Esophageal Cancer-FYI

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Former Texas Gov. Ann s's brief battle with esophageal cancer has raised

new questions about whether more people should be screened for the deadly

disease.

Esophageal cancer is one of the fastest-rising forms of cancer, but it is rarely

detected early, when it is most curable. Most patients live less than a year

after being diagnosed -- just 15% survive for at least five years. Gov. s

lived for just six months after her diagnosis.

The form of cancer that killed Gov. s -- squamous cell -- often is

associated with a history of heavy alcohol and tobacco use. Gov. s was a

recovering alcoholic and former smoker. The fastest-rising form of esophageal

cancer -- adenocarcinoma -- is strongly linked with years of chronic heartburn

and acid-reflux disease.

But whether people should be screened for the disease remains a matter of heated

debate in the medical community because it isn't clear whether screening would

be cost effective or make a meaningful difference in long-term survival rates.

The medical community routinely screens for a range of diseases in high-risk

populations, but there's no routine screening for people at high risk for " one

of the deadliest tumors known -- esophageal cancer, " says Swanson, chief

of thoracic surgery at Mount Sinai School of Medicine in New York. " We need to

consider [screening] for high-risk groups. "

The best way to screen for esophageal cancer is with an endoscopy. During an

endoscopy, the patient is sedated while a lighted tube is put down the throat to

look for changes in the esophagus that might signal cancer. The procedure costs

about $1,000 and is typically covered by insurance. Although an endoscopy is

considered a safe procedure, there are always risks associated with anesthesia

and a slight risk of bleeding or infection after the procedure. The main concern

about screening endoscopy is cost and that fact that the vast majority of

screening endoscopies wouldn't find cancer, but would tax the resources of an

already overburdened health-care system.

Currently there are more than 14,000 cases of esophageal cancer each year.

Considering that there are 40 million current smokers, 100 million former

smokers and an estimated 40 million people who suffer weekly bouts of heartburn,

the question is who among these groups is at highest risk for esophageal cancer

and should be screened.

There are no simple answers. But we do know risk for the squamous-cell

esophageal cancer is dramatically higher with long-term use of both tobacco and

alcohol. It's six times more likely to occur in African-American men than in

whites.

We also know that people with chronic heartburn -- or gastroesophageal reflux

disease, known as GERD -- are at higher risk for esophageal cancer. Many doctors

believe patients with a history of chronic heartburn for five years or more

should be screened for precancerous changes in the lining of the esophagus -- a

condition known as Barrett's esophagus. It has been estimated that from 5% to

10% of Barrett's patients will go on to develop cancer. Eating a diet low in

fruits and vegetables, or weighing 20 to 30 pounds more than your ideal weight,

also has been linked with increased risk for esophageal cancer.

Most doctors agree that patients already diagnosed with Barrett's should get

regular screenings for cancer. The more difficult question is who among GERD

sufferers should undergo screening endoscopy. Some researchers have suggested a

one-time screening for anyone who has chronic reflux, particularly if the

problem is serious enough to warrant long-term drug therapy. Others believe only

those at highest risk should be screened -- men older than 40 who have suffered

reflux symptoms at least twice a week for five years. Patients who develop GERD

for the first time after age 65 also should consider screening.

One answer to the screening question is to perform a screening endoscopy at the

same time a patient is undergoing a screening colonoscopy, which typically

happens around the age of 50. The patient already is sedated and the

gastroenterologist who performs the colonoscopy also typically specializes in

endoscopy. Some studies have shown that Barrett's is detected in as many as one

out of four patients screened this way.

Finding esophageal cancer early makes a dramatic difference in survival because

patients can qualify for surgical removal of the esophagus and sometimes the

surrounding lymph nodes. An April study published in the Journal of the American

College of Surgeons reviewed the medical records of 263 patients who underwent

the surgery from 1992 through 2002. The overall survival rate during the last

five years of the study was 50.4%, and jumped to 81% for patients who were

diagnosed at Stage I.

The results show patients can benefit from early detection, says H.

s, surgery-department chairman at the University of Rochester Medical

Center and a study co-author. " I believe we should be screening high-risk

populations, " says Dr. s. " The principle is clear -- the earlier you pick

up a cancer the more likely you are to cure it. There's very little debate about

that. "

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