Oesophageal Cancer Awareness Month – Improving Cancer Detection Rates?

Improving oesophageal cancer detection rates?

Alan Moss: Chairman of Action Against Heartburn
Jason Dunn:; Consultant Gastroenterologist and member of the British Society of Gastroenterology

Ove the past few years February has been the time when there has been organised activity in raising awareness about the signs and symptoms of oesophageal cancer.
Each year around 8,800 people are diagnosed with oesophageal cancer and around 7,200 die from it, making it the 6th most common cause of cancer death in the UK. Patients are often diagnosed with more advanced disease compared to other cancers. Oesophageal cancer has recently been described in a group of less survivable cancers (pancreatic, liver, stomach, brain and lung), as only 15% of adult patients survive their cancer beyond 5 years. This compares to an average 64 per cent chance on average of living beyond five years for more survivable cancers, such as colon or breast.

The majority of the UK’s oesophageal cancer cases are adenocarcinoma (OAC), which affects men more than women in a ratio of 4:1. It tends to occur near the junction with the stomach, and is associated with reflux and the development of Barrett’s Oesophagus. The UK is reported as having the highest incidence of OAC in the world.

The outcomes for oesophageal cancer are generally dismal, and it is very frustrating and tragic that two-thirds of patients are presenting too late for curative treatment. There are, however, some positive signs from National Audit data (NOGCA); the outcomes for patients diagnosed at an early stage are dramatically better than for their counterparts who report swallowing problems (typically when the tumour has advanced two-thirds around the circumference of their oesophagus); surgical mortality has continued to fall with centralisation of oesophago-gastric cancer services to high volume centres; combined therapy with chemotherapy and radiotherapy is increasing.

Importantly there is a pre-cancerous lesion, Barrett’s Oesophagus (BO) that can be effectively reversed with minimally invasive endoscopic therapy, such as radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR). These techniques have transformed the way high risk Barrett’s oesophagus with dysplasia, and also early cancer of the oesophagus, is managed. There is much needed research, ongoing in the UK, into non-endoscopic diagnostic tests (e.g. Cytosponge) that may help to triage patients with suspicious symptoms from GP surgeries. New initiatives are being developed to improve the monitoring of BO patients on specialist endoscopy lists. Recent research into clinical algorithms and biomarkers to assess risk of progression are promising and need further validation. A large multi-centre UK based trial on chemoprevention with aspirin (AspECT) is nearing completion and results are eagerly awaited. To impact against OAC deaths there is a need to effectively diagnose, risk stratify and treat Barrett’s oesophagus. Gastroenterologists play a vital role in this.

Action Against Heartburn is a campaign involving no fewer than eighteen charities and other organisations with an interest in promoting earlier diagnosis of oesophageal cancer. During February, we shall be approaching local pharmacies with leaflets and posters, encouraging them to refer their regular, long term consumers of Gaviscon, Nexium and other over-the-counter heartburn medications to see their GP to discuss the potential underlying causes of their symptoms. The same principle applies to dental surgeries, where the effects on tooth enamel can indicate persistent reflux. GPs surgeries can often helpfully display leaflets to improve the level of knowledge about conditions like BO.

Identifying the cases of realistically potential cancer from the multitude of patients with digestive problems is a real problem, but however good our diagnostic tests may be, we shall always need a good level of public understanding of the symptoms that should prompt a visit to a GP.

Alan Moss
Jason Dunn