Spotlight on cancer and GERD

Two recent studies used Scandinavian patient registries to assess the risk of esophageal adenocarcinoma in patients with gastroesophageal reflux disease (GERD).

The first, published by The BMJ on Sept. 13, compared incidence of esophageal adenocarcinoma among patients with nonerosive GERD (n=285,811) versus the general populations in Denmark, Finland, and Sweden for up to 31 years of follow-up. A total of 228 GERD patients developed esophageal adenocarcinomas, an incidence rate of 11 per 100,000 person-years. That was similar to the rate in the general population (standardized incidence ratio, 1.04 [95% CI, 0.91 to 1.18]) and did not increase with longer follow-up. The study also looked at 200,745 patients with erosive esophagitis and found 542 esophageal adenocarcinomas among them during follow-up, an elevated incidence compared to the general population (31.0 per 100,000 person-years; incidence ratio, 2.36 [95% CI, 2.17 to 2.57]), which became more pronounced with longer follow-up.

The results indicate that patients with nonerosive GERD have a similar incidence of esophageal adenocarcinoma as the general population, while those with erosive disease have elevated risk, according to the study authors. “These striking differences in trends strengthen the evidence for no association between confirmed nonerosive [GERD] and oesophageal adenocarcinoma,” they wrote. “Thus, this study suggests that physicians do not need to consider referring patients with [GERD] with a previous normal upper endoscopy for repeat endoscopy unless they develop warning symptoms of oesophageal adenocarcinoma, mainly dysphagia, as recommended for all individuals,” which differs from current common clinical practice, the authors noted.

In contrast, an accompanying editorial argued that the findings align with existing clinical practices. “The Montreal and Vevey consensus on management of non-erosive reflux disease does not advocate for additional endoscopic evaluations for cancer,” the editorialists wrote. They noted the challenges of diagnosing nonerosive GERD, including “the changing progression of gastroesophageal reflux disease, the complex influence of proton pump inhibitors, and the potential for a range of underlying pathophysiological causes.”

The other study, published by Gastroenterology on Sept. 8, looked at esophageal adenocarcinoma rates among patients with Barrett's esophagus in the registries of Denmark, Finland, Norway, and Sweden. Patients who underwent antireflux surgery were compared with those who only used antireflux medications, with up to 32 years of follow-up. Out of 33,939 studied patients, 542 (1.6%) underwent antireflux surgery; they were found to have an increased hazard of esophageal adenocarcinoma during follow-up versus those taking antireflux medication (adjusted hazard ratio, 1.9; 95% CI, 1.1 to 3.5), and the difference increased over follow-up, from 1.8 (95% CI, 0.6 to 5.0) within one to four years to 4.4 (95% CI, 1.4 to 13.5) after 10 to 32 years.

The authors noted that it wasn't surprising that patients who underwent surgery had a higher risk of cancer, given that esophageal adenocarcinoma increases with reflux symptom duration and antireflux surgery is often reserved for patients with severe GERD and persistent symptoms. “If antireflux surgery would have a substantially greater cancer-preventative effect in Barrett's esophagus patients compared to antireflux medication, we would, however, expect decreasing risk estimates over time after surgery, which was not found in this study,” they wrote, noting that surgery may occur too late to have an effect on cancer incidence. Based on these findings, there is little reason to perform antireflux surgery for cancer prevention alone and patients who undergo surgery should continue taking part in surveillance programs, the authors said.