If anything good can come out of Mr. Hitchensâ€™ diagnosis, it may be greater attention to the astonishingly large increase in esophageal cancer in the U.S. During the last quarter of the 20th century, its incidence increased six fold. Itâ€™s a case where scientists know the cause but not the solution.
How can the incidence of esophageal cancer be soaring in a period of declining alcohol and tobacco consumption? The drops in heavy drinking and smoking have helped to lower the incidence of the squamous cell esophageal cancers that typically occur near the mouth and neck. But in a case of â€œif itâ€™s not one damn thing, itâ€™s another,â€ rising overeating and obesity have more than canceled out these gains because they increase risk for a different type of cancer (adenocarcinoma) lower down in the esophagus.
Obese people (as well as people with bad eating habits who are on their way to obesity) are prone to chronic gastric reflux, the splashing of powerful stomach acids into the lower esophagus. In addition to being painful, over time this can cause changes in esophageal cells which make them much more cancer prone. This raises the health policy question of whether a campaign to promote mass prescription of proton pump inhibitors (e.g., Prilosec) to overweight people would pay off in terms of a lower esophageal cancer rate. Unfortunately, the answer is almost certainly no.
Although many people seem willing to take a daily pill (e.g., aspirin or a statin) to lower risk of heart attack and stroke, we donâ€™t have a comparable case for less prevalent conditions. Very few men for example seem to be taking finasteride as primary prevention for prostate cancer, and most physicians donâ€™t feel compelled to recommend it either.
The odds of having some kind of cardiovascular event are high enough to induce large numbers of people to take a pill as primary prevention, but esophageal cancer isnâ€™t as common as heart attack/stroke and therefore isnâ€™t as motivating. Public health experts think in terms of population health statistics, but as individuals, patients think like, well, individuals. They donâ€™t want to purchase and take a daily pill unless they think they have a good shot at a personal payoff.
A further complication is that some recent Australian research suggests that obesity also increases risk for adenocarcinoma by inducing hormonal changes that a proton pump inhibitor wouldnâ€™t affect. It seems therefore that the only real health policy answer is to make a direct attack on obesity itself, which if successful should reduce not only esophageal cancer, but a range of other cancers as well.