American College of Physicians: Upper endoscopy is overused in patients with heartburn

Posted By News On December 3, 2012 - 10:30pm

PHILADELPHIA, December 4, 2012 -- Heartburn is one of the most common reasons for people to see a doctor, and some physicians often use upper endoscopy to diagnose and manage gastroesophageal reflux disease (GERD). But most patients do not require the procedure unless other serious symptoms are present, according to the American College of Physicians (ACP) Clinical Guidelines Committee in a new evidence-based clinical policy paper published today in Annals of Internal Medicine.

"The evidence indicates that upper endoscopy is indicated in patients with heartburn only when accompanied by other serious symptoms such as difficult or painful swallowing, bleeding, anemia, weight loss, or recurrent vomiting," said David L. Bronson, MD, FACP, president, ACP. "The procedure is not an appropriate first step for most patients with heartburn."

ACP advises that screening with upper endoscopy should not be routinely performed in women of any age or in men under the age of 50 with heartburn because the incidence of cancer is very low in these populations.

Upper endoscopy is indicated in patients with heartburn who are unresponsive to medicine (proton pump inhibitors) to reduce gastric acid production for a period of four to eight weeks or who have a history of narrowing or tightening of the esophagus with recurrent difficult or painful swallowing.

Screening with upper endoscopy may be indicated in men over 50 with multiple risk factors for Barrett's esophagus, which include heartburn for more than five years, nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and fat within the abdominal cavity. If an initial screening exam is negative for Barrett's esophagus or esophageal cancer, recurrent periodic upper endoscopy is not indicated.

Among patients found to have Barrett's esophagus, upper endoscopy is indicated every three to five years. More frequent endoscopic examinations are reserved for patients with low- or high-grade dysplasia because of the higher risk of progression to cancer.

Physicians should utilize education strategies to inform patients about current and effective standards of care. Medicine to reduce gastric acid production is warranted in most patients with typical GERD symptoms such as heartburn or regurgitation.

"Inappropriate use of upper endoscopy does not improve the health of patients, exposes them to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary costs with no benefit," said Dr. Bronson.

Factors that contribute to overuse of upper endoscopy include differing recommendations from professional medical organizations, medico-legal liability concerns, and patient and caregiver expectations.

Unnecessary costs include the procedure itself (excess of $800 per exam) when it is not indicated and downstream costs of unnecessary follow up tests because of an original misdiagnosis.

"Upper Endoscopy for Gastroesophageal Reflux: Best Practice Advice from the American College of Physicians" and a corresponding patient summary appear in the December 4 issue of Annals of Internal Medicine, published by ACP.

This article is very, very wrong. An upper endoscope is just as, if not, more important than a colonoscopy because the acid reflux, heartburn, etc. CAN CAUSE CANCER - a very deadly cancer. Esophageal cancer is not normally found until very late stages when the prognosis is very grave.

It is the belief of most esophageal cancer patients and their caregivers that an upper endoscope should be performed at the same time a colonscopy is performed.

Esophageal cancer is one of the most rapidly growing, deadly cancers today. It strikes all ages, mostly men, but women also. This article could not be more wrong. Just ask those of us who are or have gone through the devastion of esophageal cancer. This article should be reviewed and revised immediately before more senseless losses of life can occur. Please, we beg you to reverse the opinion/s in this article.

I'm a 2 year survivor of stage 3 esophageal cancer and couldn't disagree with the author more! We have common colonoscopies for everyone without colon cancer symptoms; why on earth deny endoscopies to those with a long-standing history of GERD or heartburn? Barrette's Syndrome is a precursor to esophageal cancer - a cancer nearly as lethal as pancreatic. Instead of screening, we throw TUMS, Prilosec, Nexium, etc at the problem - all of which can mask the underlying and life-threatening problem.

THIS IS A VERY DANGEROUS VIEW
My father has had acid reflux for over 30 years. He was just told to take over the counter antacids, and was never given an endoscopy until food got stuck in his throat and he was taken to hospital at the age of 63. This is the ideal timing for endoscopy per your advice - he had lost a little weight and had swallowing difficulties.
They discovered he had Barretts Esophagus (which should have been monitored the past 3 decades), and a 10cm long Stage 3 adenocarcinoma of the esophagus. They could not get the scope through the oesophagus it was so closed up. This is an extremely aggressive cancer. The survival rates are very poor. My dad has been through chemotherapy, radiation, a massively invasive surgery, and now 3 more months of chemotherapy. I would suggest that the $800 fee for an endoscopy every few years would be far outweighed by the months he has spent in hospital with cancer treatment and side effects of that treatment.
Plus - and most importantly for us - his prognosis would be much better had he been diagnosed stage 1.
Esophageal cancer is growing rapidly in numbers every year. We need better education and more screening, not less.
I suppose if you are looking at saving some money - maybe it is better to delay all screening, so that the only time people present with symptoms they are already advanced stage IV and you can send them home to die, and avoid the massive medical bills.
OR you can do what is moral and correct and kind and just and identify these people before its too late.

I have to strongly disagree with this article. My father died last year of esophageal cancer. By the time he had difficulty swallowing and went for an endoscopy, he was already Stage III with lymph node involvement. A routine endoscopy even six months prior could have saved his life. If you knew anything about esophageal cancer, you would know that by the time patients report difficulty swallowing and other telltale signs of something being amiss, the cancer is already quite advanced and is VERY difficult to treat. A routine endoscopy would save hundreds of lives each year, given the fact that esophageal cancer is on the rise in the US.

What an outrageous and dangerous decision this was! Esophageal cancer is the fastest growing and one of the most deadly cancers there is. Early detection is the key to survival. How can you not know about silent reflux? How can you not know that when PPIs appear to have worked and symptoms disappear this is a very dangerous sign that the cells have converted to poorly differentiated adenocarcinoma?
You say wait until there is difficulty swallowing or bleeding to do an endoscopy. You can not be serious! Those are the signs that it is way past early stage.
My husband had heartburn and was treated with over the counter PPIs. Symptoms improved. No endoscopy done. When he developed difficulty swallowing, an endoscopy and follow up tests were done. By then it was Stage IV with supraclavicular lymph node involvement.
The basis of this study must have been based on shoddy, bad science. If not and it was all about money, $800 is nothing compared to the cost of chemo or radiation or the horrific surgery.
There need to be more endoscopes done, like mammograms and colonoscopies -- not less.
Please re- look at and revise this awful decision.

This article is absurd. Obviously the ACP needs to go back to school on this subject. We are advised at age 40 for women, to get a mammogram screening. How many women actually walk away with a diagnosis of cancer? Yet, they are advised to continue these routine screenings.
We are advised at age 50 to have a colonoscopy screening. How many people actually walk away from that first screening with a diagnosis of colon cancer. The same thing can be said for men getting screened for prostate cancer. Yet you are saying "The evidence indicates that upper endoscopy is indicated in patients with heartburn only when accompanied by other serious symptoms such as difficult or painful swallowing, bleeding, anemia, weight loss, or recurrent vomiting," . Do you not realize that by the time these symptoms occur that it is almost always incurable esophageal cancer. If you are lucky enough to catch it at at stage I, II or III, you are eligible for a very complicated very serious, very expensive surgery to TRY to beat this cancer. Many people do not take heartburn seriously because they can take the many over the counter medications to put the fire out. Many other people have occasional heart burn and silent reflux, so they would not get treatment at all. My 59 yr old husband, did not have chronic heartburn, only had silent reflux, was not having problems swallowing and only found out he had Esophageal cancer when it spread to his liver where there were too many tumors to even count. He is stage IV incurable, inoperable. He also Never smoked, was never over weight, does not drink alcohol and led a very active life. He is fighting with everything he has to live for all of us, and because he LOVES his family and his life.

IF there was a screening age of 50, repeated in 5 yr increments for example, my husband and many others would have had a chance for a cure.

We are telling everyone we know that they should get screened. The ACP is making a huge mistake as laid out in this article and all I can say is I hope this disease does not come to visit your families before you will see the error you are making. This cancer is on a huge increase and if you did your homework right, you would be aware of this and not making this insane recommendation. People Listen "Heartburn Kills".

Apparently the American College of Physicians (ACP) Clinical Guidelines Committee has never had a loved one who is dying of esophageal cancer who could have been diagnosed at an early stage and had a shot of survival if an endoscopy was ordered.

My mother had terrible heartburn for years. Her doctors advised her to take over the counter medicines. Even when she had difficulty swallowing and lost weight the doctor started with a chest X-ray versus an endoscopy. My mom is at home dying with ugly symptoms from esophageal cancer and is absolutely miserable. I am wondering if the committee would like to stop over to my home and meet my mother and see what she is going through…and I extend a personal invitation to Dr. Bronson. Perhaps that would reverse their assertion that the endoscopy is not required until serious symptoms are present. Any physician should know that by the time serious symptoms are present, the likelihood of survival is bleak with this cancer.

This procedure is a tool that can help save lives. I would think that would take precedence over saving dollars. Doctors and the general public need to be educated that HEARTBURN CAN CAUSE ESOPHOGEAL CANCER and it should be the norm to screen for it just as colonoscopies, mammograms, and pap tests are performed to screen for other cancers.

I am really disappointed that upper endoscopy is not considered necessary. My husband waited until swallowing didn't "feel right", and the endoscopy found stage three esophageal adenocarcinoma at the age of 44y. He is now deceased. He did not live to see his two year old daughter start kindergarten.

He had horrible gastroesophageal reflux (heart burn). He was NEVER advised that the acid could cause damage that may be fatal. He did not know the acid was causing cumulative changes that would eventually be his demise.

I am curious how the ACP can recommend not using endoscopy in the face of information showing a dramatic increase in adenocarcinoma incidence? With the increasing frequency, I do not believe this recommendation is in patients' best interest. The only entities that will benefit are insurance companies who will now have an opportunity to deny claims for upper endoscopy...

I am not only disappointed, but angry at those who are making this recommendation regarding the performance of upper endoscopies. It is obvious that you are only familiar with what you read regarding esophageal cancer because if you had anyone you knew diagnosed with any stage of this cancer, you would become much more knowledgeable regarding the importance of early diagnosis. My husband's esophageal cancer was originally diagnosed by having a gastroscopy.

I thought that part of providing good health care was to educate and screen for diseases before those diseases become extremely expensive to treat. I agree with the added comments made by others regarding having a gastroscopy as a screening tool. Also, since esophageal cancer appears to have an inherited tendency, performing such tests on family members of those with such a diagnosis becomes important. No one wants to lose a loved one to any disease, but this cancer, which is becoming more widely recognized and prevalent, continues to be the most lethal, according to the news, followed by pancreatic cancer. This makes it even more vitally important to get an early diagnosis. Almost all of the symptoms mentioned by the ACP are found in advanced cases of EC, not the early stages.

Don't you think a re-examination of your criteria and reasoning is merited?

As a physician AND a survivor of stage III esophageal cancer, I have to agree with all the other comments above and say that the article itself is absolutely outrageous. The other commentors are correct; the symptoms mentioned in the article do not manifest until the more advanced stages of this disease. Any physician who waits until the patient complains of disphagia before ordering an endoscopy is condemning that patient to death. I hope the ACP will reconsider its recommendations.

This article and the incorrect recommendations highlight the lack of knowledge among medical professionals about esophageal cancer. As a 54 year old woman I was diagnosed with stage 3 EC after an endoscopy. My physician was shocked. If he had waited longer I might not be here to write this. This is full of inaccurate information and I ask you to reconsider for the sake of the people who will die if these recommendations are followed!

I am absolutely appalled by this article and find it hard to believe that it was written by a doctor, certainly not one with any experience or direct knowledge of esophageal cancer. Are you unaware that esophageal cancer is one of the most deadly and fast growing cancers out there? Or do you just not care? With esophageal cancer, by the time the symptoms you so casually reference are evident, the patient is usually a stage III or IV with a very low chance of survival. There is something around a 22% 5 year survival rate for the lucky ones, mostly those lucky enough to be diagnosed at an early stage. The stage 3 and lower patients may have the option of a very barbaric surgery involving removing the esophagus and part of the stomach and making part of the stomach into a new esophagus. They suffer greatly and many do not survive even despite undergoing the grueling regime of chemo, radiation, and surgery if eligible. Those that have the surgery and survive face very changed lives with their eating ability forever changed, many side effects such as dumping syndrome, the inability to sleep flat for the rest of their lives, and in addition to the risk of recurrence and mets to the brain, bones, and liver, are at risk of aspiration (this happened to someone I know).

The EC death is often a slow, agonizing, and miserable one that is heartrending for those that love the victims to witness. Imagine spending your remaining life unable to eat, unable even to drink, and often in great agony. Eating is not only one of the most basic needs of our lives, it is a huge part of the social and family fabric of our lives. I still have the picture in my mind of my daughter trying to choke back tears when she came to see us mid treatment and she saw her Dad gagging even when simply attempting to drink water. And, for now, his treatments helped and he can still eat and drink unlike many other patients I know. This is what you are condemning the ever increasing number of esophageal cancer victims to with this ill thought out recommendation. As for denying this life saving scope to save a measly $800, I am just so appalled that I can't think of a polite way to express it, so I won't say too much about that other that this is just wrong. FWIW, My husband was diagnosed with Barrets - by the next scope 5 years later he had full blown stage III cancer. We had no idea how great a risk he was at as EC is not widely publicized. More frequent scoping would have saved him much suffering and increased his survival chances. Additionally, that $800 is nothing compared to the cost of his treatments to date which is in the hundreds of thousands of dollars so far. And he was not even eligible for the surgery which I am sure must add many $000 more. So far, we are one of the lucky ones (if there is such a thing in EC world). He has survived 13 months and 2 days despite being ineligible for surgery. I have lost count of the people I have come to know that have died of this horrifying disease, many of them within a year, and sometimes much less, of diagnosis and all after great suffering. These were not some invisible anonymous statistics to be used in an ill thought out and poorly researched paper - they were each and every one of them someone's father, husband, brother, son, wife, mother, sister, daughter.

My greatest gift from this horrible world of esophageal cancer has been an amazing circle of support and kindness from other caregivers and patients. They are true heroes, and life and sanity savers. Many of those who have lost loved ones to this terrible disease dedicate their time and broken hearts to trying to get the word out about EC, and encouraging scopes to try and prevent others from suffering as they and their loved ones have. This article does a huge disservice to those people who are fighting an already difficult battle against a disease I have heard described as an “orphan” because it does not attract the research that some other cancers do. I would urge you to consult with some of the wonderful and knowledgeable doctors at some of major cancer centers that specialize in treating this cancer. Hopefully their input, and perhaps some time spent actually seeing the horror that EC patients go through, will lead you to change this recommendation.

I am as appalled as everyone else here at the very existence of this highly misleading article! My mother was diagnosed in August with Stage 3 Esophageal Cancer after just about 3 weeks of difficulty swallowing. She has now been through chemo and radiation and will be undergoing a very risky and painful esophagectomy in January, followed by more chemo. EC doesn't present symptoms at ALL until stage 3 in the majority of cases and even then the survival rate overall is low. Her condition started out as Barrett's Esophagus, the result of silent reflux. I suffer from moderate to severe reflux that is now being managed, but I still need to have this endoscopy to confirm whether or not I too have Barrett's - the precursor to adenocarcinoma of the esophagus! I am a 42 year old woman! The very person that your article says should NOT have this procedure!

This recommendation is a slap in the face to my mother and to all of the people that I have come to know in support groups for EC. For that matter, it's a slap in my face too, as I have a higher than average chance of one day finding myself battling EC. Shame on you, ACP...save a few bucks to toss away a few thousand lives a year. Sure sounds like a great idea to me! WRONG!

I completely agree with all the comments above. With EC by the time symptoms appear it is usually too late. I am one of the lucky ones, I started having problems swallowing and by the time an EGD was done I could hardly swallow anything. Within a few days, after being quickly diagnosed, having a CT and a PET scan done (showing no metastasis), I had a J-tube for feeding put in place so I could begin Chemo & Radiation treatment followed by an 8 hour Gastroesophagectomy and a very long difficult recovery. I am 18 months post-op and just had another PET/CT scan that showed me to still be cancer free. My life has been drastically altered by this debilitating horrible disease and yet I am one of the lucky ones. I was put on Protonix several years ago after complaining to my primary physician (a Board Certified Internist)about having chronic gas pains that seemed to move around all over my abdomen but that Tums would alleviate the pains. He just said I am going to give you a super Tums that you only have to take once a day. Never mentioned EC, Barretts Esophagus but he did say I probably should have an EGD but while he pushed me into having a colonoscopy never brought up the EDG again. I am not sure why my cancer had not spread, by all accounts it should have but it didn't and I actually have a fairly good prognosis for 5 year survival. I think this "recommendation" you have published is more about money and the physician shortage we have in the the United States than anything else. Drs need to take a few minutes with patients who suffer with GERD or GERD like symptoms and inform them of the risks involved, educate the patient about EC (both kinds) and let the patient have some say in their treatment. Don't just take the position that since the risk appears to be low I just won't order a very low risk, low cost procedure that just might save someone's life.

This article is absurd!!! And, it's written by doctors??? My husband was diagnosed June 2011 with Stage 3B esophageal cancer. He got to the point where he couldn't swallow chicken broth and shortly after, couldn't swallow his own saliva! The tumor mass was at the bottom of the esophagus and top of his stomach. They had to put a stent in so he could swallow and eat again!! And, you don't think upper endos are necessary?? Excuse me???? He swallowed Tums, Rolaids, etc for years, years ago. We were told that his cancer mass had "brewed" for years before finally catching up with him. He went through painful radiation and strong chemo last summer. On November 1, 2011, he went thru a massive surgery - removing the burnt part of his esophagus and creating a new one using his stomach!!!!!! Recoup was slow, including a feeding tube he used for over 3 months! He did get rid of the cancer, only to have the crap come back!!! He is now Stage 4, Chronic - his/our life is chemo every 2 weeks until further notice!! His latest CT showed that the lymph nodes have grown, even with the chemo, so this week he starts 5-6 weeks (that's 25-30) radiation treatments. Again, you say upper endos are a waste of time and money??????? You/those docs are sick and should have their heads examined!!! I don't know how long my sweetheart will be with me, but I want him around as long as possible. Without those endos done last year, and he had several, and without that surgery done last year, I wouldn't have him with me right now. I hope to God the docs print a retraction to this article of 100% fiction and write and print the truth! Our surgeon told us that esoph cancer is on the rise and from a support group I belong to, yes, it's on the rise and there are some real pathetic stories out there. Sick article, sick, sick, sick.

My husband is a 4 yr. survivor of EC. It started out with the hiccups and "something gets stuck" here type of situation. He went through absolute misery and still suffers from the effects. When he saw his doctor, he thought like you...don't bother and told my husband "take a peppermint 10 min. before eating". Six months later, he was at stage 3A and his oncologist put him on a research protocol. He had NO heartburn...just the hiccups as he started to eat! NO endoscopy? PLEASE...say it's not what you TRULY believe!

If it had not been for an endoscopy they would not have caught my esophageal cancer when they did. I was blessed having been caught at stage1 headed to stage2 and was blessed not to have to take chemo and Rad. Stright into surgery to remove my esophagus. If doctors follow what you are saying then we can only prey that GOD steps in and rids the world of this dreaded beast called cancer.

This article is unbelievable!!! If anything more awareness of how deadly cancer of the Esophagus is needs to be made! Once my dad finally got an upper endoscopy the tumor was large growing fast and stage 4 with lots of metastasis. He survived less than a month after diagnosis. This is a nasty disease that is becoming more and more common and routine checks should be a priority same as prostate colon and breast cancer.

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