Antireflux surgery may not reduce esophageal cancer risk

Antireflux surgery may not reduce the risk for adenocarcinoma in patients with Barrett’s esophagus any more than medication. While antireflux surgery (fundoplication) is useful for counteracting gastroesophageal reflux, a population study conducted by researchers in Sweden found its effect on cancer risk is negligible. Barrett’s esophagus is an important risk factor for esophageal adenocarcinmoa. It is a condition in which there are abnormal changes to the mucosal cells lining the lower portion of the esophagus believed to be caused by chronic acid exposure from reflux. These changes can progress from nondysplastic epithelium to low-grade dysplasia, high-grade dysplasia, and invasive esophageal adenocarcinoma, the researchers wrote. Antireflux treatment is recommended for patients with Barrett’s esophagus to decrease the risk of esophageal adenocarcinoma, with proton pump inhibitors (PPIs) being the dominant therapy. However, the evidence for whether medication or surgery reduces the risk for esophageal adenocarcinoma is mixed. On the other hand, fundoplication alters anatomical features and can prevent reflux and thus reduce acid exposure even more than medications. The study was done to compare the outcomes of both approaches in terms of cancer incidence. The study was a population-based cohort study of all adults aged 18 years and above who had a Barrett’s esophagus diagnosis in Denmark, Finland, Norway or Sweden. Data were available for up to 32 years of follow-up came from the Nordic Antireflux Surgery Cohort and national health data registries, and spanned from 1987 through 2020. Age, sex, country, year of entry into the cohort smoking history and comorbidities were taken into account in the analyses. A total of 33,939 patients with Barrett’s esophagus were included. Of these, 542 (1.6%) had undergone antireflux surgery while the remaining 33,397 were treated with antireflux medication. About a third of the cohort were female. Those who underwent surgery had a mean age of 52.9 years compared to 64.3 for those using medication. A total of 14 cases of esophageal adenocarcinoma occurred in the antireflux surgery group, and 437 cases in the antireflux medication group. This showed that the risk of esophageal adenocarcinoma was higher in the antireflux surgery group. The differences were statistically significant, said said study coauthor, Dr. Johan Hardvik Aakerstrom. He is a physician and researcher at the Karolinska Institute in Sweden. In fact, “it was about twice as high as in the antireflux medication group overall,” The overall risk of esophageal adenocarcinoma in the antireflux surgery group was 1.9 times that of the risk in the antireflux medication group overall,” he told the Medical Post. Generally, surgery is reserved for patients with severe GERD and is usually done only after long periods of persistant symptoms, despite the use of antireflux medications. However, not all patients with Barrett’s esophagus have severe reflux symptoms, but because of the changes in their esopphagus still have a higher baseline risk of esophageal adenocarcinoma. “If antireflux surgery would have a substantially greater cancer-preventative effect in Barrett’s esophagus patients compared with antireflux medication, we would expect decreasing risk estimates over time after surgery, which was not found in this study,” the study said. GERD symptoms recur in abouty 15% of patients who have undergone antireflux surgery, which “might contribute to the lack of superiority over antireflux medication for esophageal adenocarcinoma prevention,” the study said. Cancer-prevention alone should probably not be a primary motivation to conduct fundoplication since “patients who have undergone antireflux surgery seem to remain at an elevated risk of developing esophageal adenocarcinoma,” the study said. The study did not examine whether antireflux surgery is helpful for quality of life purpose. The Canadian guideline on screening for esophageal adenocarcinoma in patients with chronic GERD, published in the CMAJ in 2020, stated that about 5% to 15% of patients with GERD develop Barrett esophagus. Canadian experts did not respond to interview requests. “About 93% of diagnoses of esophageal adenocarcinoma are made while investigating patients with alarm symptoms, such as dysphagia, odynophagia, recurrent vomiting, unexplained weight loss, anemia, appetite loss or gastrointestinal bleeding, which can be associated with late-stage adenocarcinoma,” the guideline said. It did not address treatments. But a U.S. 2022 guideline in the American Journal of Gastroenterology stated that Barrett’s esophagus is the only known precursor to esophageal adenocarcinoma, described as a highly lethal cancer that has had an increasing incidence over the last five decades. It suggested a single screening endoscopy for patients with chronic GERD symptoms and who have three or more additional risk factors for Barrett’s esophagus, and possible repeat endoscopies depending on the findings. As for treatment, the guidelines recommended use of PPIs. When it came to the idea of surgery it stated “Several issues argue against the routine application of surgical antireflux procedures as an antineoplastic measure in the setting of (Barrett’s esopagus). First, the risk of progression to cancer in the setting of (nondysplastic Barrett’s esopagus or NDBE) is so low that incurring the risks inherent in surgery, even a surgery with a low rate of life-threatening complications such as laparoscopic fundoplication, may not be merited in patients who do not require fundoplication for symptoms not controllable by medical therapy.”

Antireflux surgery may not reduce esophageal cancer risk

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