According to the American Cancer Society (ACS), more than 16,000 new esophageal cancer cases are diagnosed each year in the U.S. Unfortunately the survival rate in these cases is only 10 percent. This alarming statistic is due largely to the fact that by the time the majority of cases are diagnosed, the cancerous tumors have grown to the point of inoperability. Raising patient awareness about potential conditions that, if left untreated, could progress into esophageal cancer, will encourage patients to seek the appropriate care through their physician.

Many people are aware that tobacco use increases the risk of developing esophageal cancer; however, there are several other common contributing risk factors including:

- Excessive alcohol consumption;
- Obesity;
- Lye ingestion; and,
- Gastroesophageal reflux disease (GERD), also known as acid reflux or heartburn.

A recent ACS Gallup poll revealed that 44 percent of adults in the U.S. have heartburn at least once per month and that approximately 30 percent of esophageal cancer cases can be linked to GERD. GERD is a condition in which acid (with some pepsin and bile) splashes up from the stomach into the esophagus. These three fluids are potentially dangerous to the sensitive esophageal tissue, as they can inflame and damage the lining of the esophagus, a condition known as esophagitis.

If GERD becomes a chronic condition, it can develop into Barrett's esophagus, a precursor to esophageal cancer. Barrett's esophagus is a condition in which the color and composition of the cells lining the lower esophagus change due to repeated exposure to stomach acid. Only a small percentage of people with GERD develop Barrett's esophagus, but once it is diagnosed, patients should be sure to meet with their physician regularly as they are at a greater risk of developing esophageal cancer.

Symptoms of advanced GERD or the presence of Barrett's esophagus include:

- Frequent heartburn. A burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the mid-abdomen.
- Difficulty swallowing. Often, a narrowing of the esophagus (esophageal stricture) leads to trouble swallowing or dysphagia.
- Bleeding. A person 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.

According to the ACS, prevention of Barrett's esophagus can begin with controlling GERD by making some simple lifestyle changes, such as:

- Losing weight. Obesity increases abdominal pressure, which can then push stomach contents up into the esophagus;
- Eating a diet full of fruits and vegetables, eating smaller and more frequent meals and not eating two to three hours prior to bedtime;
- Smoking cessation, as nicotine relaxes the esophageal sphincter and smoking also stimulates the production of stomach acid;
- Discontinuing the consumption of alcohol.

People with severe GERD and Barrett's esophagus often require aggressive treatment and prevention methods including medications, other nonsurgical medical procedures such as endoscopic therapies, or even laparoscopic and open surgeries. Often times, swallowing difficulty (known as dysphagia) and other symptoms can be treated if identified early.

However, due to the aggressive nature of the disease, the majority of patients who have esophageal cancer are not surgical candidates. In these situations, the primary focus becomes palliative care - providing comfort measures to help maintain quality of life. This includes treating the dysphagia and restoring the patient's ability to swallow food and drink liquids by opening the stricture within the esophagus.

To open the barriers caused by tumor in-growth physicians use an esophageal metal stent. Prior to the stent placement the patient may require dilation of the stricture to allow room for the stent to be positioned, thereby expanding the lumen of the esophagus. Traditionally, the placement of the stent can be a painful process for the patient, yet new technologies are making this procedure easier on the patient and physician.

New, innovative delivery systems enable accurate deployment and recapturability of the stent. This reduces the stent from moving or migrating into the stomach and thus the need for repeat procedures to replace or reposition the stent, one of the more common complications in traditional esophageal stenting.

Raising awareness about the primary pre-cursors to esophageal cancer - GERD and Barrett's esophagus - will encourage patients with these conditions to consult their physicians for the necessary screenings and treatment options. However, when palliative care becomes the primary option for patients with esophageal cancer, recent advancements in medical device technologies enable physicians to more easily implant an esophageal stent and in turn improve patients' quality of life.

Written by Dr. Ali Fazel
Dr. Fazel is the Chief of Gastroenterology and Medical Director for Advanced Endoscopy at INOVA Fairfax Hospital in Fairfax, Virginia.
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