
6. American Society for Gastrointestinal Endoscopy (ASGE). Patient Education brochure. http://www.asge.org/patients/patients.aspx?id=402.
7. Banerjee S and Van Dam J. GERD: Reflux to Esophageal Adenocarcinoma. N Engl J Med 2007; 356:1897-1898. May 3, 2007. DOI: 10.1056/NEJMbkrev57846.