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Reducing the risk of esophageal cancer

September 26, 2018 | UCI Health
uci health gastrointestinal surgeon brian smith
UCI Health gastrointestinal surgeon Dr. Brian Smith is researching whether reducing chronic acid reflux can curb the incidence and risk of esophageal cancer. 

UCI Health gastrointestinal surgeon Dr. Brian Smith was always the analytical, problem-solving type. As a young man growing up in Southern California, he had a natural affinity for math that led him to attend college at the University of California, Santa Barbara. He planned to become an engineer.

“Unlike a lot of doctors, I didn’t come from a medical family,” he says. “In fact, I was the first in my family to even go to college.”

It was a basic anatomy class that introduced Smith to medicine, opening up an intriguing world of complexity and problem-solving potential. After college he attended medical school in Guadalajara, Mexico, where he met his wife.

“It was a new country, a new culture, and the final years were conducted entirely in Spanish, which has been really beneficial,” says Smith, an associate professor in the UCI School of Medicine’s Department of Surgery. “My experience there definitely inspired my desire to care for underserved populations.”

Choosing a path in surgery

After returning home from Mexico, Smith re-assimilated into the U.S. medical system with a fifth year of study at New York Medical College. He then matched for his surgical residency with Harbor-UCLA Medical Center in Torrance, where he found a mentor in Dr. Bruce Stabile, the surgery department chairman.

“He singlehandedly changed my career trajectory. I was a general surgeon, and he taught me a lot about research, about cancer and about surgical oncology,” Smith says. “He also taught me to be a scholar — to look at my own outcomes and try to learn from them. To always ask, ‘How can we make them better?’”

Today, Smith does double duty, working both as a general surgeon serving military veterans at the VA Long Beach Healthcare System where he serves as chief of Surgical Services, and as a gastrointestinal specialist at the UCI Health H.H. Chao Comprehensive Digestive Disease Center.

“There are all kinds of issues that affect the GI tract,” Smith says. “It really lets you think and use your head. I’ve always been drawn to that.”

Solutions for chronic heartburn

One of the biggest puzzles Smith is working on is whether reducing chronic acid reflux can curb the incidence and risk of esophageal cancer. Acid reflux — or heartburn — is one of the most common medical conditions in the country. More than 20 percent of Americans suffer from the chronic form of reflux called gastroesophageal reflux disease (GERD), sometimes silently.

GERD is not only painful and debilitating to some people who suffer from it, but it can also lead to esophageal cancer. The burning sensation of reflux happens because corrosive stomach acid back-washes into the esophagus, altering the inside of the lower esophagus. When the lining of the esophagus is constantly bathed in stomach acid over many years, it can undergo a cellular change to protect itself, mutating to become more like stomach tissue. This condition — called Barrett’s esophagus — lays the groundwork for cancer.

“Once you have Barrett’s, there’s some data showing that risk increases by about half a percent per year,” Smith says. “So if that goes on for 30 years, you’re looking at a 15 percent chance of getting cancer.”

And for those who develop esophageal cancer, the chances for survival are daunting.

“Esophageal cancer kills about 15,000 people per year out of about 16,000 who get it. Almost all patients die from it,” Smith says. Even worse, esophageal cancer is one of only a few types of cancers for which the incidence rates are rising.

A focus on innovation

Finding a way to stop reflux early on is a high priority, and Smith and his UCI Health colleagues are using a medical device called the LINX Reflux Management System. “We’re comparing the effectiveness of this device to proton pump inhibitor (PPI) medications to see which is better at controlling reflux,” he says.

LINX is a relatively simple solution to a persistent and complex problem. It’s a small titanium collar made of beads of rare-earth magnets that the surgeon attaches like a bracelet around the bottom of the esophagus. The magnets are strong enough to hold the esophagus shut but weak enough for swallowed food to push them open and pass into the stomach before closing themselves back down.

The procedure is an alternative to Nissen fundoplication, which had been the main surgical option for GERD. Fundoplication involves wrapping part of the stomach around the lower esophageal sphincter to reinforce it and prevent reflux.

“LINX is easier to install and it gives the same results without the side effects of fundoplication,” Smith says.

An alternative to symptom-masking medications

It is also an alternative to the PPI medications that have been a mainstay of non-surgical GERD treatment for decades.

“One problem is PPIs can obscure reflux,” Smith says. “Patients may feel better even though some acid continues to reach the esophagus, which can still lead silently to Barrett’s and possibly cancer.”

Recent studies also have shown potential connections between PPIs and other problems such as bone density loss, chronic kidney failure and an increased risk of infection.

“It will take years of treating reflux aggressively to look back and see if decreasing reflux actually helps reduce cancer rates,” Smith says.

“But it the meantime, I’m improving patients’ quality of life — they can stop taking meds, they can eat what they want, and they can lie flat and sleep well at night. Reflux interventions are quite possibly the most impactful work I do, and I really believe there is a benefit to long-term cancer risk reduction as well.”

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