After 20 years of annoying but seemingly harmless hiccups, burping and heartburn, Peter Denson was shocked to be diagnosed with oesophageal cancer.
The cancer had developed from a pre-cancerous condition called Barrett’s oesophagus, where cells in the lining of the oesophagus (or gullet) start to behave abnormally after being damaged by stomach acid.
An estimated 650,000 people in the UK have Barrett’s, yet only 150,000 are diagnosed — mainly because, like Peter, they don’t realise how damaging acid reflux or heartburn can be in the long term.
While millions of people who suffer from heartburn or acid reflux are not at risk of cancer, doctors say those with persistent symptoms that last for three weeks or more should seek medical attention
And while millions of people who suffer from heartburn or acid reflux are not at risk of cancer, doctors say those with persistent symptoms that last for three weeks or more should seek medical attention rather than relying on over-the-counter remedies. (Although only 10 per cent of people with acid reflux will have Barrett’s, 10 per cent of those will go on to develop oesophageal cancer.)
For Peter, hiccupping at bedtime, along with a sour taste in his mouth, had become a nightly nuisance.
‘The attacks would happen several times a week, usually when I went to bed and lay down,’ says Peter, 66, who is separated with two grown-up children.
‘They would last for 15 minutes or sometimes longer. I couldn’t get to sleep when I was hiccupping every few seconds. It became the bane of my life, but I didn’t think it was anything sinister.’
Peter, a retired coach engineer from Gillingham, Kent, thought his indigestion was too trivial to bother the doctor with, and blamed it on his love of kebabs, toad-in-the-hole and full English breakfasts.
‘My job sometimes involved being out on the road. I’d grab food on the run and it would often be greasy and unhealthy,’ he says. ‘I tended to rush my food, too, so I thought I was probably swallowing too much air.
‘I took over-the-counter heartburn pills such as Gaviscon and just blamed my bad eating habits.’
‘The attacks would happen several times a week, usually when I went to bed and lay down,’ says Peter, 66, who is separated with two grown-up children (file image)
After almost two decades of suffering, in 2016 Peter finally saw his GP, who advised him to avoid greasy food. ‘I did cut back,’ says Peter, ‘but old habits are hard to change.’
As a precaution, he was also sent for a gastroscopy, where a thin, flexible tube with a small camera on the end is put down the throat. This revealed he had a hiatus hernia, a common condition where part of the stomach is pushed up into the chest.
‘I was told it was nothing to worry about, that I should try to lose some weight and it would correct itself,’ says Peter, who was only slightly overweight.
He adds: ‘I carried on taking heartburn pills, but the hiccupping and acid reflux continued. Then in February 2017, after suffering some breathlessness unrelated to my indigestion, I was sent for a CT scan, which picked up a shadow on my oesophagus.
‘Another gastroscopy and some blood tests followed and this time it was bad news — I was told I had early stage oesophageal cancer affecting a few centimetres of the lining of my oesophagus. I was stunned.’
Peter was told the cancer had been caused by Barrett’s oesophagus — where, over time, stomach acid splashes up and damages the lining of the oesophagus.
‘I was later told that my hiatus hernia lay directly below my oesophagus and was pushing up on it,’ he says. ‘This caused my diaphragm to go into spasm and triggered my hiccups.’
As well as chronic hiccups, the risk factors for Barrett’s include burping, acid reflux and an unpleasant taste in the mouth. It is not known why some people with persistent acid reflux develop Barrett’s and others don’t, although the condition is most common in middle-aged men who are obese — this may be related to men being more likely to put on weight around the middle, which, in turn, increases the likelihood of a hiatus hernia and Barrett’s.
Doctors are also seeing much younger people with Barrett’s —probably because obesity is becoming more common.
Peter’s cancer was diagnosed early and he was able to have the tumour removed via an endoscopic mucosal resection, in which an endoscope — a long, flexible tube — is inserted down the throat, along with a camera and tools to remove the abnormal cells.
He then had a treatment called Halo, where any remaining abnormal cells are burned away.
Dr Jason Dunn, a consultant gastroenterologist at Guy’s and St Thomas’ Hospital, in London, says only about a quarter of the 650,000 people in the UK estimated to have Barrett’s oesophagus have the condition diagnosed. ‘So many are missed because people dismiss their symptoms and continue taking over-the-counter remedies,’ says Dr Dunn, who treated Peter.
‘There is also lack of awareness that in some cases persistent acid reflux can lead to Barrett’s, which can then lead to cancer.
‘Although there is a low risk of developing oesophageal cancer with Barrett’s, if the cells lining the oesophagus start behaving abnormally — known as dysplasia — the cancer risk rises from 0.5 per cent a year to 15 per cent.’
Dysplasia is where the cells lining the oesophagus are replaced by the type of cell normally found in the stomach. Viewed through an endoscope camera, the oesophagus looks red and inflamed.
Each year, about 9,000 people have oesophageal cancer diagnosed and it claims 8,000 lives.
One case in five is diagnosed in A&E at a late stage, when symptoms include difficulty swallowing, vomiting blood and weight loss — all signs the cancer has grown to block the oesophagus.
Experts estimate that at least 950 lives a year could be saved if oesophageal cancer was diagnosed earlier.
One way to do that is by identifying people who have Barrett’s oesophagus and monitoring them at a specialist centre, with regular endoscopies to check for dysplasia and early treatment to remove abnormal cells.
Dysplasia can be treated with endoscopic techniques in many cases, rather than open surgery.
British research published in The Lancet last year showed taking the proton pump inhibitor omeprazole to cut stomach acid production could reduce the risk of cancer for those with Barrett’s oesophagus.
Sometimes extensive surgery is needed: the section of the oesophagus with the abnormal cells is removed and the stomach is joined to the remaining part.
Concern about the failure to spot Barrett’s earlier led surgeons and cancer charities to launch a campaign group for greater awareness of the symptoms.
Alan Moss, chairman of Action against Heartburn, says: ‘We’re highlighting that symptoms such as persistent hiccupping, heartburn, a bad taste in your mouth and indigestion that carry on for three weeks or more are not normal, and you need to see your GP about them.’