When Should You Be Screened for Esophageal Cancer?
- Esophageal cancer screening isn’t recommended for people at average risk, says Dr. Raja Flores, Chairman of the Department of Thoracic Surgery at the Mount Sinai Health System, but it is available for those at higher risk. According to the American Cancer Society, no U.S. medical organization recommends screening for people at average risk, because no test has been shown to reduce deaths from the disease in that group.
- For people at increased risk, the American College of Gastroenterology’s 2022 guidelines recommend a one-time screening for Barrett’s esophagus, a precancerous condition. This applies to people with chronic acid reflux plus at least three other risk factors: being male, over 50, white, a smoker or obese, or having a close relative with Barrett’s or esophageal cancer.
- Screening is done by upper endoscopy, or by a swallowable cell-collection device with a follow-up endoscopy if the device test is positive. If the result is normal, no repeat screening is needed. If Barrett’s is found, patients get follow-up endoscopies every few years, or treatment if precancerous cells are present.
In the United States, no professional organization recommends esophageal cancer screening for people at average risk, according to the American Cancer Society (ACS), because no test has been shown to reduce deaths from the disease in that group. Instead, doctors focus on people with risk factors such as long-term acid reflux, Barrett’s esophagus or certain inherited syndromes, who may benefit from regular upper endoscopies to catch precancerous changes or early cancers.
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The American College of Gastroenterology (ACG) recommends a one-time screening endoscopy for people with chronic acid reflux symptoms plus three or more additional risk factors for Barrett’s esophagus, according to its 2022 guideline. Those risk factors include:- Being male
- Being over age 50
- Being white
- Smoking
- Obesity
- Having a parent, sibling or child with Barrett’s esophagus or esophageal adenocarcinoma
“The risk increases when several factors occur together,” Flores says.
People already diagnosed with Barrett’s esophagus are often monitored with regular upper endoscopies, according to the ACS. People with certain inherited syndromes, such as tylosis, Bloom syndrome, Fanconi anemia or familial Barrett’s esophagus, may also need frequent endoscopies, sometimes starting at a younger age.
Why Reflux Matters, and Why It Usually Doesn’t Lead to Cancer
Chronic acid reflux, or gastroesophageal reflux disease (GERD), can inflame the esophageal lining, known as esophagitis. Reflux is the most common cause, but Flores explains that esophagitis can also result from certain medications, infections, or eosinophilic esophagitis, an immune-related condition often linked to allergies.
“The underlying cause is much more important than the word ‘esophagitis’ itself,” Flores says. “Most people with esophagitis will never develop esophageal cancer.”
The connection doctors watch most closely, he says, is long-term acid reflux, which in some people can lead to changes in the esophagus lining known as Barrett’s esophagus. Barrett’s is considered a precursor to esophageal adenocarcinoma, although most people with Barrett’s esophagus will never develop cancer.
What Is an Upper Endoscopy?
An upper endoscopy, also called an esophagogastroduodenoscopy or EGD, allows a doctor to examine the lining of the esophagus and upper digestive tract using a flexible camera.
Doctors can also take tissue samples during the procedure if they see an abnormal area. Those samples can be examined for Barrett’s esophagus, dysplasia or cancer.
For people who are diagnosed with Barrett’s esophagus, the presence or absence of dysplasia [abnormal growth or cells] can help determine whether ongoing surveillance is necessary.
“Once Barrett’s esophagus is actually identified, the presence or absence of dysplasia helps determine how closely the patient needs to be monitored,” Flores says.
Symptoms That Should Prompt an Evaluation
Screening and diagnostic testing are not the same thing. A person experiencing certain symptoms may need an evaluation even if they don’t fall into a typical screening group.
“We become more inclined to perform an upper endoscopy when reflux has been present for years, when someone has multiple risk factors for Barrett’s esophagus, or when there are warning symptoms,” Flores says.
Warning signs include:
- Difficulty swallowing
- Food getting stuck
- Painful swallowing
- Gastrointestinal bleeding
- Persistent vomiting
- Unexplained weight loss
- Unexplained anemia
“Those symptoms deserve evaluation rather than simply being attributed to reflux,” Flores says.
He adds that people should also discuss persistent or worsening heartburn with a doctor, as should any change in their usual reflux symptoms.
One symptom doctors pay particular attention to is progressive difficulty swallowing.
“A person may first notice that solid foods do not go down as easily, and eventually softer foods or liquids may become difficult to swallow,” Flores says. “That is not something that should simply be treated as heartburn.”
These symptoms do not necessarily mean a person has cancer. Many benign conditions can cause similar symptoms. But people should discuss them with a doctor rather than repeatedly treating them with over-the-counter reflux medication without further evaluation.
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Are There New Screening Methods?
Upper endoscopy remains the traditional approach for evaluating the esophagus and identifying Barrett’s esophagus. But researchers are working on options that could make screening easier and more accessible.
“Newer, less invasive methods are being developed and evaluated,” Flores says. “These include swallowable devices that collect cells from the esophagus, which can then be tested for biomarkers associated with Barrett’s esophagus.”
For example, EsoCheck is a swallowable balloon that collects cells from the esophagus, which are then tested for DNA changes linked to Barrett’s esophagus using a lab test called EsoGuard, according to a study published in Surgical Endoscopy.
Another example is the capsule sponge, sometimes called Cytosponge. A patient swallows a small capsule attached to a string, which dissolves and releases a sponge that collects cells from the esophagus as it’s pulled back up, according to NHS inform. In a U.K. study published in The Lancet, this approach identified ten times more people with Barrett’s esophagus than usual primary care, according to Cancer Research UK.
The ACG’s 2022 guideline says a swallowable capsule device combined with a biomarker test is an acceptable alternative to endoscopy for Barrett’s screening. Still, these technologies have not replaced endoscopy as the standard diagnostic test.
Dr. Sofya Pintova explains how esophageal cancer is diagnosed.
What Patients Should Know
“I would not want someone to hear the word ‘esophagitis’ and immediately think ‘cancer,'” Flores says. “Esophagitis is common, and the majority of people with it do not have and will not develop esophageal cancer.”
What matters, he explains, is why the esophagus is inflamed, how long the problem has been present, and whether there are changes such as Barrett’s esophagus or dysplasia.
Flores says one of the biggest misconceptions is that reflux, esophagitis, Barrett’s esophagus and cancer represent an inevitable progression.
“The biggest misconception is that they are all points on an inevitable progression: reflux leads to esophagitis, esophagitis leads to Barrett’s, and Barrett’s leads to cancer,” he says. “That is not what happens in most patients.”
More Resources On Esophageal Cancer
- Considering Different Treatment Combinations for Esophageal Cancer
- Esophageal Cancer Surgery: What to Expect
- Esophageal Cancer: Getting Emotional Support
- Esophageal Cancer: Key Terms to Know
- Esophageal Cancer: What to Ask About During Radiation Consultation
- Floss Today to Slash Your Chances of Stomach and Esophageal Cancer Tomorrow
- Health Alert: Can Hot Tea Cause Deadly Esophageal Cancer?
- Immunotherapy For Esophageal Cancer — Has It Worked?
- Nutrition Support for Esophageal Cancer Patients
Millions of people have reflux without developing Barrett’s esophagus, and most people with Barrett’s esophagus never develop cancer.
“The reason we screen selected higher-risk patients is to identify the smaller group in whom precancerous changes do occur, when we have an opportunity to intervene before an invasive cancer develops,” Flores says.
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Contributing: SurvivorNet Staff
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