Christopher Hitchens’ illness: II. Responding to the rising rate of esophageal cancer

If anything good can come out of Mr. Hitchens’ 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. It’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 “if it’s not one damn thing, it’s another”, 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 don’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 don’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 isn’t as common as heart attack/stroke and therefore isn’t as motivating. Public health experts think in terms of population health statistics, but as individuals, patients think like, well, individuals. They don’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 wouldn’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.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

6 thoughts on “Christopher Hitchens’ illness: II. Responding to the rising rate of esophageal cancer”

  1. It would seem, though, that the reduction in pain would be fairly motivating; unlike statins and aspirin, the immediate effects of a proton pump inhibitor in chronic gastric reflux are noticeable and desirable.

  2. Got that right: After chemotherapy I ended up with a hiatal hernia, due to severe coughing spells, and the gastric reflux was absolutely motivation enough to take my pills faithfully. It's miserable condition. I'm also on a diet to try to help; My weight isn't reflected in my blood chemistry, (Good genetics, I suppose.) but it produces pressure which aggravates the hernia.

    OTOH, I hear some people don't notice the symptoms, they're probably the ones at risk.

  3. I agree with SamChevre and Brett. I have some problems with reflux and take a daily Prilosec. It sure beats waking up at 3 AM with acid sloshing around one's insides.

  4. If the "being really fat" sort of esophageal cancer is on the rise while the "drinking and smoking" sort is declining, I don't think Hitchens's illness has much direct connection with the epidemic. (That might sound like snark, but it is not. CH is known to enjoy a drink and a smoke, and although he could, like most of us of a certain age, profitably have spent more time at the gym, he is hardly obese.) That said, even if the sort of e-cancer whose incidence is increasing bears no relation to the illness CH has been burdened with, if the publicity about his illness results in a general "better have myself checked out" reaction, and that reaction results in more early catches and a higher cure rate, CH's illness will have done a good thing. I hope it does, and I hope that the knowledge is some comfort to him.

    As an aside, Brett, I hadn't known you were ill. I am sorry to hear it; my best wishes for the best possible outcome.

  5. I must say that SamChevre raises an excellent point that I left out of my analysis: Is there a more immediate reinforcement to pill taking than whatever anxiety relief you get from lowering your risk of a possible, distant-in-time illness. Finasteride though does have a benefit that many men value (fighting hair loss), though one could argue that that is less reinforcing than the removal of heartburn pain because it becomes evident more slowly.

    Just as a friendly warning, if any of you are taking PPIs for extended periods, you should check out this recent FDA warning on potential increased risk for fractures

  6. Regarding the friendly warning, I take Nexium every day, and my gastroenterologist advised me to take calcium supplements (and Vitamin D to help absorb the calcium).

Comments are closed.