Heartburn: the burning issues

Exploring the Science of Digestion

December 6th 2016

Birmingham Town Hall, Victoria Square, B3 3DQ

Dr John de Caestecker

Consultant Gastroenterologist

Digestive Diseases Centre University Hospitals of Leicester

What is heartburn?

10-20% of UK/US population at least weekly

Why do people get heartburn?

After meals, lying flat, bending, pregnancy

Does acid reflux always damage the gullet?

Normal/hiatus hernia 70% ‘Inflammation’ 30%

Is heartburn risky?

8x increased risk if heartburn > once a week

44x increased risk if heartburn ‘severe’ and for >20 years

Why can heartburn be risky?

Severe ‘inflammation’

~30%

~5% Barrett’s oesophagus

Barrett’s and cancer

45 year old with advanced oesophageal adenocarcinoma

in Barrett’s

How common is oesophageal cancer?

Oesophageal Cancer: 1971-2011

Age-Standardised Five-Year Net Survival, England and Wales

Stage of Oesophageal Cancers, England, 2014

What is Barrett’s?

Can we prevent Barrett’s progressing? AspECT 82 UK centres

Prof Janusz Jankowski (UCLan Medical School, Cumbria)

20mg PPI

Symptomatic

treatment

80mg PPI

Strong acid

suppression

No aspirin

20mg PPI +

300mg aspirin

80mg PPI +

300mg aspirin

Aspirin

Low dose PPI High Dose

PPI

2500 Barrett’s patients, 8 years, finishes Feb 2017

Can we detect early precancer/cancer in Barrett’s?

• Yes, but many patients with Barrett’s never get cancer

– So ideally target those most at risk

• 5-20% lifetime risk (men, long Barrett’s, overweight)

• Only about 20% of patients with Barrett’s are ‘known’

Can more Barrett’s be diagnosed?

• Patients with Barrett’s can be identified from among heartburn sufferers

– Resource issues if all have an endoscopy

BEST 1, 2 & 3 studies

– Prof Fitzgerald, Cambridge

– Hope to be able to reduce late cancer by ~50%

• BUT 50% of oesophageal cancer patients have NO history of heartburn.

Identifying people at risk of Barrett’s

How genes might work to result in Barrett’s

Can surveillance endoscopy detect early precancer/cancer?

• Yes … but is it worthwhile? – No good evidence so NICE cannot recommend

• The UK BOSS study – 5000 Barrett’s patients, surveillance 2 yearly or ‘at need’

– Prof Hugh Barr, Gloucester

• Another 5 years to go …

• In the meantime, can we target surveillance?

Targeting surveillance

• Long segment Barrett’s

• Markers on biopsies

– Intestinal metaplasia

– Dysplasia (precancer changes)

– p53

Maybe genetic tests will help?

Can surveillance be improved? Acetic acid enhanced endoscopy – the ABBA study

Prof Pradeep Bhandari, Portsmouth

Recruitment finishes Dec 2016

Cost effective treatment - avoiding surgery

‘Cap and band’ endoscopic resection

Endoscopic resection alone – 30% recurrence

Radiofrequency ablation (RFA)

Argon plasma coagulation (APC)

Comparing APC to RFA: BRIDE study (UK, 6 centres)

• Finished May 2015

• 76 patients, similar outcomes at 1 year

• RFA six times as costly

• BUT this is only a preliminary study

– BRIDE 2 planned

Conclusions – and questions!

• Heartburn common and troublesome

• Can be a marker for potentially pre- cancerous Barrett’s

• Oesophageal cancer curable if identified early

• Can we identify, screen and survey high risk individuals?

• What are the most successful and cost effective treatments?