Upper Endoscopy for Gastroesophageal Reflux Disease

TO THE EDITOR:

Shaheen and colleagues (1) thoughtfully illuminate a perplexing problem. However, I believe that 2 further indications for upper endoscopy to evaluate gastroesophageal reflux should be considered.

First, upper endoscopy may be more reassuring and more cost-effective for patients worried about cancer than explanation alone. In a study of gastric acid suppressants versus immediate gastroscopy for dyspepsia, Bytzer and colleagues (2) found that the group assigned to endoscopy was not only more satisfied with medical care but also had lower health care costs, in part because of decreased drug costs, sick days, and physician follow-ups presumably from the reassurance provided by a normal gastroscopy. Discussion, reassurance, and support without endoscopy ring hollow in light of articles showing an increased incidence of cancer in reflux, even without Barrett esophagus (3), and the rarity of curing cancer once alarm symptoms have developed. Esophageal cancer may not even be that rare in younger persons: Our center has reported 29 cases of Barrett esophagus with early esophageal cancer or high-grade dysplasia in patients younger than 55 years collected from the province of Ontario alone over 9 years without even delving into surgical files (4). As further justification, I refer to a survey of 1040 upper endoscopies done to investigate dyspepsia presenting to primary care physicians (5), the very group to which Shaheen and colleagues' guidelines are directed. The study found 2 potentially curable cases of cancer; neither had alarm symptoms, but no cancer was found in the 29 cases that did.