One well-known risk factor for developing esophageal cancer is Barrett’s esophagus (BE), which is associated with a minimal increased risk of .1 percent of patients. With the presence of high-grade dysplasia, that risk increases to about one percent.
“Barrett’s esophagus, in itself, is not particularly dangerous” says Rajat N. Parikh, MD, of Birmingham Gastroenterology Associates. “But it is imperative that these patients are followed closely to make sure the condition does not progress to dysplasia or cancer.”
Parikh says proton pump inhibition (PPI) and acid reduction is often effective in preventing the progression of BE with dysplasia, but it also can cause other issues. “There is a lot of controversy with the long-term use of PPIs. While the medication helps prevent BE from progression, it has come into question for long-term use. We see things like bone density issues in post-menopausal women and chronic kidney disease associated with PPI use,” he says. “We also see H. pylori and increased incidence of Clostridium difficile colon infections.”
In spite of the best treatments to prevent progression of BE, dysplasia can occur as the condition progresses. In addition to heat ablation techniques used to remove the precancerous cells, a number of physicians now are turning to cryotherapy to treat the condition. The minimally invasive treatment destroys diseased cells in the esophagus using liquid nitrogen and a regular upper endoscope.
According to Parikh, a thin tube is passed through the endoscope and out the tip, then the liquid nitrogen is sprayed onto the lining of the esophagus which freezes the cells. The body then has an inflammatory reaction which gets rid of the cells and new, normal esophageal mucosa grows over the area where the Barrett’s cells were located.
“Cryotherapy is not yet a mainstream treatment for BE, but a lot of good research studies have come out in the past year showing excellent results with this therapy. There may or may not be fewer complications, and that’s something we are looking at long-term,” Parikh says. “In terms of ablating dysplastic cells, cryotherapy is doing an excellent job. We expect it to become more mainstream in the coming years, and we are keeping an eye on it.”
Radiofrequency ablation (RFA) has been the standard treatment for BE with dysplasia. RFA uses thermal therapy or burning ablation, and Parikh says the cryotherapy is more comfortable for patients and better tolerated. “We don’t have head-to-head data for comparison of the two techniques yet, but cryotherapy seems to be well tolerated and easy to do. The cost of cryotherapy should be less, so that is a benefit,” he says. “It is still a developing technology and I think it will play a large role with ablation in the future.”
Parikh reiterates the importance of surveilling these patients and urges physicians to recognize the patients who might be at risk for BE and esophageal cancer. “It’s easy to write a prescription for a PPI to make a patient feel better, but it can also mask symptoms until there is a problem. If a patient is on long-term therapy, he may be a candidate for BE screening,” he says. “If you see an obese middle-aged white man with chronic reflux, it’s not necessarily an indication of BE but is something to discuss with the patient. Unfortunately, there are no strong recommendations. It’s just a one-on-one thing between the primary care physician or gastroenterologist and the patient.”
