The public health risks of persistent heartburn
Alan Moss, Chairman Action Against Heartburn
14th May 2019
One of the many challenges in primary care is identifying patients with common symptoms who may nevertheless be at risk of developing cancer. This challenge is increased by the NHS 10-year plan which aims to raise the rate of early diagnosis of all cancers so that 75% are diagnosed at stages 1 and 2 by the year 2028. The current figure is about 50% – so finding effective methods of early diagnosis are crucially important. Fortunately, there are opportunities for oesophageal cancer (OC) to achieve this aim.
OC is the seventh most common cause of cancer death in the UK. Around 9,000 case are diagnosed each year; 7,900 die from it. The 5-year survival rate is only 15% so it is one of the less survivable cancers, along with other digestion-related cancers such as stomach, pancreas and liver.
Around 70% of OC cases in the UK are adenocarcinoma (OAC), where there is a strong association with persistent heartburn and dysplastic Barrett’s Oesophagus (BO). The UK is reported as having the highest incidence of OAC in the world. Barrett’s Oesophagus occurs when the effect of reflux, over time, changes the lining of the oesophagus to become more like stomach cells. This can protect the patient from the pain of heartburn, but may mask the development of dysplasia, so a past history of apparently resolved persistent heartburn can be relevant. Barrett’s Oesophagus is the only known precursor lesion for OAC.
Around 10% of persistent heartburn sufferers are estimated to be suffering from BO. The risk of BO then progressing to OAC is reported as between 0.3% and 0.6% per patient year, which translates to an overall lifetime risk of 7.5-12.5%, or even as high as 25% in the unusual case of a patient living 50 years after a diagnosis of BO. The presence of low grade or high grade dysplasia multiplies the risk of progression, which has also been shown to be higher in male patients, concurrent smokers, and those with a long BO segment length or family history of OC.
Action Against Heartburn is a campaign by eighteen charities with an interest in promoting earlier diagnosis of OC. One main target is the regular customer of over-the-counter heartburn remedies such as Gaviscon, Nexium, Rennies or Tums. We encourage pharmacists to refer these customers to their GP to discuss underlying causes.
NICE Guidelines Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184) include the following advice:
1.11.1 Consider referral to a specialist service for people of any age with gastro-oesophageal symptoms that are non responsive to treatment or unexplained
Regardless of cancer risk, patients responding to this campaign my benefit from advice about their lifestyle.
The existence of BO can currently only be established by endoscopy, with biopsies identifying dysplasia or cancer. Fortunately, endoscopic therapies like radio frequency ablation can now treat dysplastic BO successfully. One diagnostic device, Cytosponge is undergoing clinical trials (BEST3) to diagnose BO. Breath and saliva tests to identify cancer are also being researched. If successful, these devices may potentially act as an effective triage system prior to endoscopy, which does remain, despite the resource constraints, the standard diagnostic method for longstanding, unresolved digestive problems.
The organisations supporting Action Against Heartburn are:
- AUGIS – Association of Upper GI Surgeons
- Barrett’s Oesophagus UK
- Barrett’s Wessex
- BSG – British Society of Gastroenterology
- Cancer Research UK
- CARD – Campaign Against Reflux Disease
- GUTS UK (formerly CORE) – Funding research into diseases of the gut, liver and pancreas
- FORT – Fighting Oesophageal Reflux Together
- GOSH – Gastro-Oesophageal Support & Help, Bristol
- Gutsy Group
- Heartburn Cancer UK
- Humberside Oesophageal Support Group
- Michael Blake Foundation
- Oesophagoose – National Oesophago-Gastric Cancer Awareness
- OOSO – Oxfordshire Oesophageal and Stomach Organisation
- OCHRE charity (Scotland); OG Cancer NI (Northern Ireland)
- PCSG – Primary Care Society for Gastroenterology
- UKBOR – UK Barrett’s Oesophagus Registry