Barret’s and cancer. Combination treatments
The same patient, approximately one year later, had another endoscopy and he had developed a Barrett’s esophagus in the meantime. Here on the right is the typical epithelium found in a Barrett’s esophagus – glandular; note the goblet cells. You can see the little sort of oval holes in the cells here. This is intestinal metaplasia; this is not the normal type of epithelium found at the upper end of the stomach . This is the hallmark of Barrett’s esophagus and the type of epithelium that most adenocarcinomas of the esophagus are found to occur in.
Here are some endoscopic pictures; we are looking down in about the mid esophagus here at an untreated patient with Barrett’s esophagus. You will see these erosions, these triangular, pale-centered, bright-red margined lesions in the squamous mucosa. This is typical reflux esophagitis. If you look further down here, however, you will see red mucosa which covers a long segment of the lower esophagus and that is the Barrett’s mucosa. Here, on the retroflexed view, looking upward, is the hiatal hernia that this patient had.
Supposing we treat a patient like this effectively to prevent reflux, either with proton pump inhibitors, such as omeprazole, or with a laparoscopic Nissen. What will happen? What will probably happen is that you will control their heartburn and acid reflux and their esophagitis will resolve if you endoscope them again, but the Barrett’s is almost certain to remain. It may develop squamous islands. These are squamous islands partially occupying some of the area of columnar mucosa. Doing an anti-reflux operation, or controlling with Prilosec, has not been shown to reduce the cancer risk in the remaining Barrett’s esophagus, so you still have to keep on with surveillance.
What is the risk of adenocarcinoma in patients with Barrett’s? There are many series; these are just three of the larger, more recent series, number of patients followed, number of follow up years median and the number of cancers per patient years. Take the top series of 166 patients, followed for an average of 9.3 years, one cancer per 180 follow up years, or out of 180 patients, one would get cancer each year. That looks bad, but it isn’t quite as bad as you might think. Some patients we see with Barrett’s really feel sure that they are going to die of cancer, but that is just not the case.
Here are four series, one of which was a paper I had in the New England Journal in 1985; these are longer follow ups. These are patients followed up 3-cm Barrett’s or longer, the number of follow up years and if you follow people for long enough, a proportion will die of a cause of some sort. If you follow everyone in this room for 100 years, you would get 100% mortality. So if you follow people with Barrett’s long enough, people will die of something. These are the numbers of those who died and these are the numbers of those who died of cancer of the esophagus; it was between 2.5 and 6%, roughly about 5%. Therefore, in these series, with the present methods of management, only about 5% of patients with a long-segment Barrett’s actually died of esophageal cancer. We sometimes find early cancers in these people, and at least four other patients in these different series developed a cancer but did not die of the cancer, they died of something else. That is quite different from a cancer causing an obstructive mass in the esophagus. So, 95% of patients with Barrett’s will not die of esophageal cancer.