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THE WALL STREET JOURNAL

Esophageal Therapy You Can Stomach

Got heartburn? Several times a week for five or more years? Then you're at increased risk for a form of esophageal cancer that, though rare, is the fastest-growing cancer in the U.S., particularly in white men over 50. It's also one of the most deadly, with a fiveyear survival rate of just 17%.

Doctors can sometimes see the cancer coming years earlier when acid reflux causes cells in the esophagus to mutate to become more like stomach tissue, a condition called Barrett's esophagus. In adenocarcinoma, the Barrett's cells keep mutating into cancer.

The standard treatment for Barrett's has been to watch for precancerous changes called dysplasia, and in some cases remove the patient's esophagus. But a new outpatient procedure that lets doctors zap Barrett's tissue with radiofrequency ablation (RFA) is showing promise.

At a conference of gastroenterologists in San Diego on Monday, researchers presented interim results from a multi-center trial showing that among patients treated with RFA, 85% were free of dysplasia, and 74% were free of all signs of Barrett's, 12 months later. None of the treated patients progressed to high-grade dysplasia or cancer. In the control group, several patients got worse, and none was free of Barrett's.

Other studies showed that RFA caused few side effects and that genetic changes in the esophagus returned to normal afterward.

"It's way cool. It's far and away the most effective endoscopic treatment that we've ever had," says Nicholas Shaheen, director of the Center for Esophageal Disease and Swallowing at the University of North Carolina-Chapel Hill School of Medicine and the lead investigator.

The RFA procedure involves no incisions, but the patient is sedated. Agastroenterologist inserts a tiny camera, along with a sizing balloon, down the patient's esophagus. A second balloon delivers a short burst of energy that burns out the Barrett's tissue, which appears rough and red in contrast to healthy pink tissue. The technology, called the HALO Ablation System, is made by BÂRRX Medical Inc., a privately held company in Sunnyvale, Calif.

The RFA procedure is usually repeated a few months later, with a smaller HALO device. "It's like removing old wallpaper -- you do a big stripping and then go back and remove any bits that are left," says Charles Lightdale, a gastroenterologist at NewYork-Presbyterian Hospital/ Columbia, who also consults for BÂRRX.

To date, about 16,000 RFA procedures have been performed since 2001; it's available at about 200 centers in the U.S., and covered by Medicare and most insurers. It's too soon to know whether the Barrett's will return in the long run. Patients are usually kept on acid-blockingdrugs.

No one knows why adenocarcinoma of the esophagus is rising so fast -- up sixfold in the U.S. since 1975. It appears to be related to obesity, especially belly fat, which puts pressure on the abdomen. Another form of esophageal cancer, squamous cell, linked to alcohol and tobacco use, is declining in the U.S.

An estimated 3.3 million Americans have Barrett's. Only about 1in every 200 of them will develop esophageal cancer. But people with high-grade dysplasia have a much higher risk.

For them, RFA appears to be a good alternative to an esophagectomy, a grueling operation that severely restricts eating. A big question now is whether people with earlier stages of Barrett's should be treated with RFA, which is still new and costly, or just watched with endoscopes and biopsies.

"This is very safe and effective therapy," says Dr. Shaheen, who gets no remuneration from BÂRRX. "But as we move from high-risk to lower-risk patients, the calculus changes."

Some patients are eager to eliminate the cancer risk. Louis Plzak, a retired thoracic surgeon from Philadelphia, had monitored his Barrett's for several years when he learned about RFA at a surgical conference and decided to have it done preventatively. "This will allow me to start living without the fear of Barrett's," says Dr. Plzak, age 74.

If you're having reflux several times a week, if you need medicine to control it or if you had it in the past, see a gastroenterologist. Chronic heartburn may stop once Barrett's sets in, since the mutated tissue isn't as sensitive to reflux. Controlling your weight will also help cut your risk of esophageal cancer.