Barrett's esophagus as seen by transnasal esophagoscopy (TNE)

Esophageal screening by Transnasal Esophagoscopy (TNE) will provide better healthcare for Americans at a much lower cost.

The Reuter’s article, Special Report: Cancer screening feeds overdiagnosis debate, by Frederik Joelving (April 20, 2012) contains erroneous premises and incorrect information so that its conclusions are all wrong. It appears that Joelving would like to throw the baby out with the bath water! Here are the facts:

  • Acid reflux is epidemic, and reflux-caused esophageal cancer—having increased 850% since the 1970s—is now the fastest growing cancer in America … by far.
  • Acidity in the American diet is the cause of the reflux epidemic, and proper dietary treatment for reflux is highly effective. Reflux disease can be reversed!
  • People with airway (“silent”) reflux—with hoarseness, chronic cough, and breathing difficulties (including asthma)—are more likely to have esophageal cancer and precancer (Barrett’s esophagus) than people with typical acid reflux with heartburn and indigestion.
  • People with both esophageal and airway reflux should have esophageal screening examinations by TNE.

    Reflux and Reflux-Related Esophageal Cancer is Epidemic

    The prevalence of acid reflux disease has increased dramatically in our lifetimes.1-6 Analysis of 17 prevalence studies showed that the rate of growth of reflux disease has been 4% per year since 1976.2 In the last decade alone in ENT (ear, nose and throat) practice, office visits for reflux increased 500%.3

    In 2010, we estimated the prevalence of reflux (GERD and LPR) in America by interviewing 656 people waiting to purchase discount theater tickets (at TKTS) in Times Square in New York City.1,5 The data revealed that an astonishing 40% (262/656) of the study group had reflux disease with 22% (144/656) classic esophageal reflux (aka GERD, gastroesophageal reflux disease) and another 18% (118/656) with silent (airway) reflux (aka LPR, laryngopharyngeal reflux).6 The most striking and unanticipated result was that 37% of the 21-30 year-old age group had reflux.5 In the past, reflux was primarily a disease of overweight, middle-aged people. But now we are finding that many of our reflux patients are neither old nor obese.7

    An even more ominous trend is that the prevalence of esophageal cancer in the United States has increased 850% since 1975.1,4 During this same time period its mortality (deadliness) has increased seven-fold.5 In addition, the prevalence of esophageal precancer (Barrett’s esophagus) is also increasing, and it is just as high in people with hoarseness, sore throat, and chronic cough as it is in people with heartburn and indigestion.8

    In addition, today, asthma is very often overdiagnosed and misdiagnosed. The author (JK) recently reported a series of patients with a chief complaint of chronic cough for 10 years and found that reflux was mistaken for asthma by physicians 80% of the time.9 (If you have “asthma,” and if during breathing attacks you have more trouble getting air “in” rather than “out” (wheezing), you don’t have asthma; you have reactive airways disease because of reflux.)

    Dietary Acid May Be the Missing Link

    Coincident with the reflux epidemic, the American diet has changed dramatically.1,10 Since the 1960s, there have been four parallel unhealthy dietary trends: (1) increased saturated fat, (2) increased high-fructose corn syrup, (3) increased exposure to organic pollutants (e.g., DDT, PCBs, dioxins), and (4) increased acidity.10 The last of these trends—increased dietary acid—may hold the key to understanding the contemporary reflux epidemic and the dramatic increases in Barrett’s esophagus and esophageal cancer.

    In 1973, following an outbreak of food poisoning (botulism), Congress enacted Title 21, mandating that the Food and Drug Administration (FDA) assure the safety of processed food crossing state lines by establishing “Good Manufacturing Practices.”1,10-12 How was this accomplished? Through acidification of bottled and canned foods, intended to prevent bacterial growth and prolong shelf life. Today, almost all food that is bottled or canned is pH <4.11-13

    Today, in the office, I saw a woman from Seattle whom I had first seen a year ago. She had originally come to see me because she knew that I would help her find the best diet for her Barrett’s esophagus with the idea that it might be reversed. (She had been previously diagnosed, biopsy-proven Barrett’s, by a gastroenterologist shortly before coming to see me.)  I knew that pepsin was produced in Barrett’s, and I knew that a low-acid diet was likely to be beneficial. So today, my patient showed me a recent endoscopy/biopsy report from her gastroenterologist: Now a year later, her Barrett’s was gone. How? Low-acid, low-fat, pH-balanced eating with Manuka honey (t.i.d.) and alkaline water. FLASH: Barrett’s esophagus reversed by healthy diet!  In other words, this patient chose lifestyle and dietary modifications over ablation — she had no procedures for her Barrett’s — with the best possible result.

    Connect the dots. While it may sound like a conspiracy theory; it is true. Dietary acid appears to be the primary factor in the prevalence, mechanisms, manifestations (including cancer), and outcomes of reflux disease. Until now, it appears that fundamental nutritional questions related to how food has been preserved for the last two generations may have been overlooked.1,10,13 In the meanwhile, the proof of the pudding is that people with reflux disease, including some with Barrett’s esophagus, significantly benefit from a low-acid diet. Contrary to popular belief, reflux disease is reversible.1,10

    Who Should Be Screened for Esophageal Cancer?

    Last month alone, I found Barrett’s esophagus in two refluxers in their 20s. Reflux used to be a disease of people in middle age. Not any more. Now, we are seeing advanced disease in young people, and in thin people, too. It’s no longer a disease of just the obese. In fact people with airway reflux tend not to be overweight. But here is a statistic for you: In 2010, the average 12-29-year-old American consumed 160 gallons of acidified soft drinks, almost a half-gallon per person per day (American Beverage Association data).

    I recently reported that a staggering 63% of patients with chronic cough had significant esophageal pathology, including 47% with esophagitis and 8% with Barrett’s.9 The problem with reversible-by-healthy-diet reflux disease is that it needs to be properly diagnosed to be properly treated.1,9,10

    Today, 40% of Americans have reflux (22% with esophageal reflux another 18% with airway reflux). If any disease needs screening it is reflux. The introduction of transnasal esophagoscopy (TNE) a decade ago provided an important advance in the care of patients with reflux, dysphagia (swallowing problems), and esophageal pathology.14 The TNE endoscope offers brilliant illumination, excellent image quality, and the capability to obtain biopsies. TNE is inexpensive, well-tolerated by the vast majority of patients, though it is performed in a comfortable, seated, awake patient who can walk out the door as soon as the procedure is complete.

    The esophageal examination test that is expensive and wasteful is EGD (esophagogastroduodenoscopy) under aesthesia, and not TNE, but some medical specialists have a huge financial stake in maintaining the status quo of EGD. Last year in the U.S., 10 million sedated EGDs were performed at a “facility fees” cost of $10 billion (and that doesn’t include physician fees or biopsies).

    TNE is one of the most important and cost-effective advances in the diagnosis and prevention of serious disease in the past decade. Who should have it? The 100 million Americans with reflux. It is foolish to lump TNE with any other screening tests that have low yield and high cost. Save the baby!


    1. Koufman JA. Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications. Ann Otol Rhinol Laryngol 120:281-87, 2011.

    2. El-Serag HB. Time trends of gastroesophageal reflux disease: A systematic review. Clin Gastroenterol Hepatol 2007;5:17-26.

    3. Altman KW, Stephens RM, Lyttle CS, et al. Changing impact of gastroesophageal reflux in medical and otolaryngology practice. Laryngoscope 2005;115:1145-53.

    4. Pohl H, Welch HG. The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence. J Natl Cancer Inst 2005;97:142-6.

    5. Conio M, Blanchi S, Lapertosa G, et al. Long-term endoscopic surveillance of patients with Barrett’s esophagus. Incidence of dysplasia and adenocarcinoma: A prospective study. Am J Gastroenterol 2003;98:1931-9.

    6. Koufman JA, VanHorn G. The Prevalence of Reflux in America—The Times Square Study. (Unreported data), 2010 (manuscript in prepartion).

    7. Halum SL, Postma GN, Johnston C, Belafsky PC, Koufman JA. Patients with isolated laryngopharyngeal reflux are not obese. Laryngoscope 2005;115:1042-5.

    8. Reavis KM, Morris CD, Gopal DV, Hunter JG, Jobe BA. Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Ann Surg 2004;239:849-56.

    9. Koufman J. Diagnosis and management of non-pulmonary chronic cough. Presented at the annual meeting of the American Broncho-Esophagological Association, April 19, 2012, San Diego, CA (submitted to the Annals of Otology, Rhinology & Laryngology).

    10. Koufman JA, Stern JC, Bauer MM. Dropping Acid: The Reflux Diet Cookbook & Cure. Reflux Cookbooks LLC (Brio Books), Minneapolis MN, 2010.

    11. “Acidified Foods.” Code of Federal Regulations—Title 21—Food and Drugs Chapter I, Department of Health and Human Services Subchapter B—Food for Human Consumption Part 114. United States Food and Drug Administration. Arlington, VA, Washington Business Information, 2010.

    12. “Generally Recognized as Safe Food Additives: FDA Database of Selected GRAS Substances.”  United States Food and Drug Administration. National Technical Information Service, Springfield, VA, 2009.

    13. “Food Safety: FDA Should Strengthen Its Oversight of Food Ingredients Determined to Be Generally Recognized as Safe (GRAS).”  GAO-10-246: United States Government Accountability Office, February 3, 2010.

    14. Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: A position statement from the American Broncho-Esophagological Association. Otolaryngol Head Neck Surg 2008;138:411-3.

Comments are closed.