Wake Forest Baptist Medical Center
Offering a Full Spectrum of Treatments for Barrett’s Syndrome and Esophageal Cancer
Barrett’s Esophagus with Dysplasia – A new treatment option.
By Jason D. Conway, MD, MPH, Assistant Professor, Director, Advanced Endoscopy Fellowship Program
Barrett’s esophagus is a pre-cancerous condition where the normal squamous mucosa of the distal esophagus is replaced by specialized intestinal epithelium. Barrett’s esophagus is seen in less than 10% of patients with gastroesophageal reflux disease (GERD), suggesting that chronic acid exposure in the esophagus plays a critical role in the development of Barrett’s esophagus. Patients with Barrett’s esophagus are at a slightly higher risk for developing adenocarcinoma and are typically treated with acid suppression (usually proton pump inhibitors) and surveillance upper endoscopy every few years.
Risk of esophageal cancer in patients with Barrett’s
The incidence of esophageal adenocarcinoma in the U.S. has increased by 500% since the early 1970’s. Over 16,000 new cases of esophageal cancer will be diagnosed in the U.S. in 2009. Longitudinal cohort studies have shown that while the presence of Barrett’s esophagus is a risk factor for esophageal cancer, most patients with Barrett’s do not go on to develop esophageal cancer. However, a small minority of patients will develop cellular atypia called dysplasia – classified as either low or high grade. Patients with low grade dysplasia have a less than 1% risk of developing esophageal cancer per year. Patients with high grade dysplasia have a 10% or higher risk per year of developing esophageal cancer.
A new treatment option – radiofrequency ablation
Until very recently patients with Barrett’s esophagus with high or low grade dysplasia had two treatment options: continued endoscopic surveillance (“watchful waiting”) or esophagectomy. For many patients these treatment options seemed at opposite ends of the treatment spectrum, and neither seemed appropriate for a pre-cancerous condition.
Over the past several years there has been increasing interest in endoscopic ablation or removal of dysplastic Barrett’s esophagus. These procedures have focused on removing all or most of the Barrett’s esophagus (and therefore reducing the risk of cancer) in a safe and relatively non-invasive way.
The most promising technology is radiofrequency ablation (HALO system, BÂRRX™ Medical, (www.barrx.com). This innovative system uses a flexible catheter with small electrodes on the end which can be guided endoscopically into the esophagus and used to ablate or burn the Barrett’s esophagus. Energy delivery is precisely controlled by a radiofrequency generator, so only the epithelial lining of the esophagus is ablated.
A recent study by Shaheen et al. (N Engl J Med 2009;360:2277-88) enrolled 127 patients in a multicenter, randomized, sham-controlled trial where Barrett’s esophagus with dysplasia underwent radiofrequency ablation using the HALO system. After 12 months of follow-up, nearly 80% of the patients in the ablation group had complete eradication of all Barrett’s esophagus, as well as significantly less disease progression and fewer incident cancers compared to those who did not undergo ablation. Side effects included mild to moderate chest discomfort, nausea, or difficulty swallowing which resolved within a few days. Esophageal stricture formation occurred in 6% of patients, all of which could be managed with serial endoscopic dilations.
A comprehensive program for endoscopic management for Barrett’s esophagus with dysplasia
The management of Barrett’s with dysplasia is complex and must be individualized for each patient. Patients referred to Wake Forest Baptist are invited to an initial office consultation where they are educated about their risk for developing esophageal cancer and presented with all the treatments options. Patients who choose radiofrequency ablation first undergo an initial endoscopic ultrasound (EUS) as well as extensive endoscopic biopsies and, if needed, endoscopic mucosal resection (EMR) of any nodular tissue within the Barrett’s.
Assuming no adenopathy or esophageal wall abnormalities are seen on EUS, the Barrett’s esophagus will be ablated with the HALO system. This outpatient endoscopic procedure is performed with monitored anesthesia care in the Advanced Endoscopy Unit. Patients typically go home the same day. Several ablation sessions are needed usually 2-3 months apart with a goal of complete eradication of Barrett’s esophagus.
The Digestive Health team is excited to offer this new safe, effective, and non-invasive way to manage Barrett’s esophagus with dysplasia. Amanda Williams-Kalaf, RN coordinates referrals and can be reached at 336-713-7315 or 336-713-7322 (FAX).
One Patient’s Perspective
Keith Rowland, 66, had suffered from heartburn his whole life. Almost 20 years ago he underwent Nissen fundiplication surgery. His acid reflux was immediately relieved, but years of stomach acid refluxing into his esophagus had left lesions on his esophagus. He had no symptoms and went on with his life. Several months ago he was diagnosed with Barrett’s esophagus with high grade dysplasia. Mr. Rowland was not interested in surgery, but was also not willing to take a “watchful waiting” approach. He was referred to the Digestive Health Center at Wake Forest Baptist and was determined to be a good candidate for radiofrequency ablation.
He has undergone two ablation procedures and is doing well. “Aside from some pain swallowing for a couple days, I had no side effects from the procedure,” said Mr. Rowland. “In fact, a few days after my last procedure I was out in the garden and picked 18 quarts of corn.”
“I received excellent care at Wake Forest Baptist. I was admitted in the morning and the next thing I knew I was awake, the procedure was over, and I was headed home,” he added.
Surgical Approach to Treating Esophageal Cancer
By Edward A. Levine, M.D., Professor of Surgery, Chief, Surgical Oncology
Although great strides have been made in treating the precursors to esophageal cancer, most patients will unfortunately have an advanced stage of disease at the time of diagnosis. For such patients with esophageal cancer, it can be a devastating diagnosis. At Wake Forest Baptist we believe that patients are best treated by a multimodality team including cancer surgeons, medical oncologists, radiation oncologists, gastroenterologists and specialized nurses.
For patients whose cancer has not spread widely, surgery remains the primary curative treatment. Preparing patients for treatment for esophageal cancer can seem daunting to patients. To make things easier, Wake Forest Baptist has an experienced nurse coordinator for esophageal cancer (Lynn Wooten, RN) who simplifies evaluation and referrals for both patients and physicians.
Surgery for esophageal cancer involves removing the diseased esophagus with an area of normal tissue around the cancer, to be certain as possible that it is completely removed. The stomach is then pulled up into the position of the esophagus near the base of the neck to do double duty as both an esophageal replacement and a stomach. This has traditionally required a major incision between the ribs to get to the esophagus. However, in selected patients surgeons are now able to perform the surgery in the chest without the need for a large chest incision. Most patients return to normal swallowing just a few weeks after surgery.
Improving Patient Care through Research
The team treating cancer of the esophagus at Wake Forest Baptist is an integral part of the Comprehensive Cancer Center. We continue our long standing efforts to improve the care of esophageal cancer patients through research. Led by Dr. Edward Levine, the team was awarded a grant from the National Cancer Institute to evaluate the utility of PET scanning for patients with esophageal cancer treated with multimodality therapy.
Ongoing research projects for patients with esophageal cancer are focusing on updated approaches to surgery, adding newer "targeted" agents to the preoperative chemotherapy and improving radiation for those who need it. Patients may receive radiation or chemotherapy at other centers, and have any needed surgery at Wake Forest Baptist. Surgeons also work with numerous medical and radiation oncologists throughout the region to make multimodality care available where surgical support for these patients is not available.
An Experienced Team
Surgery for cancer of the esophagus is a serious operation, best undertaken by an experienced team. Research has clearly shown that experienced surgical teams treating patients in hospitals experienced in the care of patients after this surgery have the best results. Wake Forest Baptist is a high volume provider and Dr. Levine is a knowledgeable surgeon with extensive experience in treating patients with esophageal cancer. Their outcomes, as shown in published research, are competitive with any reported in the nation.
We remain ready to offer comprehensive multimodality care for patients with esophageal cancer. Lynn Wooten, RN will be coordinating referrals and can be reached at 336-713-2025.