NERD: no increased risk of oesophageal cancer

Do patients with non-erosive gastro-oesophageal reflux need regular follow-up endoscopies to prevent cancer? A long-term cohort study argues against this.

Reflux disease and oesophageal cancer: is there a connection?

Gastro-oesophageal reflux disease (GERD) is common in industrialised nations. It occurs in around 20% of adults here.
GERD is the main risk factor for adenocarcinoma of the oesophagus.
The incidence of the tumour disease is increasing and the prognosis is usually poor.
Non-erosive gastro-oesophageal reflux disease (NERD) is the term used to describe GERD without erosive oesophagitis. The connection with oesophageal carcinoma was previously unclear.

Nobody wants to overlook oesophageal cancer. Therefore, patients with NERD usually have regular check-up endoscopies to recognise malignant changes at an early stage. Dag Holmberg from Karolinksa University Hospital in Stockholm and his colleagues wanted to find out whether this is really necessary.

Which endpoints were analysed?

In a large-scale population study (DOI: 10.1136/bmj-2023-076017), they collected data from 486,556 adults from all hospitals and specialised outpatient facilities in Denmark, Finland and Sweden over a period of three decades. 200,745 subjects had reflux disease with erosive oesophagitis, 285,811 suffered from NERD.

The following endpoints were recorded:

Incidences and incidence rates of adenocarcinomas of the oesophagus.
Standardised incidence ratios.

The latter means that the observed number of oesophageal adenocarcinomas in each of the cohorts was divided by the expected number derived from the general population. The scientists took care to ensure comparability in terms of age, gender and calendar period. This made it possible to determine whether the respective disease risk was above or below the general average.

What was the risk of cancer in GERD and NERD?

Of the NERD patients, 228 (0.08%) developed oesophageal cancer in the course of the study. The incidence rate was 11/100,000 person-years and was thus similar to that of the general population: the standardised incidence ratio was initially 1.04 and increased only marginally to 1.07 even after a longer follow-up of 15-31 years.

In contrast, 542 (0.27%) people with erosive oesophagitis developed adenocarcinoma of the oesophagus. This corresponds to an incidence rate of 31/100,000 person-years, which means that the standardised incidence ratio was 2.36. With increasing duration of follow-up, it continued to rise to 2.73 after 15-31 years. As expected, the incidence was significantly higher in the general population.

Check-ups do not seem to be necessary

Patients with NERD do not appear to have an increased risk of cancer. The Scandinavian researchers conclude that patients with normal endoscopy findings do not require any further checks - unless they develop warning symptoms such as dysphagia. However, current clinical practice is often different. According to the authors, this is both costly and ineffective.

Sources

Holmberg D et al. Non-erosive gastro-oesophageal reflux disease and incidence of oesophageal adenocarcinoma in three Nordic countries: population based cohort study. BMJ 2023; 382: e076017; DOI: 10.1136/bmj-2023-076017.