Cancer of the esophagus, the tube that conveys food from the mouth to the stomach, has increased by a whopping 600% over the last thirty years. Yikes! Rick and I expound on PodMed this week, that's a lot of cancer, and a cancer with a poor prognosis. Now a study in this week's JAMA offers hope for people in the presumed early stages of the disease, using a technique called radiofrequency ablation. Before citing the specifics of the study, I'd like to first describe why I used 'presumed' in the above sentence. Research that is at least a decade old suggests that at least some of the rapid increase in the incidence of esophageal cancer is due to gastroesophageal reflux disease, abbreviated GERD, eroding the area of the esophagus that connects to the stomach over time. That's because stomach contents are regurgitated back into the esophagus, where the tissue is susceptible to damage by the very acidic stomach slurry. Repeated injury leads to a stepwise progression through an inflammatory condition known as Barrett's or Barrett esophagus, until frank esophageal cancer develops. This is thought to be the case for adenocarcinoma of the esophagus. Yet attempting to reduce the acidity of reflux by H2 blockers or other types of antacids has proven disappointing in reducing progression, and at least one study I'm aware of also casts some doubt on the Barrett's esophagus goes to esophageal cancer link. Indeed, today's study also reveals that many people resolve low grade dysplasia on their own, so the solid line relationship really can't be drawn. Okay, but what about this study?
One hundred thirty-six patients with low-grade dysplasia were randomized to either radiofrequency ablation or to usual care with endoscopic surveillance. Sixty-eight patients comprised each arm of the study with those who had ablation doing so by one of two techniques over a maximum of five treatment sessions. The primary outcome measure was progression from low-grade to high-grade dysplasia or adenocarcinoma of the esophagus over three years of follow-up. The trial was stopped early because of the clear superiority of the ablation in preventing progression, with almost 27% of the control group progressing compared with 1.5% of the ablation group. Ablation reduced the risk of progression to adenocarcinoma by 7.4%.
Pretty impressive numbers, of course, and at face value appears to be clear evidence that radiofrequency ablation should be considered in folks with low grade dysplasia. But hold on, Rick and I discuss. People who entered this study were examined and their diagnosis confirmed by people who were expert in the field, and the authors themselves state that 50-85% of people thought to have low grade dysplasia were downstaged to Barrett's esophagus when an expert pathologist examined the biopsy. Moreover there are some people who clear such conditions on their own, and it's worth considering helping that along with even more conservative measures such as weight loss, eliminating alcohol, chocolate, spicy foods and other irritants from the diet, avoiding eating within 4 hours or so of bedtime and so on. In our quick fix culture this technique appears attractive but seems the potential for overuse is rife.
Other topics this week include screening and intervention for alcohol abuse in college students and measuring hemoglobin A1c as a risk factor for cardiovascular disease, also in JAMA, and e-cigarette use in JAMA Internal Medicine. Until next week, y'all live well.