What is Barrett's Oesophagus?
Professor Rebecca Fitzgerald – Trustee of Heartburn Cancer UK
heads up BEST Cytosponge Trial https://www.best3trial.org/
“Early diagnosis is essential to improve outcomes from cancer of the oesophagus. To do this we need to improve awareness of the importance of symptoms like heartburn and also providing easy access to tests. One approach that we have developed is a non-endoscopic test called Cytosponge which can be done at the GP surgery. We now have over 1,000 patients who have swallowed the device in our BEST3 trial"
Launched in 2017, 40 surgeries across the country have now offered the test (with 120 practices expected to take part overall) and 9000 patients being tracked for their outcomes. The Trial is assessing whether the test could offer a better way of detecting the early stages of oesophageal cancer in a shift toward prevention strategies for oesophageal cancer. Surgeries across East Anglia, Hampshire, the North East, Nottingham and London in a wide range of UK locations have been taking part over 2017-2018.
Over 20 research and practice nurses have been newly trained to give the test to patients many of whom can now work independently. Early results suggest that primary care patients are tolerating the test well with more than ½ of patients rating their Cytosponge experience a 9 out of 10 (Where 10 is totally acceptable).
These early findings, as well as the Trial providing a practical opportunity to test out large-scale nursing management and laboratory processes, are promising in terms of the potential deployability of the test in primary care. The introduction of the test, if the study is successful, could represent a major shift in the way in which the condition is detected and eventually treated in the health service.
HCUK, and more broadly patient and public groups, have played a key role in development of the materials used in the Trial through their ongoing work with Prof Fitzgerald and her research teams. Results of the Trial are expected in March 2020.
Barrett’s Oesophagus - often known just as Barrett’s - is a condition that affects the lining of the oesophagus, the muscular tube that carries food, liquids and saliva from the mouth to the stomach.
Normally, the oesophagus is lined by a layer of short, flat cells, called squamous cells.
This lining is similar to skin in that it is multi-layered and protects the oesophagus from injury caused by swallowed food.
Reflux occurs when juices from the stomach and small bowel flow back up into the oesophagus repeatedly.
This exposure to acid and bile can injure the lining of the oesophagus.
This injury may cause inflammation called Oesophagitis.
In some cases, as healing occurs, the normal squamous lining is replaced by cells that resemble those in the stomach or intestine, a process called metaplasia or change in cell shape.
It is this abnormal lining that is called Barrett's Oesophagus.
About Barrett's Oesophagus
Barrett's Oesophagus was first identified in the early 1950s by a surgeon called Norman Barrett. When examined with an endoscope, Barrett's Oesophagus appears to be a dark red colour compared with a normal oesophagus, which is due to a richer blood supply. In some people it can extend up the oesophagus from 1 centrimetre to 15 centimetres. Biopsies are taken to confirm the diagnosis and work out which cell types are present. When these biopsies are examined under the microscope the cells lining the lower end of the gullet, which are normally layered like the skin for protection, have changed to look like those of the stomach or intestine which are more used to handling acid and bile.
We don't know how or why this happens. Damage to the lower part of your oesophagus by reflux can lead to a condition called Barrett's Oesophagus. Barrett's Oesophagus appears to be more common in white men and people who are overweight. Although most patients will have experienced reflux symptoms, reflux can go unnoticed. Smoking may be linked to Barrett's Oesophagus but is not a strong risk factor, and it is not clear whether heavy drinking plays a role. Barrett's also occurs in people who do not appear to have these risk factors..
Persistent Heartburn do not ignore it
Heartburn is a burning sensation behind the breast bone and is due to acid and/or bile reflux. This occurs when the muscles at the lower end of your oesophagus, sometimes called your gullet or food pipe, become weak and allow digestive juices from your stomach and small bowel to flow back up. This is more likely to occur if you have a hiatus hernia which means that part of the stomach has moved up from its normal position to above the diaphragm.
Digestive juices containing acid and bile cause the typical feeling of a burning pain in your chest which may rise up and spread to your throat and jaw.
You might have other symptoms such as:
• a sour taste in the back of your mouth
• food coming back up into your mouth after eating (regurgitation)
• hoarse voice
• a cough that does not go away
If you often have Heartburn, you may find it useful to try to track the foods and drinks that trigger your symptoms, so that you can avoid them. Spicy foods, smoking and alcoholic drinks can provoke symptoms and should be avoided.
It is tempting not to take heartburn too seriously. Lots of people get it. You may think that it will go if you were just less stressed, or lost weight, or ate more regularly. But if you are often suffering heartburn attacks, and regularly have to take over-the-counter medicines to relieve it, talk to your doctor sooner rather than later. Your doctor may prescribe you drugs called acid-suppression tablets, which stop acid being made before it can cause damage.
Your doctor may wish to prescribe regular medication to prevent heartburn symptoms and to arrange for you to have an endoscopy. The medication is usually to prevent the stomach making acid and there are a number of different brands. If you have difficulty in swallowing foods with food sticking, pain when you swallow, weight loss or symptoms of anaemia (e.g. feeling tired all the time, feeling dizzy, faint, or generally looking unwell), you should consult your doctor straight away because this should be investigated.
How is Barrett’s Oesophagus diagnosed?
One in 10 individuals in the UK with a history of Heartburn is estimated to have Barrett’s Oesophagus. In a very few individuals with Barrett's the cell changes may develop into cancer. Cells that begin to show abnormal changes may gradually be developing a condition called dysplasia which occurs long before cancer develops. That is why many people with Barrett’s Oesophagus have regular check-ups.
Barrett’s Oesophagus is diagnosed by endoscopy. This involves a tiny camera on a thin tube being passed down your oesophagus so that the doctor can look at the lining. The doctor will also take small samples of the cells, called a biopsy, so that they can be looked at under the microscope.
Check-ups of Barrett’s Oesophagus
If you have been diagnosed with Barrett’s Oesophagus you may be offered regular check-ups with an endoscopy and biopsy. How often you have these check-ups will depend on your particular case. Most people only need an endoscopy every 2 to 5 years. Occasionally doctors will ask to see you more frequently.
Check-ups allow the doctors to monitor any changes in the cells of your oesophagus and alter your treatment if necessary. This may involve changing the dose of your acid-suppression medication or removing the abnormal areas in the oesophagus. If dysplasia is found early, it can usually be cured before cancer develops.
Treatments to relieve acid reflux
Individuals with Barrett’s Oesophagus often have bad acid reflux but, curiously, not all people have symptoms. The treatment for reflux in people with Barrett’s Oesophagus is the same as for people who do not have Barrett’s.
There are three approaches:
A) Things you can do for yourself
Avoid eating large meals within two to three hours of going to bed.
Avoid eating the foods that you know will trigger reflux, these will often include: fatty foods such as cheese, red meat; chocolate, coffee, alcohol, fizzy drinks, spicy foods and citrus.
It is worth making these lifestyle changes, although they only abolish symptoms in about one in five people.
Antacids immediately neutralise the acid that has already been made. They may be either liquids or tablets, and should be taken as soon as you get symptoms. Rennies® and Tums®, and most of the other medicines which you can buy over the counter, work in this way.
Alginates also contain antacids but, in addition, have a special ingredient which coats the lining of the stomach and oesophagus. This barrier prevents the acid from reaching the area where it would otherwise cause damage. Gaviscon® and Gastrocote® are examples of this class of medicine.
Acid suppression tablets work to stop acid being made before it can cause damage. There are two types: histamine receptor antagonists like ranitidine (Zantac®) and proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. PPI drugs are far more effective at controlling acid reflux. Most patients with Barrett’s Oesophagus will be taking one of these routinely.
C) Fundoplication Surgery
Fundoplication surgery is a treatment which aims to restore the normal valve mechanism at the lower end of the oesophagus which often does not work properly in individuals with Barrett’s Oesophagus. This treatment is routinely carried out as a keyhole operation. You would only need to stay in hospital for one or two days, although it usually takes four weeks to recover completely from the operation.
Fundoplication surgery is successful in stopping acid reflux in the majority of people who are treated. It does have recognised side effects. Before agreeing to have surgery it is important to discuss these with the surgeon. Things which can trouble people after surgery include bloating of the abdomen, difficulty in swallowing and, rarely, diarrhoea. For more information, you should ask to meet a specialist surgeon..
Treatments to prevent Oesophageal Cancer
Since the vast majority of patients with Barrett’s Oesophagus do not get oesophageal (gullet) cancer, the usual practice in the United Kingdom is not to attempt to remove the Barrett’s cells. Treatment is usually only offered if the cells look as though they are starting to change and the risk of getting cancer starts to rise.
Prevention of reflux
Although in theory, exposure to acid and bile may make cells more likely to turn cancerous, there is no clear evidence that aggressive suppression of acid reflux does actually reduce the risk of cancer. Decisions about these treatments should generally be made on the basis of symptoms, not on the likelihood of preventing cancer.
This word is derived from the Greek meaning roughly “bad formation”. Dysplasia in tissue is when the cells have changed abnormally, and may in some cases lead to cancer. Dysplasia is the earliest form of pre-cancerous change that can be recognized and may be rated as either low grade or high grade, the latter representing a more advanced progression towards cancer. Dysplasia can be a difficult diagnosis for the pathologist to make and therefore it is recommended that if dysplasia is suspected that this is confirmed by an independent, expert pathologist and discussed at the multi-disciplinary meeting to decide whether treatment is recommended.
Treatment for dysplasia
The risk for developing cancer is higher with dysplasia and therefore treatment should be considered. The precise treatment offered will depend on your fitness, your preference for treatment over monitoring and the expertise available at your hospital. Endoscopic treatment is now recommended, provided that there is no cancer present invading into the deeper layers of the oesophageal wall. More than one type of treatment may be required and this may include removing pieces of tissue (endoscopic resection) or a treatment aiming to remove the entire Barrett's tissue (ablationtherapy).
Endoscopic Mucosal Resection or EMR
Some patients with high grade dysplasia have a visible nodule in their oesophagus. It is relatively straightforward to remove the nodule during endoscopy. If you have this procedure you will be given a sedative to make you slightly sleepy. The procedure takes around 30-45 minutes and you can usually go home the same day. Most people can eat and drink normally afterwards. In about one in ten people there may be minor bleeding, and more serious bleeding in one in 100 people which can be stopped by treatment at endoscopy. If severe, a blood transfusion may occasionally be required. EMR procedure can be repeated a number of times if there are several nodules, but it cannot remove large sections of affected oesophagus without causing scarring and difficulty in swallowing. This treatment does not aim to remove the Barrett’s Oesophagus cells completely. Endoscopic mucosal resection is a particularly useful technique if the diagnosis is not clear because the removed nodule can be sent to the laboratory to be checked by the pathologist. In this situation, it serves as both a diagnostic test and a treatment..
HALO® RFA (radiofrequency ablation)
HALO® RFA is a new treatment, which uses radiofrequency, a type of heat therapy to destroy the dysplasia. It can also be used to treat the entire area of Barrett’s oesophagus. The treatment is given during an endoscopy procedure and patients go home the same day.
Patients are given a sedative to make them sleepy. A tiny probe is used during an endoscopy to deliver the radiofrequency to the affected parts. The procedure takes about 45 minutes. Some people return to normal activity immediately after treatment, but many feel nauseous and have chest pain, particularly when they eat, this lasts for around 5-10 days in most people, although, for a few, the discomfort can last for up to 3 weeks. Very few people (around 1 in 20) suffer scarring of the oesophagus. This treatment is usually repeated two or three times at intervals of two to three months until not only the dysplasia, but also the entire Barrett’s Oesophagus has been removed.
The outcomes of this treatment for dysplasia look very promising. Approximately 85% of patients have reversal of the dysplasia at the end of the course of treatment, which usually takes a few months to complete. It is still a relatively new treatment and we are not yet certain about how long the benefits last. For this reason, in the long term all patients having the treatment will need to have follow-up endoscopies to ensure they remain well.
Although HALO® RFA can be used very successfully to completely remove the Barrett’s Oesophagus, we do not recommend it unless people already have dysplasia. The reason for this is that most patients will never get dysplasia or cancer and, although the treatment is generally safe, side effects do occasionally occur. .
A small proportion of patients with high grade dysplasia will also be found to have cancer cells. For these patients surgery may be recommended in order to completely remove the cancer cells and the Barrett’s cells. Some patients with high grade dysplasia and no definite cancer elect to undergo surgery so that they can be certain that the high grade dysplasia has been removed. These decisions are difficult and should be made only after discussion with the team of specialists conducting your treatment.
Research is going on all the time into new ways to treat Barrett’s Oesophagus. New studies are being published regularly. Please speak to your specialist about the current state of knowledge regarding the treatments available. You may also wish to discuss with a specialist the possibility of taking part in a research study. Some patients with high grade dysplasia have a visible nodule in their oesophagus. It is relatively straightforward to remove the nodule during endoscopy. If you have this procedure you will be given a sedative to make you slightly sleepy. The procedure takes around 30-45 minutes and you can usually go home the same day. Most people can eat and drink normally afterwards. In about one in ten people there may be minor bleeding, and more serious bleeding in one in 100 people which can be stopped by treatment at endoscopy. If severe, a blood transfusion may occasionally be required.
EMR procedure can be repeated a number of times if there are several nodules, but it cannot remove large sections of affected oesophagus without causing scarring and difficulty in swallowing. This treatment does not aim to remove the Barrett’s Oesophagus cells completely.
Endoscopic mucosal resection is a particularly useful technique if the diagnosis is not clear because the removed nodule can be sent to the laboratory to be checked by the pathologist. In this situation, it serves as both a diagnostic test and a treatment..
Why Heartburn Cancer UK Exists
As a recognised and trusted authority in the field of Cancer of the Oesophagus, we know that with your help we can make significant inroads in the Prevention, Detection and Treatment of this disease by focussing on 5 key areas of action:
Education leads to a lasting change. We are working hard to influence public and social policy, to lobby politicians, to campaign for change, to promote greater collaboration amongst the medical profession, the public and the government. We are already in the process of developing a network of effective partnerships with businesses, the pharmaceutical industry, medical professionals and other like-minded groups. We intend to effect change and influence how this disease is perceived, detected, diagnosed and treated.
Our aim is to significantly reduce incurable oesophageal cancer in the UK.
Our renowned medical professionals, all experts in the field of oesophageal cancer, will continue to play a key role in research and trials designed to reduce the incidence of this appalling disease.
Early detection rates are vital to ensure a positive outcome. We are creating a communication network to facilitate greater awareness of the importance of diagnosing the disease early, identifying the symptoms associated with the disease and seeking medical help quickly. Oesophageal cancer affects everyone regardless of their race, gender or age.
We will ensure consistent support is available to everyone affected by Barrett’s Oesophagus, regardless of who they are and where they live. Information and advice is available to all those affected by the disease and to the people who support them, on our website or by telephone.
We need your help to bring this to the attention of your employees, friends & family or indeed anyone who might suffer from persistent heartburn!
You can make a difference. Perhaps you know someone who has suffered from persistent heartburn, Barrett’s Oesophagus or Oesophageal Cancer. Perhaps you run an organisation and would like to help. Why not make it your company’s corporate responsibility?
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Working with UK businesses and voluntary organisations' our outward facing collaborative approach will ensure we are the first place to come to for reliable, up to date information about Heartburn, Barrett’s and Oesophageal Cancer.
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