A Safer, Effective Alternative to Surgery for Barrett's Esophagus

Radiofrequency ablation works well against this precursor condition to esophageal cancer

In much the same way that adenomatous polyps can be precursors of colon cancer, esophageal tissue changes, known as Barrett's esophagus, may precede the development of esophageal adenocarcinoma. Surgery can be used to eradicate these "dysplastic" or "metaplastic" cells, but it involves a high degree of risk and leaves the patient without a properly functioning esophagus.

At the same time, the incidence of esophageal adenocarcinoma has quintupled over the past 40 years, and the disease now kills nearly 15,000 Americans each year, according to the American Cancer Society.

So, the problem of how to safely treat Barrett's esophagus, especially those with dysplasia, has never seemed more urgent.

That's why a new multicenter trial, published earlier this year in the New England Journal of Medicine, has sent a ripple of excitement through the field. The study, led by Dr. Nicholas J. Shaheen of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill, focused on a minimally invasive technique, radiofrequency ablation, which is already widely used to treat other cancers or precancerous lesions.

The technique uses an ablation device to focus high-energy radio waves at suspicious lesions, effectively heating and destroying cells in a given area. The new study involved 127 adults with dysplastic Barrett's esophagus and was conducted at 19 centers across the U.S. Patients were tracked for one year after receiving either radiofrequency ablative therapy or a ‘sham’ procedure.

The result: "Most patients who were treated with radiofrequency ablation had complete eradication of intestinal metaplasia and dysplasia and a decreased risk of disease progression at 12 months," the team wrote in the NEJM.

And, somewhat surprisingly, rates of eradication and disease progression were similar whether patients had low-grade dysplasia (90.5% eradication rate) or higher grade lesions (81%). The team also noted a lower rate of esophageal cancers in the treated vs. nontreated group over the 12-month follow-up, but they stressed that the number of patients studied was too small for this result to be statistically reliable.

Side effects were rare and included transient chest pain and one case of gastrointestinal hemorrhage - a far cry from the 40 to 50% complication rate seen with esophagectomy, according to editorial author Dr. Jacques Bergman, of Academic Medical Center, Amsterdam. The results of this rigorous trial make it “a landmark study in the field,” Bergman wrote - one that could change standard practice for the treatment of Barrett's esophagus.

Based on the findings, "surgery for high grade dysplasias should no longer be offered routinely," Bergman concluded, with radiofrequency ablation being considered instead. And the (former) alternative to surgery – an endoscopic look at the esophagus every 3 or 4 months - may also need to be reconsidered, especially "when three or four ablation sessions may resolve the problem permanently," he wrote.