Preventing progression of Barrett's esophagus to cancer without surgery
February 22, 2013 12:00:00 AM
Many people wonder what the treatment for Barrett's Esophagus (BE) is. Treatment for BE without dysplasia consists primarily of controlling esophageal acid exposure, usually with once a day proton pump inhibitor (PPI) medications like omeprazole (Prilosec®). Occasionally, twice a day dosing or even anti-reflux surgery may be necessary to completely control acid reflux. Unfortunately, suppressing acid does not usually cause the Barrett’s tissue to regress or even prevent it from progressing to cancer.
If dysplasia is found on any biopsies, treatment recommendations change:
- Low-grade dysplasia: Close surveillance with endoscopy every 6-12 months or ablation.
- High-grade dysplasia: Endoscopic therapy to destroy Barrett’s tissue or surgery.
- Early cancer: Endoscopic removal of focal cancer followed by tissue destruction or surgery
Experiments performed 20 years ago showed that in most people, once the Barrett’s tissue has been removed or destroyed, normal squamous tissue tends to regrow in the area as long as acid reflux is suppressed.
Endoscopic tissue destruction can be performed many ways:
- Photodynamic therapy (PDT). This aggressive technique relies on the combined effect of a photosensitizing medication followed by laser treatment to kill tissue. Side effects include light sensitivity requiring avoidance of outdoor light for a month as well as esophageal pain and stricturing. This technique is rarely used anymore.
- Endoscopic Mucosal Resection (EMR). This involves injecting saline (salt water) under the lining of the esophagus and shaving off dime-sized discs of tissue and overlapping them to remove larger areas. This technique not only destroys the tissue, it allows the pathologist to inspect larger pieces for the presence of any small area of cancer that may have been missed.
- Radiofrequency ablation (RFA). This technique uses a balloon covered in thin electric coils that provide a short burst of controlled heat that destroys only the most superficial tissue layer without damaging deeper structures. This is the most commonly used technique for treating BE.
- Cryoablation. Like treating skin cancers, the physician sprays liquid nitrogen through the endoscope to freeze Barrett’s tissue.
- Argon plasma coagulation. Used to “touch up” treatment areas where small islands of Barrett’s may persist, this endoscopic catheter shoots a jet of inert gas and an electric pulse to create a superficial burn over a small area.
Recent studies have shown that cancer can still develop even years after “successful” ablation therapy. For this reason, patients need to have close follow-up with endoscopy and biopsy every 1-2 years, even if no Barrett's Esophagus remains at the end of treatment.
Research suggests that centers that treat higher volumes of patients with BE and dysplasia experience greater success and allow more people to avoid surgery or progression to cancer. Expert centers should coordinate care closely with patients’ local gastroenterologists, primary physicians and care team members to ensure close follow-up, control of symptoms and to watch for side effects. Early involvement with expert thoracic surgeons—even if no surgery is anticipated—helps patients stay informed of options for both definitive surgery if necessary or anti-reflux surgery for acid control if medications prove ineffective.