October 18, 2005
Halloween, Part 2
Like a verse from Billy Joel’s “We Didn’t Start the Fire,” there is so much scary stuff out there. That it were only “Birth control, HoChiMinh, Richard Nixon back again, Moonshot, Woodstock, Watergate, punk rock, Begin, Reagan, Palestine, terror on the airline, Ayatollolah’s in Iran, Russians in Afghanistan.” Ah, those were much simpler days. The more things change…and we ask, “Why are these people scaring me?”
In Halloween, The First Part we discussed the human inability to accurately assess personal risk, health and otherwise. Bottom line: we aren’t very good at it. And we have created some processes by which to manage our obsession with causation like religion, science, and politics. In the latter instance, “crisis” is communicated--whether for real or manufactured for effect. It plays to our need to assign causation (or blame) and control. But it still scares the hell out of us. It makes us want to “do” something--anything--thinking our personal survival is at stake. It’s time we look behind the second Halloween mask.
One of the more confusing scary things of the last week I took personally. It was the one about heartburn…esophageal reflux and esophageal cancer. I have reflux. In our family we call it Grandmother’s Disease. For all the time I knew her, my proper, Victorian grandmother suffered from gastroesophageal reflux manifested in her later years by rather resounding postprandial belching. I mean this was belching that would make most guys with a six-pack proud. She managed her symptoms with diet and some very disciplined if unusual eating habits. And she was always thin. She lived to be 95 years old, dying not of esophageal cancer but of gastric lymphoma--her first and only real disease.
So I read with interest Tara Parker-Pope’s article called “The Hidden Dangers of Heartburn” in the October 10 Wall Street Journal. It is a tortured back and forth of “is it or is it not” a big deal. On the one hand, we all die of esophageal cancer if we don’t submit to unproven monitoring methods. On the other, the vast majority of people with reflux will never have a significant complication.
So, good to know and file it away? Or, this should scare you into some sort of survival fugue? Which is it? How do we know?
First, some of the numbers she used: “An estimated 100 million Americans suffer from it every month; about 15 million battle it at least once a day.” For those counting, that is fully a third of the US population, including children. This number may derive from this factoid: “Prescriptions for PPIs (medicines that decrease acid to treat the symptoms of reflux) have nearly doubled from 50 million in 1999 to more than 93 million last year, according to pharmaceutical sales research firm IMS Health.” So what? As even she points out, these drugs work really well at relieving the symptoms. Probably a lot of people weren’t getting good treatment before the medications went over-the-counter.
Then in the article comes the piece de resistance: “esophageal adenocarcinoma -- the type linked with heartburn -- has jumped fivefold in the past 30 years. Although esophageal cancer remains relatively rare -- about 14,000 people were diagnosed last year -- it has the dubious distinction of being the fastest-growing cancer in the country. And many health experts worry that this is just the beginning.” (by the way, in case you forgot, that’s 14,000 out of 100,000,000)
And then she gets someone to create the crisis and utter the “e” word. "There may be only 14,000 cases now, but if you keep up that rate of rise, it's going to pass them all," says Scott Swanson, chief of thoracic surgery at Mount Sinai School of Medicine in New York. "If it continues, we're going to be dealing with a real epidemic." I wonder if he smiled when he said this, even a little.
And if that doesn’t scare the hell out of you this should do the trick: “Even more troubling are the theories about why esophageal cancer due to heartburn is gaining ground at such an alarming rate. Although obesity and poor dietary habits are likely culprits, there's mounting evidence that the way doctors and patients treat heartburn symptoms may also be making things worse.” A period after “culprits” would have been good.
Another problem with the entire logic of the article is that although esophageal cancer may be rising, apparently so is reflux disease. There is no comparative of the numerator and denominator. Leading me to remember my old professor’s admonition, “Statistics don’t lie; statisticians do!”
What does the medical establishment think is the problem? “Many doctors believe more aggressive monitoring of PPI users is needed, to ensure that the underlying problem is being treated along with the symptoms.” Fortunately for the doctor and unfortunately for you, there is no proven effective monitoring available. But what is available is a very expensive endoscopy procedure to take a “look see.”
Now, I’m all for progress in understanding disease. The article goes on to explain that bile acid reflux may also play a role in esophageal damage from this condition. But then she leaps back to attempt to create causation from this observation.
Here’s my hypothesis after a lifetime of observation of myself and family: Gastroesophageal reflux disease is a primary stomach motility disturbance. The event that triggers the reflux and the esophageal problem is delayed gastric emptying. This could be antral, pyloric, or both in nature (see stomach anatomy). It is one reason why taking antacids relieves all the symptoms, not just the burning but also the fullness and bloating. Antacids promote gastric emptying.
Back to Grandmother: if she were alive now, despite the fact that she was thin, she had some of the manifestations of what we now call metabolic syndrome. She had hypertension (never treated successfully) and hypertriglyceridemia (over 1000), but never diabetes or vascular disease. Both of her children, who were more 20th century in their eating habits, had diabetes and reflux disease. Could there be a linkage here? Someone should look into it.
