Barrett’s Esophagus

This image, taken from my cell phone, shows glass microscope slides from two separate patients.  You can see the tissue (it has been stained) as the red and purple things on the glass slides.  On the left are small biopsies that Dr. Dunbar took from a patient in surveillance.  There are lots of spots because the tissue was cut into lots of tiny slices to put under the microscope to learn if the patient has dysplasia.  You can see by comparing the small biopsies on the left to the pencil that such biopsies are quite tiny (and therefor it is perfectly safe for you to have lots of biopsies).  In fact, the small spots actually consist of three separate biopsies so each is only about a millimeter! The endoscopic mucosal resection (EMR) on the right is much larger, but still a pretty small amount of tissue.  You can see from these samples that if you have an endoscopic procedure, the tissues removed from you are small fragments compared to what is removed during major surgery.

E. Montgomery, MD

Many of the dietary recommendations for Barrett’s esophagus are similar to the diet recommended for patients with GERD (gastroesophageal reflux disease).

Here are some recommendations for reducing GERD and decreasing the amount of acid and food exposure in the esophagus

Stay upright for 3 hours after eating – this will allow your food to digest more completely and reduce the amount of reflux you have when you lay down

• Elevating the head of the bed – this can also decrease the amount of reflux that occurs when you lay down as gravity will help keep food in your stomach. Propping on pillows may not be as effective as putting blocks, books, or bricks under the upper posts of your bed. A big pile of pillows can cause you to hunch over, which may increase reflux
• Eat a low-fat diet – lower fat meals will digest more quickly, so you’ll have less reflux
• Don’t smoke – while smoking is more strongly associated with squamous cell cancer of the esophagus, it can also contribute to esophageal adenocarcinoma, which is the kind of esophageal cancer related to BE
• Reduce caffeine intake – caffeine relaxes the lower esophageal sphincter, which is the muscle at the bottom of the esophagus. When this muscle is relaxed, you’re more likely to have reflux of stomach contents into the esophagus. A little caffeine is probably okay, but multiple cups of coffee a day is too much. Remember that a standard size cup of coffee is actually pretty small, so one giant cup of coffee is actually equal to 2 or 3 cups of coffee! Many carbonated sodas also contain caffeine and tea (hot and iced) also contain some caffeine. To find out the caffeine content of beverages, a quick internet search for ‘caffeine content’ will pull up several sources, such as this one: http://www.cspinet.org/new/cafchart.htm
• Alcohol – drink in moderation. Alcohol relaxes the lower esophageal sphincter and can increase reflux. However, there are some studies that suggest moderate wine or alcohol intake can lower the risk of Barrett’s and esophageal adenocarcinoma (this will be addressed in a separate post)
• Weight loss – weight loss will also help improve reflux symptoms. Obesity increases the risk of both Barrett’s esophagus and esophageal cancer

- posted by Kerry Dunbar, MD

As Dr. Montgomery described in her post, ‘buried Barrett’s esophagus’ occurs when there is Barrett’s tissue underneath the normal squamous lining of the esophagus.  It is also referred to as ‘subsquamous Barrett’s’ or ‘squamous overgrowth of Barrett’s’. 

The study Dr. Montgomery mentioned followed the patients in the big photodynamic therapy study (mentioned in the blog post on PDT) for 5 years.  This new paper includes 5-year results for 138 patients who were treated with photodynamic therapy plus omeprazole and 70 patients treated with only omeprazole for 5 years.  Patients in the study were followed with upper endoscopy after treatment to look for residual BE, subsquamous BE, and dysplasia. 

Here are some details of what the study showed:

• The researchers looked at 33,658 biopsies from patients in both study groups (PDT vs omeprazole)
• About 5% of patients had subsquamous BE prior to treatment
• About 1/3 of patients in each group had some subsquamous BE after treatment
• The number of biopsies for each patient that showed subsquamous BE was very low, with only about ½ of one biopsy showing subsquamous BE for each patient (the exact numbers are 0.48 biopsies with subsquamous BE in patients treated with BE and 0.66 biopsies per patient in patients treated with omeprazole)
• The risk of buried BE was very low for patients in the study
• For study patients who later went on to develop dysplasia or cancer, the dysplasia/cancer was found in multiple biopsies on the surface. No dysplasia or cancer was only found in the subsquamous BE.

Another study, presented at Digestive Disease Week 2008, an international GI meeting (but not yet published as a full article), looked at subsquamous BE before treatment with RFA (Barrx) and after treatment with RFA. 

Here are details of what the study showed:

• 127 patients participated in the study and 2,151 biopsies were examined prior to any treatment
• Before treatment, 32 of 127 patients had some buried BE – about 25% of the patients
• Of all 2,151 biopsies, only 67 (3%) showed buried BE, so the number of buried BE biopsies per patient is low
• 35 patients had RFA and had completed all their follow-up biopsies. After treatment with RFA, only 1 biopsy showed subsquamous BE out of 1,223 biopsies
• For 16 patients who received sham treatment (they didn’t get RFA), and have had follow up biopsies: 20 of 290 biopsies showed subsquamous BE (about 4% of the biopsies)
• The final results of this study analyzing all the patients in the study haven’t been published yet, but probably will be soon

To summarize this information about subsquamous BE:

• Subsquamous BE can be found in many patients with Barrett’s esophagus whether they are treated with ablation or not
• The rate of buried BE/subsquamous BE is low after treatment with ablation therapy
• For patients who have been treated with ablation therapy, surveillance endoscopy with 4 quadrant biopsies should still be performed. Biopsies of the normal-looking squamous tissue (where the BE used to be) should be taken. This is the best way to detect subsquamous BE.

References:

Bronner MP, Overhot BF, Taylor SL, et al.  Squamous Overgrowth is not a Safety Concern for Photodynamic Therapy for Barrett’s Esophagus with High-Grade Dysplasia.  Gastroenterology 2009, volume 136, issue , p. 56-64. 

Shaheen NJ, Bronner MP, Fleischer DE,  et al.  Subsquamous Intestinal Metaplasia Is a Common Finding in Ablation-Naive Patients with Dysplastic Barrett’s Esophagus, and Significantly Decreases in Prevalence After Radiofrequency Ablation. Gastrointestinal Endoscopy, Volume 67, Issue 5, April 2008, Page AB176.

- posted by Kerry Dunbar, MD

We have all been reading a lot about “buried Barrett’s” mucosa lately.  This image is at high magnification and shows a microscopic view of what a pathologist (a  specialized medical doctor who reviews biopsies under the microscope) sees in “buried Barrett’s”.  The top part of the image has a pink layer of normal squamous epithelium.  The glands underneath (the circular structures) are Barrett’s epithelium with dysplasia.  The concern among some is that an endoscopist might not see such areas since they are covered with normal lining epithelium.  This is more of a theoretical concern than a real problem since usually such areas are accompanied by areas that are easy for the endoscopist to see.  The other concern is that some types of treatments will fail to reach this buried layer.  There is a recent publication that shows that this is not a concern for patients treated with photodynamic therapy.  The reference for that study is below.  We are still learning the answer to this question for BARRx.

Bronner MP, Overholt BF, Taylor SL, Haggitt RC, Wang KK, Burdick JS, Lightdale CJ, Kimmey M, Nava HR, Sivak MV, Nishioka N, Barr H, Canto MI, Marcon N, Pedrosa M, Grace M, Depot M; International Photodynamic Therapy Group for High-Grade Dysplasia in Barrett’s Esophagus. Squamous overgrowth is not a safety concern for photodynamic therapy for Barrett’s esophagus with high-grade dysplasia. Gastroenterology. 2009 Jan;136(1):56-64

One of the readers (Jack) posted a comment with some questions about how research in BE is conducted.  The answers are too long to fit in a reply box, so I’ll address the questions here.

1. Do you feel that all hospital GI departments are coordinating in an effort to preserve or save all records of patients treated for LGD and HGD, and by all available treatments? I guess that I am trying to ask you if this precious data is being collected by any one particular organization, such as the American College of Gastroenterology, or the National Institutes of Health?

Hospital GI departments do keep records of all procedures, but mainly for clinical use.  Keeping records of individual patients by diagnosis and treatment type for research is more challenging.
Depending on the type and amount of data collected, permission may need to be obtained from every patient to store their information in a database.  Databases for research need to be secure (password protected, securely backed up, etc) to protect patient privacy and prevent loss of data.  This kind of data collection and storage is expensive, so not all departments and programs are able to afford this. To my knowledge, the NIH doesn’t have a BE database.  There’s a national database of cancer patients (the SEER network), but it doesn’t include precancerous conditions like BE.  There is a national data collection project, the CORI project, which stands for Clinical Outcomes Research Initiative (www.cori.org),  that collects some data on endoscopy outcomes.  This group has published a few papers on BE, but I haven’t seen anything specifically on types of BE treatment.

2. I was diagnosed with BE without dysplasia, around 3 months ago and have read about a lot of research that has one common theme; “small studies”. This is very discouraging for myself, when cancer from BE has been around so long and is increasing.

Small studies are a problem in many areas of medical research.  As common as Barrett’s seems to be, recruiting research patients isn’t always easy.  Academic referral centers can attract more patients with BE if they have specialized diagnosis and treatment programs, but for small centers and community practices, BE is a less common diagnosis.  For anyone who’s interested in participating in research studies for BE, one place to look for studies is on www.clinicaltrials.gov. This is a searchable website sponsored by the government where clinical trials are registered.  Details are given about research studies that are available and the contact information for the researchers is on the site. 

3. There seems to be a lack of funding from the NIH for BE research. Do you agree? I believe that we need a campaign for awareness of BE and its potential.

I searched the CRISP database, which is a list of all the NIH funded studies.  Using the search term ‘Barrett’s’, there are 25 grants that currently fund (at least in part) research into Barrett’s esophagus.  Certainly there are more NIH funds devoted to other cancers (colon, breast, etc) and for other diseases, such as heart disease, which affect more people.  There’s only so much NIH funding to go around and the budget has been stretched for the last few years for a variety of reasons.  Funding for research studies is also available through several of the gastroenterology societies, such as the American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and American College of Gastroenterology, although these grants are generally smaller in size than NIH grants. Occasionally funding from private donors is available for research and several of the pharmaceutical and device companies also have research funding programs.

An awareness campaign for Barrett’s would be great!

4. Also, all of the currently available treatments for HGD, excluding removal of the esophagus, must carry a bias by the treatment specialist, as these treatment centers invest in the different equipment, for different treatments. Do you think that any of the treatment results are skewed, or not properly reported due to rival technologies?
There are several treatment options for BE. Not all specialists get trained in every type of therapy.  Buying each type of equipment is also expensive and not feasible for every academic medical center.  These issues make head-to-head comparisons of Barrett’s therapies more difficult.  From attending gastroenterology research conferences, it does seem that there is interest in comparing RFA with cryotherapy, so hopefully some of these studies will be up and running soon. 

There are commonly accepted criteria for reporting studies in the medical literature. For clinical trials, the rules are called the CONSORT criteria and are a list of issues that must be reported in papers about clinical trials.  Most studies also go through the peer-review process, first if they’re being funded by grants, then by the local institutional review board at each hospital, and then also when the manuscript is submitted for publication. The scientific design, results, and reporting are closely inspected, which can help with the reporting process.  Clinical trials of drugs and treatments are also required to be registered with clinicaltrials.gov. These things can help make sure results are reported clearly and honestly. 

Also, most researchers have spent years training (think 8 years of college and medical school plus 3 years of internal medicine and at least 3 years of gastroenterology training), and get specific training in research ethics, so intentional misreporting shouldn’t be common.  For almost all the medical research journals, authors are required to report where all the funding for the study came from.. Authors are also required to report any potential conflict of interest related to the research, such as whether the author is on the board of directors for the company, has been paid to consult for the company, etc. The information about study funding and potential conflicts of interest is usually located at the end of a medical research article.  So, for all the reasons listed above, I don’t think there’s a lot of intentional misreporting or skewing of research results. 

Several of you have mentioned participating in Barrett’s research studies, such as clinical trials of new treatments (cryo, RFA, etc).  There are several different ways to find clinical research studies to participate in. 

If your gastroenterologist works at a university academic medical center, this is a good place to start to find studies. He/she may have suggestions for participating in trials of new therapies in your area.   You can also check the websites of nearby academic medical centers for available research studies.

In the US, one of the best sources of information is www.clinicaltrials.gov.    Many clinical trials in the US get registered with this site and they have an straightforward search function for locating studies. From the main page, select ’search for clinical trials’.  In the search box, then enter the words you’re interested in. For example, entering ‘Barrett’s esophagus’ produces a list of 60 studies, 34 of which are recruiting.  With more specific terms, such as ‘cryotherapy AND Barrett’s’, 6 studies are listed with 3 active or recruiting.  There is also a ‘refine search’ page, where you can enter more specific details, such as searching only a specific state for available studies.  You can click on individual studies to read more about them and the contact information for the researchers is listed. 

Internationally, there are other clinical trials registries, sponsored by the WHO and individual countries.  I’m not as familiar with these, but here’s a list of a few:

International clinical trials registry:  www.ISRCTN.org

Australia and New Zealand: www.anzctr.org.au

Japan:  www.umin.ac.jp/ctr/index/htm

The Netherlands: www.trialregister.nl

China: www.chictr.org/

Germany: www.germanctr.de/

India: www.ctri.in:8080/Clinicaltrials/trials_jsp/index.jsp

- posted by Kerry Dunbar, MD

Photodynamic therapy (PDT) is another way to treat Barrett’s esophagus with high grade dysplasia or early cancer.  PDT was one of the first successful alternatives to surgery for Barrett’s with HGD.

Photodynamic therapy has a few steps:

1. A photosensitizing chemical is given.  The two commonly used chemicals are intravenous porfimer sodium (Photofrin), which is most commonly used in the US and oral 5-aminolevulinic acid, which is used in Europe.  The photosensitizer spreads throughout the body and locates in rapidly dividing cells, like cells in the esophagus with Barrett’s and dysplasia
2. Upper endoscopy is performed, often 2 days after the photosensitizer is given.  A special laser fiber is passed through the channel in the endoscope and the laser light causes a photochemical reaction in the cells containing the photosensitizing chemical.  This destroys the BE and dysplasia.
3. 2 days later, upper endoscopy is often repeated, to look for areas that weren’t completely treated by session #1.  Any areas that were missed are retreated during this endoscopy

A large randomized multicenter controlled trial of photodynamic therapy was published in 2005.  208 patients with Barrett’s esophagus and high grade dysplasia were randomized either to porphyrin PDT plus a proton pump inhibitor (PPI -acid suppression medication) or to PPI alone. 

Study results:

• For the patients randomized to PDT, 77% had complete ablation of their HGD and 52% had complete ablation of all their BE.
• 39% of the PPI-only patients had resolution of their HGD, but only 7% had regression of their BE. 
• 28% of the patients in the PPI-only group developed cancer while 13% of patients receiving PDT eventually developed cancer. 
• 5-year follow up of the patients showed that the cancer rates were not different than listed above (29% of the PPI- only patients vs. 15% of the PDT patients).  The patients treated with PDT who did eventually get cancer didn’t develop cancer as soon as the PPI-only patients.

There are some complications of photodynamic therapy that are typically discussed with patients before beginning treatment.  Everyone getting PDT is at risk for severe sunburn – the photosensitizing chemical also collects in the skin, so avoiding sunlight is very important. The photosensitivity typically lasts about 8 weeks. About 1/3 of patients getting PDT may develop a stricture, or narrowing of the esophagus, in the area that was treated. These can be treated with esophageal dilation, although more than one dilation session is usually needed. Chest pain and difficulty swallowing are not uncommon right after the procedure.  And like other ablation techniques, there is always a concern about ‘buried Barrett’s’, or left-over BE tissues that gets buried under the new squamous (normal) esophageal mucosa. 

This study was a large, well-designed study that shows PDT is effective for treating BE with high grade dysplasia. There are other studies that show it is an effective option for treating Barrett’s with dysplasia and early cancer.  As with any treatment, it’s important to discuss options with your doctor to determine which treatment would be best for you.

Here are a few references for the studies mentioned:

Overholt BF, et al. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial. Gastrointestinal Endoscopy 2005;62(4):488-98.

Overholt BF, et al.  Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett’s high-grade dysplasia. Gastrointestinal Endoscopy. 2007 Sep;66(3):460-8.

posted by Kerry Dunbar, MD

Another option for ablation of Barrett’s esophagus with dysplasia is cryotherapy. 

Cryotherapy works by spraying freezing liquid or gas onto the lining of the esophagus.  The depth of the freezing effect is 1-2 mm.  Cryotherapy has been used in other parts of the gastrointestinal tract, such as the stomach in patients with gastric antral vascular ectasia (watermelon stomach), or in the rectum to treat radiation proctitis.  

There are currently two different types of cryotherapy available for treatment of Barrett’s esophagus.  Each system uses a regular upper endoscope and has a thin tube that is passed through the endoscope and out the tip.  Then cryospray, either liquid nitrogen or freezing carbon dioxide, is sprayed onto the lining of the esophagus.  When cryotherapy is used, the cells lining the esophagus are frozen, which damages them.  The body then makes an inflammatory reaction, gets rid of the damaged cells, and new (normal) esophageal mucosa covers the area where the Barrett’s used to be. 

There are a few papers describing how cryotherapy works. More recently, several research abstracts were presented at Digestive Disease Week 2008, an international gastroenterology research meeting.  One study used the carbon dioxide cryotherapy system and the other used the liquid nitrogen based system.  Both studies looked at patients with high grade dysplasia or tiny (intramucosal) cancers. 

In the liquid nitrogen cryotherapy study, 32 patients participated. For the 20 patients with HGD, 16 had at least a partial response (improvement) after cryotherapy and 50% had complete resolution of their HGD.  For the patients with intramucosal cancer, 6 of 9 had at least a partial response, and 1/3 had complete resolution of their intramucosal cancer. The average number of cryotherapy sessions in the study was 4. The complications included 3 esophageal strictures, 1 lip ulcer, and 1 stomach perforation. 

In the carbon dioxide cryotherapy study, 33 patients participated. The average number of treatments for each patient was 3. 79% of patients had a reduction in the amount of dysplasia and BE.  21% had a complete response, with complete elimination of dysplasia and BE.  3 patients in the study with intramucosal cancer had complete resolution of their cancer after cryotherapy treatment.  One patient had transient mild heartburn after cryotherapy, but no strictures or perforations occurred.

So what’s the take home message about cryotherapy?  It seems to be effective for treating Barrett’s esophagus with dysplasia, but there aren’t as many papers published about it yet.  The two studies mentioned above are ongoing and the final results haven’t been published, so the final outcome of the studies might be better (or possibly worse).  At this point, there are more studies published about photodynamic therapy and radiofrequency ablation for treating Barrett’s esophagus with dysplasia.  So cryotherapy one of the choices for treatment of Barrett’s with dysplasia and worth discussing with your own gastroenterologist.

If you think you may be interested in cryotherapy treatment, there are several ongoing research studies that can be found on clinicaltrials.gov and by searching the internet. 

Here are the references for the 2 cryotherapy studies mentioned above. 

Dumot JA, et al. Results of Cryospray Ablation for Esophageal High Grade Dysplasia (HGD) and Intramucosal Cancer (Imca) in High Risk Non-Surgical Patients.  Gastrointestinal Endoscopy, Volume 67, Issue 5, April 2008, Page AB176

Canto MI, et al. Low Flow CO2-Cryotherapy for High Risk Barrett’s Esophagus (BE) Patients with High Grade Dysplasia and Early Adenocarcinoma: A Pilot Trial of Feasibility and Safety a Pilot Trial of Feasibility and Safety.  Gastrointestinal Endoscopy, Volume 67, Issue 5, April 2008, Pages AB179-AB180

 -posted by Kerry Dunbar, MD

One of the newer treatments for Barrett’s esophagus with dysplasia is radiofrequency ablation, also sometimes referred to as Barrx (the name of the company), or Halo (the name of the specific treatment).  Several people have asked questions about Barrx, so here’s some information.

How it works

Halo 360 – Upper endoscopy is performed and the length of the Barrett’s esophagus is measured. A special ‘sizing balloon’ is used to figure out the width of the esophagus where the BE is located.  Once the diameter of the esophagus is known, a special catheter with the ablation balloon on it is passed into the esophagus. There are 3 cm of electrodes on the balloon which are placed in the area of the BE to be treated. When the balloon is inflated, the electrodes touch the wall of the esophagus and energy is released.  The release of the energy creates a shallow burn, which destroys the Barrett’s esophagus without harming the tissue underneath. The treated area is then gently cleaned with a plastic cap on the end of the endoscope to remove any loose tissue. Then the BE is treated a second time with the RFA balloon. 

Circumferential RFA is most often performed with longer BE, particularly when the BE is present on all the walls of the esophagus. 

Halo 90 – A small device that looks like a paddle (about 2 cm by 1 cm in size) is placed on the end of a regular endoscope.  An upper endoscopy is then performed and the paddle is placed on areas of BE that to be treated.  The endoscopist then steps on a pedal, and energy is released, making a shallow burn in the area.  Each area of BE is treated twice, then the mucosa is cleaned with the paddle. The same areas are then treated 2 more times with the Halo90 during the same procedure. 

Halo90 is typically used in patients with small amounts of BE, such as tongues or islands of Barrett’s.  

Complications

Chest discomfort may occur after the procedure. Other possible complications include lacerations of the esophageal mucosa, which is like a shallow tear or cut which may bleed.  Some patients have had difficulty swallowing after the procedure and rarely patients will develop a stricture that needs dilation with a special balloon.  Perforation, or tearing the wall of the esophagus, is a risk, but so far no studies have been published showing a perforation during RFA.

What’s published?

There is alot of interest in ablation of Barrett’s esophagus and several ongoing research studies.  Here are a few of the published studies using RFA in dysplasia:

At Digestive Disease Week 2008, an international gastroenterology meeting, the interim results for a randomized, multicenter, sham-controlled trial of RFA were presented.  All the patients in the study had BE with HGD or LGD.  The patients were randomized (randomly assigned) to either RFA or a sham (fake) RFA.  Halo 360 and Halo 90 were performed to treat the BE and dysplasia. 

At the time of the presentation in May 2008, 127 patients had been treated.  The average number of sessions needed to treat BE with dysplasia was 3.5.  67% of patients with HGD had complete eradication of dysplasia compared to no patients who received the sham treatment.  96% of patients with LGD had complete eradication of dysplasia with RFA.  Looking at complete eradication of the BE, 60% of patients with HGD and 83% of patients with LGD had no BE left after treatment with RFA.  1 patient had a stricture treated with dilation and there were no esophageal perforations.  The study’s expected completion date was summer 2008, so complete results should be available soon. (1) 

A US Multicenter registry study of RFA was published in July 2008, which looked back at the records of 142 patients with BE-HGD at 16 different academic hospitals.  RFA was performed in all the patients using the Halo360.  In this study, patients had 1 to 2 ablation sessions.  2 patients had HGD after ablation.  Of the patients in the study who had follow up biopsies, complete eradication of HGD was seen in 90% of patient.  Complete eradication of all dysplasia (including LGD) was seen in 81%. Complete eradication of all Barrett’s esophagus occurred in 54% of patients.  One patient in the study developed an esophageal stricture (narrowing) which was treated with esophageal dilation. (2)

Another study looked at RFA in patients with early cancer, high grade dysplasia (HGD), or low grade dysplasia (LGD).  44 patients were in the study and 31 patients had endoscopic mucosal resection (EMR) of nodular BE.  The patients then had ablation of the remaining BE using the Halo360 or Halo90 system.  At the end of the study, the BE and dysplasia was completely gone in 98% of the patients (43 of 44).  Follow up at 21 months showed no recurrence of dysplasia in the patients. (3)

Who Should Consider RFA?

Most of the research done with RFA has been targeted to patients with Barrett’s esophagus and dysplasia. The response to treatment is very good in most of the studies, and is a reasonable option to consider for treatment.  For patients without dysplasia, the use of RFA is not as clear, which will be addressed in a separate post. 

Here are the references for the 3 studies discussed above:

1. Shaheen NJ, Sharma P, Overholt BF, et al.  A randomized, multicenter, sham-controlled trial of radiofrequency ablation for subjects with Barrett’s esophagus containing dysplasia: interim results of the AIM dysplasia trial.  Gastroenterology, Volume 134, Issue 4, Supplement 1, April 2008, Pages A-37
2. Ganz RA, Overholt BF, Sharma VK, et al.  Circumferential ablation of Barrett’s esophagus, that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointestinal Endoscopy 2008, vol 68(1), pp 35-40. 
3. Pouw RE, Gondrie JJ, et al. Eradication of Barrett’s esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 2008, vol 12, pp 1627-37.

3 November 2008

Dear Dr. Montgomery,

Thank you for your prompt reply to my inquiry regarding donations in the memory of Philippe (Phil) Ross. I know that you are responding to each donor with a thank you note; that is a wonderful gesture. I also want to express my gratitude to each of them for honoring Phil.

I know that with the relatively low numbers of cases of esophageal cancer diagnosed each year, it is considered an “orphan” disease and doesn’t get the attention that more widespread cancers do. Recently, I read that the number of cases of esophageal cancer diagnosed yearly is increasing, especially adenocarcinoma, the form of esophageal cancer that Phil had. Our hospice nurse, who has been in nursing for 30 plus years and in hospice for the last 18 years, told us that she is seeing an increase in the number of patients in the hospice system in Denver with esophageal cancer.

I hope that some of the research effort taking place in esophageal cancer is outreach and education to doctors. Phil woke me in the middle of the night in late 2003 with excruciating pain in his upper abdominal area and drove himself to the emergency room to be seen. Phil was not a person to visit the emergency room; for him to seek relief there meant it was serious. However, he was treated for an episode of acid reflux with the usual medications. There was no examination beyond an oral account of his symptoms and the monitoring of standard vital signs. I understand that triage nurses and emergency room doctors and nurses see many patients, some with gastric distress, but I can’t keep myself from thinking that if someone had taken the symptoms more seriously, he would be here now. He was a member of the population most susceptible for esophageal adenocarcinoma, a white male in his fifties. If I knew then what I do now, I would have insisted on further tests. He was diagnosed with cancer at the gastroesophageal junction in October 2005 while on a teaching and research sabbatical at a university in Aveiro, Portugal. At that time, he was in apparent excellent health; he worked out regularly at the University’s gym and ran about 30 miles per week. He consulted a doctor there when he started having difficulty swallowing. By then, the cancer was stage IV. When I read the prognosis on medical websites, my world was shattered. When Phil returned to the U.S. for follow-up and treatment, he gave me the option of not being involved in his care, knowing that it was going to be hard and that the likely outcome was a short survival time. I told him then and throughout his treatment that we were a team; I couldn’t imagine not being there to love and support him and act as his caretaker and health care advocate. Today is the four month anniversary of Phil’s death and I still can’t believe that it happened. He fought such a brave fight – a cliché – but it is true. He suffered through chemotherapy, radiation, radical surgery and visits to the emergency room with systemic infections, a suspected lung infection and bowel impactions. He lost the ability to do the things that he loved the most but never adopted a “poor me” attitude. Anything that we can do to keep other people and those who love them from going through this is an effort that deserves attention and support. I have enclosed a contribution today and will continue to contribute to your department when I am able – in recognition of ‘Team Phil’.

I hope for continued advances in detection and treatment from your department’s research.

With kind regards,
Sherry Skipper