Despite criticism from some quarters, there is sound logic for persistent heartburn to be featured in Public Health England’s latest Be Clear on Cancer campaign on oesophagogastric (OG) cancer.
The aim of the new campaign is to help save 950 lives a year by matching our OG cancer outcomes with the best in Europe, primarily through earlier diagnosis. Opportunities for earlier diagnosis are available to us because of the relationship between persistent heartburn, Barrett’s Oesophagus and oesophageal adenocarcinoma (OAC). Detecting undiagnosed Barrett’s can enable its ablation and hence prevent the cancer in many cases. Around 67% of patients diagnosed with OG cancer at its earliest stage survive for at least five years, but only around 3% at a late stage.
The UK incidence of OAC has increased eightfold over the past thirty years, shifting the oesophageal cancer balance dramatically from 90% squamous to 70% adenocarcinoma.1 OAC in the UK is now the highest in the world. The reason is the increase of gastro-oesophageal reflux disease (GORD), a common symptom of which is heartburn, and its principal complication, Barrett’s Oesophagus. The risk of a Barrett’s patient developing OAC is 0.3% in any one year, but 6% if high grade dysplasia is present. A patient with newly-developed Barrett’s aged 30 years may have a risk of 7-25% of developing OAC before they reach the age of 80.2 A landmark Swedish study quantified the link between heartburn and OAC, with an odds ratio (OR) of 8 for a patient experiencing heartburn once weekly in developing OAC, through to an OR of 44 for those with severe, long-standing heartburn.3
If we are to counter the depressing 13% five-year survival rate for oesophageal cancer (the sixth most common UK cancer) we do need to investigate more patients with potential Barrett’s Oesophagus and to look at unresolved persistent heartburn in a new light.
None of us wishes to harm patients through over investigation, but persistent heartburn is not normal, and we should not be prescribing proton pump inhibitors indefinitely or ignoring those currently self-medicating with over-the-counter remedies.
As far as GP workload is concerned, a sample of 50 practices in the regional campaign area (Northern England Strategic Clinical Network) found an additional 0.6 attendances per practice per week for OG symptoms mentioned in the campaign.4 On average, there were an additional 16 gastroscopies per week per Trust as a delayed effect from March 2014 onwards.
Our colleagues performing endoscopies coped well with the 52% increase in referrals. The diagnoses made through the two week wait pathway increased by 29 percentage points in the 60 -69 age group, and surgeons reported they were beginning to see patients in time for curative, rather than palliative, therapy because of the campaign.
Professor Mike Pringle is President of the Royal College of General Practitioners and an advisor to Action on Heartburn.
1 Watson A, Galloway J. Br J Gen Pract 2014, 64; 120-121.
2 Gatenby et al (UKBOR). Diseases of the Oesophagus: Histological Sequence in a large UK series of columnar-lined oesophagus (CLO). 2004.
3 Lagergren J, et al. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Eng J Med 1999:340:825-831
4 Cancer Research UK. OG campaign: Information to help you prepare. 2015.