esophageal adenocarcinoma without Barrett's, some studies

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theacidrefluxman
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   Posted 4/6/2012 2:18 PM (GMT -6)   
Hi all,

I've been a bit worried for a while about esophageal cancer even though I don't have Barrett's. My fears were mostly based on this study:

An important study published in the Mar. 18, 1999, issue of the New England Journal of Medicine examined the links between adenocarcinoma of the esophagus, Barrett's esophagus, and heartburn (GERD) in the entire population of Sweden. The authors found a strong association between heartburn and cancer. Adenocarcinoma was almost as likely to occur in patients without the changes of Barrett's esophagus as patients with the changes, suggesting that Barrett's esophagus may not be a stronger predictor of malignancy than heartburn alone.

My doctor falls into this group: Moreover, there still are experts who feel that the changes of Barrett's esophagus always precede adenocarcinoma and provide a satisfactory means to identify patients who are at risk for adenocarcinoma and who need regular endoscopy and biopsy. (Perhaps in the Swedish study the changes of Barrett's esophagus were missed or destroyed by the adenocarcinoma.)

http://www.medicinenet.com/script/main/art.asp?articlekey=8796

So my dr. told me that you need barrett's to get adenocarcinoma, and that studies had proven that. I hadn't found any but have had some luck lately, and wanted to post them. My dr. said it was fairly well established that this was true...but then I don't understand why Barrett's is "a risk factor"...it wouldn't be a risk factor, it would be the necessary precondition....

Here is some of the stuff I came across.

2007. Adenocarcinoma of the distal esophagus and gastroesophageal junction are believed to arise in Barrett’s esophagus with intestinal metaplasia. These data strongly support the contention that adenocarcinomas of this region, including those in the gastric cardia, arise in intestinal metaplastic epithelium. The absence of residual intestinal metaplasia in larger tumors is the result of tumor overgrowing
the intestinal metaplasia from which it arose.

http://www.surgery.usc.edu/foregut/demeesterpub/415.pdf

2005. Histologic progression from Barrett's epithelium to cancer is associated with a gradient of increasing changes in gene expression characterized by an early loss of gene function governing differentiation that begins before histologic change; gain in function of genes related to remodeling and invasiveness follows later. This correlation of histologic progression with increasing changes in gene expression suggests that gene expression changes in biopsies taken from Barrett's epithelium potentially could serve as a marker for neoplastic progression that could be used to predict risk for developing cancer.

http://www.ncbi.nlm.nih.gov/pubmed/15814623

theacidrefluxman
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Date Joined Oct 2009
Total Posts : 739
   Posted 4/6/2012 7:14 PM (GMT -6)   
I wonder why there is not more interest in this. It makes me think I am taking it too seriously, which would be good news I guess...

sunbeam48
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Date Joined Jun 2011
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   Posted 4/6/2012 7:29 PM (GMT -6)   
This isn't something I choose to worry about. I focus on info posted in mmms thread, including the statement that 90 percent of the people with Barrett's don't develop cancer.

mudmagnetmum
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Date Joined Apr 2011
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   Posted 4/7/2012 4:35 AM (GMT -6)   
I think from what I've read that you can get adenocarcinoma of the oesophagus without Barretts - you don't have to have Barretts. And if you do have Barretts that doesn't necessarily mean you will get cancer - and if you have Barretts you possibly have the 'advantage' of having something that can be monitored.

I think if I were worried about cancer sneaking up on me in the absence of Barretts, I would focus on detectable signs such as weight loss, difficulty swallowing (dysphagia) and anaemia. Having dyspepsia is not a reliable indicator - and in fact can be absent in patients who develop upper GI cancer. This study I've just skimmed through this morning found that 93% (56 out of their 60 patients) of the cancer cases had red flag symptoms (anaemia, weight loss etc). In the few patients who were under 55 they ALL presented with alarm symptoms and NONE of them had indigestion. So they're suggesting having heartburn as a symptom isn't a reliable indicator (though obviously anyone getting heartburn as a NEW symptom is going to enjoy the delights of an endoscopy just to be sure - though this article is questioning whether that is appropriate).

http://www.medscape.com/viewarticle/759544_3

They comment that "These results suggest that early upper GI cancer is largely asymptomatic until alarm features develop, and that current guidelines do not delay its diagnosis."

I think your risk (if you have any at all) of upper GI cancer may well be far lower than your risk of other more common cancers such as those of bowel or prostate - and how much thought do you give to those on a daily basis? Nobody, no study and no test can tell you if you will or won't get cancer - you just have to see how life plays out and not let the worry spoil your life.

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

theacidrefluxman
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Date Joined Oct 2009
Total Posts : 739
   Posted 4/7/2012 10:45 AM (GMT -6)   
Hey MMM,

Some may call me over the top, but in about 1 minute I was able to find the email of the head of the Swedish study (Jesper Lagergren, Professor of Surgery, Karolinska Institutet, Stockholm, Sweden). This is the guy who wrote the study linking heartburn to adenocarcinoma, and not esophageal mucosal state. He was nice enough to respond to a quick email. Here is his response.

"Barretts esophagus is a necessary step in virtually all cases of adenocarcinoma of the esophagus, but it cannot (yet) be entirely ruled out that some adenocarcinomas might develop from the glandular cells of the squmous cell of the normal esophagus."

So it looks like he does agree with my Dr. after all...I guess, like you had said, things have changed since his 1999 study. Even though the odds are still greatly in favor of those who have Barrett's, this is great news for those without Barrett's.

stkitt
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Date Joined Apr 2007
Total Posts : 32602
   Posted 4/7/2012 1:21 PM (GMT -6)   
Refluxman,
 
The following info was in an article from 2003 with numerous contributing authors including your Professor.
 

Is Barrett's esophagus precarcinogenic?

In 118 (62%) of the 189 esophageal adenocarcinoma cases, Barrett's esophagus was detected. The strength of the association with symptoms of reflux was identical for patients with esophageal adenocarcinomas who had Barrett's esophagus and those who did not. Barrett's esophagus appears not to be a necessary step in the evolution of esophageal adenocarcinoma. The excess risk of adenocarcinoma among patients with Barrett's esophagus has been estimated to be 30-60 times that of the general population in large studies. Because the risk among subjects in our study with the most severe and long-standing symptoms of reflux was of the same magnitude, and because the association was equally strong among esophageal adenocarcinoma with Barrett's esophagus and those without it, we hypothesize that gastroesophageal reflux, may be the crucial factor. Therefore, it may be necessary to reappraise the critical role of Barrett's esophagus in the carcinogenic pathway.

http://www.hon.ch/OESO/books/Vol_6_Barrett_s_Esophagus/Articles/vol2/art086.html -Publication: August 2003

In your response from the professor he used the words virtually and well as stating "cannot (yet) be entirely ruled out that some adenocarcinomas might develop from the glandular cells of the squmous cell of the normal esophagus."

I truly think you would feel better if you worked on finding ways to stop the "what if?" thinking and enjoy the good in your life.  Big breath and enjoy your life,   look for all the good around you and do things that make you feel happy.
 
Kindly,
Kitt


 
~~Kitt~~
Moderator: Anxiety, Osteoarthritis,
GERD/Heartburn and Heart/Cardiovascular Disease.

www.healingwell.com

"Life is not about waiting for the storms to pass...
It's about learning how to dance in the rain."~ Vivian Greene

Post Edited (stkitt) : 4/7/2012 1:31:39 PM (GMT-6)


sunbeam48
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Date Joined Jun 2011
Total Posts : 795
   Posted 4/7/2012 2:19 PM (GMT -6)   
Most people die in bed, so you better not go to bed!:>)

GerdyGirl
Regular Member


Date Joined Feb 2012
Total Posts : 69
   Posted 4/7/2012 10:44 PM (GMT -6)   
A 2011 New England Journal of Medicine study on the entire population of Denmark showed only an extremely tiny relationship of Barrets with adenocarcinoma. The conclusion was basically that it is more likely that these cancers are picked up more in people with GERD because they receive endoscopies. Chances of developing it with GERD were 0.12% and the rate is only slightly lower in healthy people.

Here's the article: http://www.nejm.org/doi/full/10.1056/NEJMoa1103042

mudmagnetmum
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Date Joined Apr 2011
Total Posts : 1604
   Posted 4/8/2012 5:02 AM (GMT -6)   
Does knowing cancer is possible with or without Barretts change what you are going to do with your life or your treatment?

I repeat what is on the other Barretts thread - biggest cause of death for people with Barretts is not cancer - it's heart disease!

Personally I'd settle for a life without symptoms, whatever I may ultimately die of!

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

theacidrefluxman
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Date Joined Oct 2009
Total Posts : 739
   Posted 4/8/2012 2:13 PM (GMT -6)   
I get that you have to accept a certain level of risk, but I am really interested in this from a clinical point of view and think it makes sense to be.

In other words, if my dr. says I don't have Barrett's and that virtually all cases of adenocarcinoma are preceded by Barrett's, that would influence a decision regarding surgery. Ultimately, decisions for treatment will be based on risk/reward, and the question of how dangerous NERD or non-Barrett's is is obviously central to understanding one's risk. Its understanding risk to make a decision r.e. surgery when all else has failed...not understanding risk to worry about it for no reason...

What I am talking about is making a treatment decision (surgery) based on ones risk for cancer, and vital information to that is whether or not Barrett's always precedes cancer. I would think it would be in the mind of anyone without Barrett's before they decide for or against surgery....

But I do completely get your point MMM that you would "settle for a life without symptoms, whatever I may ultimately die of!" Sometimes it does come down to symptoms and not risk, I understand that.

IMO when Jesper writes ""Barretts esophagus is a necessary step in virtually all cases of adenocarcinoma", and "but it cannot (yet) be entirely ruled out that some adenocarcinomas might develop from...the normal esophagus.", it makes me conclude that it is only a matter of time before it is proven that all cases arise from Barrett's. I read a study where 100% of small tumors were surrounded by Barrett's, whereas few large tumors were. It is because large ones consume the Barrett's over time, so it disappears. From info I've gathered it makes me conclude that this is a correct conclusion...

Of course, that is why after an endoscopy if you don't have Barrett's dr's take it a lot less seriously...after all, if just symptoms raised risk then I think we would see more aggressive treatment.
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