Amanda Wilde (Host): If you are one of the 20 percent of Americans who have GERD, or gastrointestinal reflux disease, you are at higher risk for another disease called Barrett esophagus. And Barrett esophagus is often a precursor to esophageal cancer, so it is a concerning diagnosis. But Dr. Aaron Tokayer says that Barrett esophagus is too often misdiagnosed.

We're talking about why this happens and how that fits into your health next. This is Maimo Med Talk. I'm your host, Amanda Wilde. And joining me today is Dr. Aaron Tokayer, Chief of Gastroenterology at Maimonides Health. Dr. Tokayer, welcome to the podcast.

Aaron Tokayer, MD: Thank you very much, Amanda.

Host: Doctor, this is sort of an evolving field. Define what Barrett esophagus is, if you would, please.

Aaron Tokayer, MD: Of course. Barrett esophagus is a change in the skin or the mucosa of the lower esophagus that's thought to be a consequence of chronic reflux disease. Gastroesophageal reflux can cause damage to the skin of the lower esophagus. And, in some people, that can heal with abnormal types of cells called metaplasia.

This metaplasia occasionally can lead to esophageal problems and cancer down the line. However, although we feel that reflux is the cause of Barrett esophagus, only 3 percent of people with reflux might be predisposed to Barrett esophagus, and more importantly, most Barrett esophagus does not progress to anything as ominous as cancer.

Host: Are gastrointestinal cancers on the rise because more and more people have GERD? I mean, is, gastrointestinal reflux disease the root cause of these progressions into cancer areas?

Aaron Tokayer, MD:

Esophageal cancer has been around for a long, long time. The form of esophageal cancer of adenocarcinoma is the most increasing form of cancer in the gastrointestinal tract that currently accounts for the seventh leading cause of GI cancers in the United States. This might be because of reflux disease.

However, only 3% of people with reflux might develop Barretts esophagus. Most concerning to me and to gastroenterologists is that 80 percent of people who develop Barrett's cancer never had the diagnosis of gastroesophageal reflux preceding it. That's probably because they have reflux that is silent or doesn't bother them, but yet we know that despite our efforts to be concerned about reflux and screen people for Barrett esophagus when they have chronic reflux, we have not yet affected the incidence of Barrett cancer in society. Because of that, there are efforts to adjust our screening protocols relating to Barrett and to remove the necessity of chronic reflux symptoms from the screening protocol for Barrett.

Only recently, the guidelines have changed and state that people who are at risk of Barrett esophagus should be screened for Barrett progression. This can be done either in the classic way with endoscopy, but there are non invasive or less invasive forms of diagnosis for Barrett. So, if someone is 50 years of age, if someone is Caucasian and male, yes, if someone has chronic reflux, but it's not necessary to be part of the screening protocol.

But if they have smoking, obesity, family history of esophageal or gastric cancer, then the current recommendations are to do a screening test just once for Barrett esophagus in those people. If someone is screened once, they do not have to be screened again, even if they have ongoing reflux over the years. If someone has reflux that causes damage to the lower esophagus called erosive esophagitis, those are people that are at risk of developing Barrett and they should be re-evaluated after the erosive esophagitis has healed.

The goal is to find people who are at risk of Barrett, to screen the right people, find the people who have Barrett, and then enter them in some surveillance protocols. There are different alarm features of Barrett that might give rise to different surveillance protocol once someone is diagnosed to have Barrett. If someone has Barrett skin changes called metaplasia without any advanced features, they might be evaluated again at a three to five year interval afterwards. But if someone has advanced changes of the Barrett that are in the spectrum of progression to worse problems called dysplasia that can then develop into cancer; those people are looked at more frequently and even are eligible to have ablation to cure them of their Barrett esophagus.

There are newer techniques for Barrett ablation that have been developed over the past 15 or 20 years that are easy to perform in the proper centers of excellence to ablate and normalize the skin of the esophagus and get rid of the Barrett changes. In this way, the incidence of Barrett progression to cancer in those people who are susceptible to it, because of high degrees of abnormal cells called dysplasia can be diminished

by 98%, and these patients should still be on a surveillance protocol after the ablation to make sure that Barrett's is fully ablated and doesn't recur. In this way, if we can identify people at risk of Barrett, yes, look at people with chronic reflux, but maybe those who don't even complain of reflux, and find the Barrett esophagus patients, we can identify who should be surveilled at more frequent intervals, treated when necessary and prevent this advancing cancer in society.

Host: So, Barrett esophagus sounds like it's highly curable and somewhat underdiagnosed, or as you say, you're looking for theappropriate patients to test, it's under tested for, and then sometimes it's over diagnosed, is it not?

Aaron Tokayer, MD: Yes, occasionally physicians find subtle abnormalities that are within a normal range and biopsy the area of the lower esophagus, and might come back with a biopsy finding of a degree of metaplasia that is not the Barrett specialized metaplasia. According to the American guidelines, we should not be biopsying tissue that is not within the realm of Barrett changes. So the American diagnosis of Barrett, based on our American Society guidelines, is an appearance that looks like Barrett and biopsies that prove it to be the Barrett changes of concern that then would put that person in a category to have ongoing surveillance for Barrett.

Host: So if it isn't Barrett, but it looks like Barrett esophagus, what is it really?

Aaron Tokayer, MD: Occasionally, there can be an appearance of mucosa or skin of the lower esophagus that seems to be misplaced emanating up from the stomach. It could be normal stomach tissue that seems to be slightly misplaced up into the lower esophagus, or it could be a level of skin changes that are not at the level of Barrett esophagus with the specialized changes that would raise concern for surveillance.

Host: Now, no one appreciates an inaccurate diagnosis, but there are also implications not only for patient health, but there's medical costs and psychological stress due to perceived cancer risk. That leads me to my final question. What are the top GI concerns you think we're missing? Who needs to be especially concerned? Because it sounds like these cancers do emanate from chronic GERD. So what should we be aware of? We talked about screenings. Are there lifestyle changes also that would reduce the risk of Barrett esophagus and other GI complications from GERD?

Aaron Tokayer, MD: That's an excellent question. Again, the concern is that many people with Barrett do not have appreciable reflux. So currently, the guidelines for screening and the advice of experts are people who are,

in addition to people who have chronic reflux symptoms, if someone is age 50 or up, Caucasian, male, cigarette user, people who have central obesity or a family history of esophageal or gastric cancer, they should discuss with their physicians the potential concern for Barrett's and the availability of non invasive testing mechanisms to diagnose Barrett. Additionally, if someone does have Barrett, the biopsies must be obtained in a center that is specialized and knowledgeable in taking care of patients with this Barrett finding and assess their biopsy with expert pathologists.

The implication of a biopsy that is low level of a concern versus a more high level of concern, is tremendous. Because if someone has a low level of concern based on the biopsy and they do have Barrett, but it doesn't have the more alarming features, they have an extremely low risk of developing esophageal cancer of the order of less than one percent in a lifetime.

But if someone has higher degrees of more alarming changes, that risk can go up to 12% or even 40 to 60%, and therefore, people with Barrett should discuss with their physicians, be cared for in specialized centers that know how to diagnose and know how to categorize people appropriately for proper surveillance and treatment to prevent cancer in the relatively few people with Barrett that might develop esophageal cancer and in that way minimize the incidence of this seventh leading cause of GI cancer in our society.

Host: These are really good guidelines to figure out who's a candidate for monitoring and who needs to participate in at least one screening. Thank you Dr. Tokayer for these important insights into Barrett esophagus.

Aaron Tokayer, MD: Well, thank you for your interest, and thank you to all the listeners for your interest in participating in improving your esophageal health.

Host: Dr. Aaron Tokayer is Chief of Gastroenterology at Maimonides Health. For more information about Maimonides, visit maimo.org. To make an appointment with a GI specialist, call 718-283-5900. If you found this Maimo Med Talk podcast helpful, please share it on your social media channels.

To listen to additional episodes of Maimo Med Talk, please visit maimo, M-A-I-M-O.org.