by Sharon Reynolds Medically Reviewed by CH Weaver M.D. 1/2021

John Mordecai, better known to his many friends as Monte, was “a healthy guy,” remembers his wife, Mindy. He was a runner. He didn’t eat sugar and kept to a low-fat diet. But for many years, he experienced unexplained choking fits that woke him up in the middle of the night.

Mindy asked him to talk to his doctor about this strange symptom, but he always said that it wasn’t a big deal, that he was fine. Neither Monte nor Mindy knew that the choking was a symptom of acid reflux, where stomach acid sloshes back through the valve supposed to contain it and into the esophagus: the long, muscular tube that carries food from the mouth to the stomach.

And neither knew that acid reflux was a risk factor for a type of deadly esophageal cancer—or that if caught early, cells in the esophagus that may become cancerous can be eliminated, saving lives.

In 2007, Monte was diagnosed with a tumor the size of a golf ball in his esophagus. Despite a year of grueling treatment, including radiation therapy, chemotherapy, surgery, and eventually new targeted drugs, his cancer spread throughout his body. He died in the spring of 2008. His daughters were only 9 and 12 years old.

Mindy was furious. “When I first discovered that my husband was going to probably die of a preventable disease, I can’t even describe the rage in my belly,” she says.

While Monte was sick, says Mindy, “my focus was on trying to find a way to save his life and take care of my kids. But after he died…how were we going to make sure this didn’t happen to other families? Someone had to.”

In the last few months of Monte’s life, their older daughter, Mara, a passionate ballet dancer, had begun organizing a fundraiser called “Dance for the Cure,” to raise money for esophageal cancer awareness in their hometown of Baltimore, Maryland. Though Monte didn’t live to see the event, it was a resounding success, raising more than twenty thousand dollars. The next year, they did it again.

“And after we did that, I thought, ‘this isn’t enough,’” remembers Mindy. “We could raise awareness in Baltimore, but it isn’t just people in Baltimore who are at risk for this horrible disease.”

“The last thing I really needed to do when I was trying to raise my two kids by myself was start a non-profit. But I grew up in a family where we were taught that if you could make a difference, that’s your job. And I thought, I have to at least try,” she says.

Mindy took out a home-equity line of credit loan and launched the Esophageal Cancer Action Network (ECAN) out of the basement of her house in 2009. In the eight years of its existence, the fledgling group— now funded by donations and in its own office space— has made large strides in increasing both the awareness of the risk of esophageal cancer and the attention the disease receives from the medical community.

Reflux and Risk

Since the 1970s, the number of cases of a type of esophageal cancer called adenocarcinoma began rising rapidly in the United States.1 A major risk factor for esophageal adenocarcinoma is acid reflux.2 The cancer has a horrendous survival rate: only about 20 percent of patients will be alive 5 years after diagnosis.3

Many people experience acid reflux as heartburn, a burning pain in the chest. Others with reflux never experience heartburn, but have other symptoms such as a persistent sore throat, a consistently hoarse voice, a regular cough, or, like Monte, choking when lying down at night, explains Mindy.

Either way, over time, reflux can lead to a condition called Barrett’s esophagus, where cells lining the esophagus die and are replaced with a type of cell that normally lines the intestines. People with Barrett’s have a greatly increased risk of developing esophageal cancer.4

A false sense of security can accompany Barrett’s because the pain that may accompany reflux often goes away. This happens because the new cells are less sensitive than the esophageal cells they replaced. When the pain disappears, patients often think

that their reflux has stopped, but it hasn’t, and neither has the damage to the esophagus, explains John Lipham, MD, associate professor of surgery at the University of Southern California and ECAN’s current board chair.

And treating the reflux with medications once Barrett’s has developed doesn’t seem to reduce the risk of progression to cancer. “There will always be a risk of cancer: Barrett’s in and of itself is a precancerous condition,” explains Bruce Greenwald, MD, professor of medicine at the University of Maryland, and ECAN’s past chair and current board member.

In addition to the false sense of security that arises in those cases when Barrett’s develops and the pain of reflux disappears, another reason that many people never tell a doctor about their reflux symptoms is that many powerful anti-reflux drugs are now available over the counter, explains Dr. Lipham. “People are self-medicating, and if their symptoms are gone, they believe their reflux is gone, and they don’t actually go to a doctor about the issue until they have a big tumor in their esophagus,” he warns. “If you have heartburn more than two or three times a week, or heartburn severe enough that you need to be on drugs like Prilosec OTC or Nexium 24HR, you need to bring that to the attention of your healthcare provider, because you may need to be checked for Barrett’s,” adds Dr. Greenwald. “And don’t think that because you have no more heartburn [while taking medication] that the risk is not there.”

Though treating reflux can’t prevent Barrett’s from progressing to cancer, the good news is that Barrett’s with precancerous changes (called dysplasia) can be eliminated, reducing cancer risk. A procedure called ablation can remove the precancerous cells in the esophagus, “We have excellent scientific studies to show that we prevent cancer by eradicating Barrett’s esophagus with dysplasia. That’s been a major breakthrough in the last 5 or 10 years,” says Dr. Greenwald.

Currently, existing guidelines don’t clearly define which people with reflux should be screened for Barrett’s esophagus, because only a small minority will ever develop the condition. The available screening technique, called endoscopy, requires patients to go under anesthesia and is relatively costly, limiting its wide use.

Some newer technologies under development may help bring esophageal cancer screening to a larger population, explains Dr. Lipham. These include a small sponge called the Cytosponge that can be swallowed and pulled back out to collect esophageal cells, some easy-to-use imaging technologies, and a breath test. Importantly, these tests could be used in a primary care doctor’s office, eliminating the need to see a specialist just for screening.

Having a cheap, universal screening test could also get around the problem that 40 percent of people with reflux never experience any symptoms. But it will likely be years before any new technique becomes widely used, says Dr. Greenwald. In the meantime, people will need to talk with their doctors and make individual decisions about whether or not to undergo endoscopy to look for Barrett’s based on their personal risk factors, he adds.

Understanding Esophageal Cancer

GERD and Nausea

Acid reflux, a symptom of gastro esophageal reflux disease (GERD), can be a cause of nausea. Recognizing GERD symptoms and treating them under the supervision of your doctor can help you avoid acid reflux-induced nausea.

You may be wondering how your acid reflux can make you nauseous. Several factors are responsible for this feeling, many of which relate to how acid reflux works.

Reflux occurs when the lower esophageal sphincter (LES), a ring of muscle that separates your esophagus and your stomach, is unable to close tightly after you’ve ingested food or fluids. A LES that doesn’t function properly allows stomach acids and food particles to flow back up your esophagus to your throat. The LES can weaken for a number of reasons. One way to weaken your LES is by eating certain types of food, such as:

  • fried, greasy, or fat-laden foods
  • tomatoes and red sauces
  • citrus fruits and juices
  • spicy foods
  • chocolate
  • peppermint
  • carbonated beverages
  • caffeinated beverages
  • alcohol
  • coffee (regular and decaf)

People who suffer from acid reflux often experience a sour taste in their mouth from stomach acids. The taste, along with the frequent burping and coughing associated with GERD, can create nausea and even vomiting in some cases.

Indigestion is another symptom of GERD that can contribute to nausea. Indigestion is largely caused by eating meals with high fat content. Fat is more difficult to digest than other nutrients, such as fiber and whole grains. When you eat a large amount of fat at one time, your digestive system slows down and can cause a condition called gastroparesis, or delayed gastric emptying. Undigested food stays in your stomach longer than usual, which can create nausea and indigestion, as well as heartburn.

Symptoms

Heartburn. Heartburn is the primary symptom of GERD. It is a burning sensation that spreads up from the stomach to the chest and throat. Heartburn is most likely to occur in connection with the following activities:

  • Eating a heavy meal
  • Bending over
  • Lifting
  • Lying down, particularly on the back

Patients with nighttime GERD, a common problem, tend to feel more severe pain than those whose symptoms occur at other times of the day.

The severity of heartburn does not necessarily indicate actual injury to the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may only trigger a few symptoms, especially in elderly people. On the other hand, people can have severe heartburn but suffer no damage in their esophagus.

Dyspepsia. Up to half of GERD patients have dyspepsia, a syndrome that consists of the following:

  • Pain and discomfort in the upper abdomen
  • A feeling of fullness in the stomach
  • Nausea after eating

People without GERD can also have dyspepsia.

Regurgitation. Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.

Less Common Symptoms

Many patients with GERD do not have heartburn or regurgitation. Elderly patients with GERD often have less typical symptoms than do younger people. Instead, symptoms may occur in the mouth or lungs.

Chest Sensations or Pain. Patients may have the sensation that food is trapped behind the breastbone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.

Symptoms in the Throat. Less commonly, GERD may produce symptoms that occur in the throat:

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  • Acid laryngitis. A condition that includes hoarseness, dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat.
  • Trouble swallowing (dysphagia). In severe cases, patients may choke or food may become trapped in the esophagus, causing severe chest pain. This may indicate a temporary spasm that narrows the tube, or it could indicate serious esophageal damage or abnormalities.
  • Chronic sore throat
  • Persistent hiccups

Coughing and Respiratory Symptoms. Airway symptoms, such as coughing and wheezing, may occur.

Chronic Nausea and Vomiting. Nausea that persists for weeks or even months, and is not traced back to a common cause of stomach upset, may be a symptom of acid reflux. In rare cases, vomiting can occur as often as once a day. All other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, and pancreas or gallbladder disorders.

Treating Acid Reflux-Induced Nausea

You can generally treat acid reflux-induced nausea with a combination of lifestyle changes, home remedies, and medication. Here are some steps you can take:

Lifestyle Changes Daily Habits That Can Halt Heartburn

Heartburn is actually a symptom of another condition and not a disease itself. The disease that causes heartburn is gastroesophageal reflux disease (GERD). GERD is the more-serious form of gastroesophageal reflux (GER), a common condition where contents of the stomach—digestive juices, or acids—rise up into the esophagus due the opening or incomplete closure of the lower esophageal sphincter (LES). The LES is the muscle that keeps the contents of the stomach out of the esophagus and airway. When GER persists and occurs more than twice a week, it is considered GERD.

Over-the-counter antacids and prescription medications are the most common treatments for GERD. Regardless of how bad your GERD symptoms are, the successful management of heartburn requires some changes in lifestyle. Here are 7 simple things you can do to reduce heartburn.

Quit smoking

Nicotine may worsen GERD symptoms by relaxing the lower esophageal sphincter, which causes stomach acid to flow back into the esophagus.
Smoking also causes bile salts to migrate from the small intestine into the stomach and reduces the amount of saliva you produce. (Saliva helps flush stomach acid out of the esophagus and contains a natural acid-fighter, bicarbonate.)

Reduce alcohol consumption

Alcohol is a bad idea for most people with GERD, because like smoking, alcohol relaxes the lower esophageal sphincter, which lets stomach acid creep into the esophagus. Studies suggest that the more alcohol you consumer the more likely you are to experience worse heartburn.

Eat right: Small meals and avoid certain foods

Meals are often a trigger for GERD symptoms, in fact a very full stomach can cause the lower esophageal sphincter to relax, pushing stomach acids back up into the esophagus. By eating several small meals throughout the day rather than the standard breakfast, lunch, and dinner, you can reduce heartburn.

Avoid certain foods that are know to worsen GERD; Chocolate, nuts, spicy foods, fatty red meat, French fries, citrus fruits, raw onions, tomatoes, butter, oil, peppermint, and caffeinated beverages including soda, tea, and coffee can all worsen heartburn.

Lose Weight

Excess weight can contribute to heartburn and acid reflux. Obese people are nearly three times more likely than people of normal weight to have heartburn and acid reflux. Experts aren’t exactly sure why, but weight loss is an important component in combating GERD.

Don't wear tight clothing

Clothing that's a tight fit around the midsection can push against your stomach and force acid into the esophagus. Skip tight belts, hosiery, and undergarments that may be too tight.

Keep Your Head Up!

Avoid eating before bedtime and elevate your head six to eight inches while you are asleep. This can be done by raising the end of your bed with blocks or a foam wedge; research shows that raising the head of the bed helps stomach acid drain from the esophagus more quickly.

Eat Right

How you eat can be as important as what you eat. To avoid GERD eat small meals, eat slowly, and avoid eating before bed. A low-fat, high-fiber diet that's heavy on whole grains, fruits, vegetables, and lean meats is optimal.

If you have GERD, avoid high-fat food, tomatoes and heavy sauces, fatty meats, butter, chocolate, certain nuts and caffeinated beverages.

Home Remedies

Chew gum. Chewing gum can reduce your incidence of acid reflux, according to a study published in the Journal of Dental Research. It can also help eliminate the sour taste in your mouth that can cause nausea.

Harness the power of ginger.The National Center for Complementary and Alternative Medicine suggests checking with your doctor about taking ginger supplements as a natural way to relieve nausea.

Medications

Take antacids. Antacid tablets or liquids may curb nausea and acid reflux by neutralizing stomach acids.

Get a prescription. Ask your doctor about doctor prokinetic medications to help your stomach empty more efficiently. Anti-emetic medications are another option to relieve nausea.

Raising Awareness and Advocating for Research

In its relatively short life, ECAN has done much to get esophageal cancer on the national radar

and to advocate for increased research funding for what has been a neglected disease. In their early days, the group launched the designation of April as Esophageal Cancer Awareness Month in states across the nation. Today, it is observed by governments, businesses, and organizations across the country and around the world.

ECAN also pushed for esophageal cancer to be included in the National Cancer Institute’s (NCI’s) project known as The Cancer Genome Atlas (TCGA). That nationwide research project aimed to identify common genetic

mutations among specific cancer types, which could be future targets for treatment or markers of risk. Results from the esophageal cancer research project, published this January, shed new light on the cellular changes driving the disease. 5 “I feel like, if we accomplish nothing else as an organization, that was important,” says Mindy.

But they’re not stopping there. ECAN is currently advocating for esophageal cancer to be included in NCI’s new Cancer Moonshot initiative, which is allocating almost two billion dollars for research to accelerate new cancer treatments. They’re petitioning the Food and Drug Administration to change the labels of over-the-counter acid reflux medications to include a warning that reflux can cause cancer and that the drugs do not reduce that risk.

And they continue to get information about esophageal cancer awareness in front of people who have likely never heard of the disease or considered their risk: in the news media,6 on film—in partnership with the estate of Humphrey Bogart (see Box)—with comedians across the country who participated in their “No Laughing Matter” night, at sporting events, and more.

Thanks to a generous private donation, ECAN is now hiring a second full-time staffer and holding a fundraiser to take their activities to the next level. This year, ECAN commissioned a national survey that found that only 14 percent of Americans know that reflux can cause cancer. “I’d like to use that as a baseline, and then do it every year, and see if we’re moving the needle,” she explains.

She likens it to recent skin cancer prevention efforts. “We all know about the sunscreen story now, but there was a day that we didn’t,” says Mindy. But to put things in perspective, she explains, esophageal cancer kills about 6,000 more Americans than melanoma—the deadliest skin cancer— every year.3,7 “We can [raise awareness] about reflux as well, and I think we have to,” she says.

Although women do have a lower risk of esophageal cancer than men, “if you’re someone who has reflux, or if you have some of these other symptoms, or if you have other people in your family with Barrett’s or esophageal cancer, get checked, even if you’re a woman,” urges Mindy.

“Also, we’re wives, partners, mothers, sisters—we can make a difference in the lives of the men we know, and when we see someone who’s popping the Tums or the Prilosec, or has those other symptoms, encourage them to be checked. And when they brush it off like it doesn’t matter, we can point out that it does. It doesn’t take that much, and it can save their life,” she concludes.

References:

  1. Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among white Americans by sex, stage, and age. Journal of the National Cancer Institute. 2008;100(16):1184-118.
  2. Lagergren J, Bergström R, Lindgren A, Nyrén O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. New England Journal of Medicine. 1999 340(11):825-31.
  3. The American Cancer Society: What Are the Key Statistics About Cancer of the Esophagus? Available at: . Accessed March 29, 2017.
  4. Sharma P, Katzka DA, Gupta N, et al. Quality indicators for the management of Barrett’s esophagus, dysplasia, and esophageal adenocarcinoma: international consensus recommendations from the American Gastroenterological Association Symposium. Gastroenterology. 2015 Nov;149(6):1599-1606.
  5. Cancer Genome Atlas Research Network. Integrated genomic characterization of oesophageal carcinoma. Nature. 2017541(7636):169-175.
  6. Mordecai M. “Obama’s sore throat could be a lifesaver.” The Detroit News. December 11, 2014. Available at: . Accessed March 29, 2017.
  7. The American Cancer Society: Key Statistics for Melanoma Skin Cancer? Available at: . Accessed March 29,2017.