With 57 per cent of Irish people obese or overweight, it is no surprise we have one of Europe's highest rates of cancer of the oesophagus, writes John Reynolds.
Lollipop Day today brings some focus nationally on cancer of the oesophagus. Ireland has one of the highest rates of this cancer in Europe, with 350-400 new diagnoses each year. The increasing problem of oesophageal cancer in the West over the last 20 years parallels emerging trends in diet and obesity, as well as the frequency of oesophageal acid symptoms such as heartburn.
It is now well established that chronic acid erosive damage to the oesophagus and obesity are directly linked to the risk of oesophageal cancer, hence strategies and initiatives targeting prevention or early diagnosis of this cancer connect not only with national cancer strategy but also with public health policies.
Studies from North America suggest that obesity may account for up to 14 per cent of cancer deaths in men and 20 per cent of cancer deaths in women. In Ireland, approximately 57 per cent of the population are overweight or obese, with concerning trends projected to continue.
Obesity is a major risk factor for cancer of the oesophagus as well as many other cancers. Researchers at St James's Hospital and Trinity College recently reported that obesity was associated with an 11-fold increased risk of cancer of the oesophagus. There are two likely mechanisms.
First, excess abdominal fat may put pressure on the stomach and promote acid damage to the oesophagus. A second intriguing mechanism is that the same changes in hormones and metabolism that cause diabetes and cardiovascular disease in obese people may also directly promote oesophageal and other cancers in those at risk.
The emerging problem of obesity in children and adolescents in Ireland is well recognised, and unfortunately cancer risk has now to be added to the acknowledged risks of diabetes, and liver and cardiac problems. The National Task Force on Obesity has made several recommendations that require implementation. Obesity must be targeted like any disease by preventive strategies and comprehensive treatment programmes - otherwise the prospect that the current generation of children in the US may be the first that will not outlive their parents may also have resonance in Ireland.
Acid in the oesophagus is normally experienced as heartburn. This type of symptom is common and not of itself worrisome. Where symptoms are severe or intractable despite the use of standard medicines, one should seek an endoscopy, a simple "camera test" assessment of the oesophagus. Some sufferers will need long-term treatment, and effective acid control may reduce the risk of cancer.
Perhaps one in 10 patients may be told after endoscopy that they have Barrett's oesophagus, where the lining of the oesophagus is altered by chronic exposure to acid. The risk of developing oesophageal cancer for any patient with Barrett's oesophagus is approximately one in 200 per year.
Although modest, this is 40-fold the normal risk, and understandably the diagnosis elicits considerable anxiety and concern. There is much scope for improvement in the overall approach to Barrett's oesophagus in Ireland, and the establishment of a national registry would be a very worthwhile initiative within a cancer prevention programme.
Most patients diagnosed with oesophageal cancer present initially with difficulty in swallowing. The organisers of the Oesophageal Cancer Fund (OCF) and Lollipop Day have played a valuable role in public education through highlighting the significance of this symptom and the imperative of seeking urgent specialist opinion.
Although sadly oesophageal cancer is all too often a devastating illness, the encouraging evidence from specialist centres is of an emerging trend for patients to be diagnosed when cancer is still localised to the oesophagus, presenting at least a possibility of cure.
The management of the disease can be complex and for many patients this requires a combination of chemotherapy, radiation therapy and major surgery.
Complex cancer care implies that the treatment itself carries significant risks of complications during treatment or following surgery, and the economic costs of the treatment programme are considerable. The magnitude of the operation for oesophageal cancer is probably greater than for any other cancer operation, and it is unassailable from international experience and policies that this operation is best undertaken in specialist centres performing large numbers of these operations each year - and providing evidence of good outcomes.
The National Cancer Control Programme under the lead of Prof Tom Keane has recently begun its important work. The organisation of breast cancer services understandably tops the initial agenda, but how the approach to oesophageal and other complex cancers is structured, resourced and implemented represents a significant opportunity.
We need to develop comprehensive models of cancer prevention and treatment that are underpinned by evidence-based standards and aligned to cancer clinical trials and research. In this way, cure rates for cancer in Ireland will be maximised. The next five years hold considerable promise in this regard.
Prof John Reynolds is professor of surgery at Trinity College, Dublin and St James's Hospital, Dublin