An epidemic of heartburn has left many patients with questions about how to prevent more serious problems.
An estimated 40 million Americans are afflicted with heartburn at least once a week — putting them at risk for a range of health worries, including esophageal cancer. Nobody knows why heartburn is on the rise, but obesity and diet likely play a role. The vast majority of people with heartburn won't suffer such a serious complication, but there is little guidance on how to find out who is most at risk. As doctors debate the best advice, here is a look at some common questions.
Should I be screened? The medical community is divided on whether it's useful to screen heartburn sufferers for early signs of esophageal cancer. The most obvious sign — a change in the lining of the esophagus — has no symptoms beyond those of the underlying heartburn. This condition, known as Barrett's esophagus, typically results from years of chronic gastroesophageal reflux disease, or GERD. As many as 12 percent of the estimated 15 million GERD sufferers will develop Barrett's esophagus, and from 5 percent to 10 percent of those will go on to develop cancer.
Barrett's may be diagnosed with an endoscopy — sliding a lighted tube down the throat to get a better look at the esophagus. Patients with Barrett's should get regular screenings for cancer. The harder question is who among GERD sufferers should undergo screening endoscopy. Endoscopy costs about $1,000 and typically requires sedation.
Some researchers have suggested a one-time screening for anyone who has chronic reflux, particularly if the problem is serious enough to warrant long-term drug therapy. Others believe only those at highest risk should be screened — white men older than 40 or 50 who have suffered reflux symptoms at least twice a week for five years. Patients who develop GERD for the first time after age 65 should also consider screening.
"Nobody can be very dogmatic about this," says Stuart J. Spechler, professor of medicine at University of Texas Southwestern Medical Center in Dallas and a leading expert on Barrett's. "It's hard to know who is the best group."
How do I know if it's serious? Anyone with chronic heartburn symptoms at least twice a week should consult a doctor. The most serious warning symptoms associated with heartburn are difficult or painful swallowing, weight loss or signs of bleeding, such as black or bloody stools. In these cases, a tumor may have already developed in the esophagus. Because esophageal cancer spreads quickly, anyone with a serious warning sign should see a doctor immediately.
Are heartburn drugs safe to use indefinitely? Heartburn drugs aren't specifically approved for long-term use, but many doctors encourage patients to use them indefinitely.
The most effective drugs, proton pump inhibitors such as AstraZeneca's prescription Nexium or Procter & Gamble's over-the-counter Prilosec, have been in use for almost 20 years and are considered safe. Questions remain about whether the drugs, which suppress acid production, cause changes in the gastric environment that might increase cancer risk. But far more is known about the damaging role that acid plays. So many doctors still advise using the drugs for now. "We need to treat heartburn well and with whatever the best method is, and currently that is PPIs," says Scott Swanson, chief of thoracic surgery at Mount Sinai School of Medicine in New York. "But we need to follow those patients closely."
Patients who are concerned about long-term use of drugs should talk to their doctor about additional monitoring. One method is ambulatory pH monitoring in which a probe is placed in the esophagus to record acid levels over 24 hours. Although not widely used, it can help determine whether acid-suppressing drugs are working to control reflux or just masking symptoms.
Is surgery an option? Antireflux surgery to tighten faulty valves or repair hernias at the base of the esophagus can also stop chronic reflux by helping prevent stomach acids from sloshing upward into the esophagus. Symptoms can return over time, however, and nobody really knows whether the drugs or surgery can slow the progression of Barrett's or prevent the onset of esophageal cancer. Other new procedures burn off the esophageal lining, but those methods are new and unproven.
Are there nondrug treatments? Some patients can manage GERD without drugs. Elevating the head of the patient's bed by about four inches — say, by placing blocks of wood under the legs — can help. The method uses gravity to keep acids down in the stomach while sleeping. Cut back on chocolate, spicy foods, tomato sauce, orange juice, peppermint, onions, soft drinks and other foods linked with heartburn. Avoid processed meats, which contain nitrates that may pose a higher cancer risk in GERD sufferers and those using acid-suppressing medications.
Most important, eliminate fatty foods, which slow the rate that the stomach empties. Fatty foods also trigger a chemical change that relaxes the stomach valve, allowing acid to surge up into the esophagus. Being overweight puts extra pressure on the abdomen and may cause the esophageal valve to loosen.
Some early studies have shown that daily aspirin use may cut the risk of esophageal cancer, and studies are under way looking at whether the anti-inflammatory drugs known as Cox II inhibitors, like Celebrex, may also help treat Barrett's. Other studies have shown that regular consumption of green tea may lower risk for esophageal cancer, but data are far from conclusive.