by Robert Sewell, MD, FACS
Most heartburn sufferers are aware of the connection between chronic gastric reflux and the development of a condition known as Barrett’s esophagus. Likewise, numerous articles have been written describing how Barrett’s carries a risk of progression to esophageal cancer. In virtually every article, authors stress the importance of controlling reflux as a means of reducing the risk of Barrett’s and subsequent esophageal cancer. The natural assumption is that since acid causes the burning sensation it must also be the cause of Barrett’s and subsequently cancer. Treatment recommendations invariably include taking drugs to stop acid from being produced by the stomach. However, there is growing evidence that that assumption may not be entirely correct.
Beginning in the early 1970’s a new type of acid suppressing medication, called Histamine-2 Antagonists (H2 Blockers) was introduced. The first of these drugs was Tagamet®, but is was soon followed by Zantac®, Pepcid®, and Axid®. These medications rapidly became among the most widely prescribed drugs in America, because unlike common antacids, (Tums®, Rolaids®, Maalox®, etc.) they could be taken as a once a day pill and they offered patients prolonged relief from troublesome heartburn. The H2 Blockers were joined by new category of drugs called Proton Pump Inhibitors, or PPIs, when Prilosec® came on the market in 1989. Other PPIs, including PrevAcid®, Nexium®, and Protonix®, followed by Aciphex®, Dexilant®, and Kapidex® are now among the most commonly prescribed medications, accounting for more that $12 Billion in sales annually. Many are now also available over-the-counter.
So what is the relationship between acid reflux and Barrett’s esophagus? If acid exposure causes Barrett’s and subsequently cancer, given the effectiveness of acid suppressing medications, and the millions of people who are taking them regularly, we should be seeing far fewer cases. However, the opposite is true. The incidence of esophageal cancer is rising faster than any other type of malignancy in the United States. (See Chart Below)
While there is no definitive scientific evidence linking any of these medication to the growing numbers of patients with esophageal cancer, the graph below demonstrates very clearly that the alarming trend began in the mid 1970s, shortly after Tagamet came on the market. At the very least, this raises the question whether the chronic reflux of non-acidic stomach fluid might play a significant role in the development of Barrett’s and subsequent esophageal cancer. Clearly more research is needed to establish any such relationship.
Meanwhile, it is clear that medications offer excellent heartburn relief for most patients without eliminating or even reducing the mechanical reflux of stomach contents into the esophagus. To actually stop reflux requires a mechanical solution. Several minimally invasive techniques are available which are designed to augment the function of the lower esophageal sphincter and effectively stop reflux. Certainly not every heartburn sufferer is a candidate for surgery, but for those who are these procedures can help them avoid a lifetime of medication while potentially reducing their risk of developing Barrett’s esophagus and esophageal cancer.
North Texas Heartburn and Reflux Center is responsible for the content of this article. For more information contact their Southlake, Texas office at 817-749-0206 or go to www.myrefluxisgone.com.