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Reflux patients shouldn't be screened routinely for esophageal cancer, new guidelines say

Endoscope
REUTERS/Kim Kyung Hoon
Endoscopy involves sliding a flexible tube with a camera mounted to it down the throat of the patient.

People with gastroesophageal reflux disease (GERD) should not undergo esophageal cancer screening unless their symptoms have failed to respond to treatment with acid-suppressing drugs and are severe, according to new guidelines published Monday by the American College of Physicians (ACP).

The procedure used for such screening is called an upper endoscopy. It involves sliding a flexible tube down the throat of the patient. A tiny camera is mounted on the end of the tube, which the doctor uses to examine the lining of the esophagus for signs of cancer.

But, as the new guidelines point out, there is no good evidence that the routine use of an upper endoscopy on GERD patients lowers their risk of dying from esophageal cancer. The screening is, however, associated with some low-level health risks, including perforation of the esophagus and pneumonia. It can also result in false-positive results, which can lead to unnecessary tests and procedures.

In addition, the procedure is costly — usually more than $800 per procedure.

GERD is a condition that occurs when the stomach’s contents leak back into the esophagus, causing heartburn, a sore throat, coughing and other uncomfortable symptoms. It’s one of the most common reasons people see a doctor. GERD is usually treated with acid-suppressing medications, as well as dietary and other lifestyle changes.

In a small percentage of people with GERD, the lining to their esophagus becomes damaged by stomach acid and changes its color and cellular composition. This condition is known as Barrett’s esophagus. The risk of developing esophageal cancer is slightly higher among people with Barrett’s, but it’s is still quite low. The new guidelines recommend that people with Barrett’s receive an upper endoscopy screening only every three to five years.

Factors in endoscopy overuse

The authors of the ACP’s guidelines quite bluntly cite financial incentives, along with malpractice concerns and patient expectations, as a key factor in the overuse of upper endoscopies.

Given how much money is involved, there’s likely to be some considerable physician backlash to the new guidelines. (GERD patients make up a significant percentage of many endoscopists' practices, according to background information presented in the guidelines.)

In an editorial that accompanies the guidelines Dr. John Allen, a gastroenterologist at the University of Minnesota, urges physicians to think beyond their own interests and “choose wisely” for their patients.

'Avoid low-value care that generates unnecessary costs'

“If our health care system is to remain dedicated to both quality and economic viability, physicians must work to avoid low-value care that generates unnecessary costs,” he writes, “even if that means sacrificing individual gain.”

The guidelines were published in the December issue of the Annals of Internal Medicine. You can read them in full at the journal’s website.

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