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The Link Between Heartburn and Esophageal Cancer

Srinadh Komanduri, MD discusses the link between heartburn and esophageal cancer. He shares what innovative research is being conducted in this area at Northwestern Medicine, where he stands as to implementing screening programs for Esophageal cancer and how Northwestern Medicine and it's Center for Esophageal Diseases play an important role in managing this disease.
The Link Between Heartburn and Esophageal Cancer
Featuring:
Srinadh Komanduri, MD
Srinadh Komanduri, MD is an internationally recognized expert in advanced endoscopy and Barrett's esophagus. He serves as the Medical Director for the GI Lab and Director of Interventional Endoscopy. He has published over 100 peer-reviewed manuscripts in Gastroenterology and serves as the course director for one of the largest endoscopy courses in the country, Chicago Live.

Learn more about Srinadh Komanduri, MD
Transcription:

Melanie Cole, MS (Host): Today we’re examining the link between heartburn and esophageal cancer. My guest is Dr. Sri Komanduri. He’s an internationally recognized expert in advanced endoscopy and Barrett’s esophagus, and he serves as the medical director for the GI lab and director of interventional endoscopy at Northwestern Medicine. Dr. Komanduri, we’re jumping right in. Is GURD a precursor for cancer? How can heartburn cause esophageal cancer?

Srinadh Komanduri, MD (Guest): Thank you. Yeah this is a great question. There’s a lot of nomenclature or sort of semantics with the wording, and that’s important here. So GURD represents sort of content from the stomach that comes up and down into the throat or the esophagus. That can either be symptomatic or asymptomatic. One of the major symptoms of this is heartburn. Now, that being said, not everybody with reflux or GURD has symptoms. That’s where this gets very tricky in the sense that the reflex is what causes damage in the esophagus which leads to Barrett’s which leads to esophageal cancer. You can imagine if you're someone who has reflux but no symptoms, you can develop cancer without ever knowing it. This is one of the problems we’re struggling with.

That being said, a majority of people still have symptoms like heartburn or that burning sensation in the middle of the chest. It’s something that a lot of us have grown to deal with as a part of day to day life. I think what we’re trying to bring knowledge and awareness to is that if that continues and is not just a rare event, it could be a sign of severe disease like reflux, which is the precursor for esophageal cancer.

Host: Then give us a little physiology lesson. What is Barrett’s esophagus? How does that differ from GURD and esophageal cancer? How does this all tie together?

Dr. Komanduri: Great question. So, as we talked about, so the reflux or stuff coming up and down causes some injury. That starts with inflammation in the esophagus. You may hear a term called esophagitis, which is just inflammation in the esophagus. That inflammation over time can either heal up, and we treat that with things like acid medication. But for some people who are predisposed, and some of this is just genetics, some of it we just don't quite understand completely why, but it not only heals up, but it heals up to look like a cell from the intestine. So, you’ll hear a term called intestinal metaplasia, which simply means change—which is metaplasia—to look like an intestinal cell.

When a pathologist sees that… So, when you get your endoscopy and a physician can see these changes visibly, they take a biopsy. That biopsy is looked at under a microscope. The pathologist then sees this change of this intestinal type of cell. That is the definition for them to call this Barrett’s esophagus. Once you have Barrett’s esophagus, there is a rate of progression. While most patients with Barrett’s don’t get cancer, the ones that do can develop what is called dysplasia, which is sort of bad change. That is also recognized by a pathologist and is something that we look for from them to understand if somebody needs endoscopic treatment because they're heading towards cancer or if they're in a very advanced stage of the Barrett’s itself.

Host: Doctor, in your opinion, do you think screening should be like a colonoscopy for prevention? Where do you stand as to implementing screening programs for esophageal cancer?

Dr. Komanduri: That’s another very important issue. So, one of the things that I brought up initially is that many patients who develop Barrett’s and even cancer don’t have symptoms. So, you can imagine that’s a problem because they’re not going to come to a physician. So how else do we attack this? In fact, there’s a lot of buzz in the field that the majority of patients who have Barrett’s who could develop cancer are unrecognized. Which means that we only see actually in data about 10% of the patients who actually have the disease, and 90% of these people are still walking amongst us because they don’t have the symptoms or are just not seeking care.

So that has spurred the interest in screening because we need to figure out a way to comers who may have some clinical risk to the attention of physicians. Screening, as you mentioned, is the best way to do that. It has been limited in the past because endoscopy is a very expensive tool. What you’ll see coming in the near future are many modalities that have been looked at that are not endoscopic or not scopes going down under sedation, but actually non-endoscopic means of screening. A lot of these are going to be office based short type of tests that can be done very practically in a primary care office. This still needs to be developed over the next few years, but in the next few years you will see this being offered to you as a patient seeing your primary care physician.

The idea that screening for Barrett’s is an option for you. Will that become standard of care immediately? It will take some development and some practical assessment of how this would work in a primary care office. But it is something that is very close to being launched in terms of many different types of innovation in that space, and something that you’ll hear about moving forward even later this year.

Host: Very cool doctor. We’ll look forward to that because I think that’s going to help so many people. Once Barrett’s is diagnosed, can it be managed? Tell us about some of the latest treatments.

Dr. Komanduri: So about 10 years ago a treatment called radio frequency ablation was pioneered, which was one of the few aspects of any endoscopy that we’ve vetted very well with very high evidence. It’s shown to be very effective, safe, and durable. So, there’s a whole concept of endoscopic therapy, which involves different techniques of heat and freezing and also resection all done through a scope. Very minimally invasive, but with the idea that anyone with Barrett’s or advances in Barrett’s, even early esophageal cancer, can be cured endoscopically. This is something that now has born out very well for the past 10 years.

And it seems to be that once we eradicate the Barrett’s, if we can continue to keep the reflux which causes it under control, the likelihood the disease comes back is extremely rare. Somewhere around 5% or so. So, the nice thing about it is the minimally invasive way that we can get rid of the Barrett’s or any sort of early cancer changes that are associated with Barrett’s without doing any major surgery and we know the effect is durable simply by controlling reflux.

Host: How does Northwestern Medicine and its center for esophageal diseases play a role in this disease? Tell us about some of the innovative research that’s being conducted in this area, and a blue print for future research. What do you see happening on the horizon?

Dr. Komanduri: That’s a great question. So, I think we pride ourselves in a lot of the aspects. I think there’s a few critical pieces from a clinical esophageal program that translate to research, which are critical. That’s having a multidisciplinary team, which includes people like me—advanced endoscopists, experts in esophageal physiology in terms of research, surgeons who are experts in the event a patient does develop cancer that needs to be treated. Even down to psychologists. Dieticians who can help patients understand reflux related diets. We have all of this in one center. So, when a patient comes here, they may or may not need every aspect of that, but they have the ability to rapidly engage with all of these physicians and experts in a way that gives them a comprehensive approach to their disease.

So, we always call this a continuum, a reflux continuum. So, between GURD to esophageal cancer is what we call it because it’s all connected. Not that everyone’s going to get cancer, but it involves so many different pathways from reflux all the way to those who, unfortunately, develop cancer that we need to have everybody ready to deal with it whether it’s endoscopic therapy, surgical therapy, medical management, testing for reflux.

To that end, we have multiple studies, clinical trials, that we have related to all of that pathway. Specifically, the Barrett’s. We have one of the largest databases of patients over the last 10 years that we look at very specific aspects that help patient outcomes. We’re looking at data in terms of recurrence of disease after treatment. We’re trying to understand the best ways to manage reflux, the best ways to sample tissue. So, when patients are getting endoscopy who have Barrett’s and what we call surveillance. What is the best way to take biopsies? Is there a better way, such as taking brushings or scrapings? Can we analyze some of this tissue for more than standard type of cellular stuff? Can we look at molecular or changes that you might develop cancer? These are all the different types of studies along that pathway from reflux all the way down to cancer that we’re looking at here at Northwestern. So, when a patient comes here, not only do they get comprehensive care from the physician standpoint, they have opportunity to participate in landmark trials that are going to change outcomes in the future.

Host: Wow, thank you so much Dr. Komanduri for coming on, for sharing your extensive expertise to explain about this link between heartburn and esophageal cancer. Very interesting topic. What a great segment. This is Better Edge, a Northwestern Medicine podcast for physicians. For more information on the latest advances in medicine, please visit nm.org. That’s nm.org. This is Melanie Cole. Thanks so much for tuning in today.