Book Review

GERD: Reflux to Esophageal Adenocarcinoma

N Engl J Med 2007; 356:1897-1898May 3, 2007

Article

GERD: Reflux to Esophageal Adenocarcinoma
By Parakrama T. Chandrasoma and Tom R. DeMeester. 447 pp., illustrated. San Diego, CA, Elsevier Academic Press, 2006. $99.95. ISBN: 978-0-12-369416-4

Esophageal cancer is the seventh leading cause of all deaths from cancer worldwide, with an estimated 14,000 deaths from this cancer in the United States alone in 2006. Since the 1970s, esophageal adenocarcinoma has been the neoplasm with the fastest-growing incidence of any cancer in the Western world. This rising incidence implies a need for improvement in identifying those at risk for the disease and in both intervention and prevention. Regrettably, there is a lack of consensus among experts regarding the diagnosis and management of Barrett's esophagus. A book that is focused on this important subject has been long overdue.

This timely and authoritative book was written by two masters in the field whose experience spans two decades and includes supervision of studies involving more than 10,000 patients. The book is well written and demonstrates the advantages of having a limited number of authors and a narrow focus — namely, consistency of style and a cohesive philosophy. There is structural coherence, with a logical progression of the 17 chapters and minimal overlap between them. Early chapters provide overviews of gastroesophageal reflux disease (GERD) and Barrett's esophagus, followed by a review of embryological development of the upper gastrointestinal tract and of normal anatomy and histology. Subsequent chapters document the pathology of GERD at the cellular and anatomic level, with evolution through Barrett's metaplasia to adenocarcinoma. The book ends with suggestions for research strategies, discussions of the rationale for management of GERD and Barrett's esophagus, and strategies for preventing reflux-induced adenocarcinoma.

The book is compelling reading, made more so by its historical approach, as the authors trace the gradual evolution of medical thought in the field. A further strength is the literature review at the end of each chapter, where the authors summarize and offer their often strong opinions of landmark studies in the field.

The authors believe that the increasing incidence of esophageal cancer is at least partly a consequence of a failed medical approach to the precursor conditions of GERD and Barrett's esophagus. This problem, they write, stems from fundamentally flawed definitions of both conditions that underestimate their true prevalence, as do current practice guidelines stating that there is no need for biopsy of endoscopically normal gastroesophageal junctions. The authors argue that esophageal adenocarcinoma is preventable and that recognition of earlier stages in the reflux-to-adenocarcinoma sequence would allow for interventions that might heavily influence its incidence. They also contend that the current therapeutic approach to GERD — acid-suppressive therapy — might be promoting the development of adenocarcinoma and that GERD should be managed with antireflux surgery.

The authors therefore propose several radical changes in the field, including new criteria for defining the gastroesophageal junction, GERD, and Barrett's esophagus, as well as a new classification system for adenocarcinoma of this region. They recommend a new biopsy protocol for patients with GERD who are undergoing endoscopy. They call for a radical overhaul in our current thinking and urge that GERD be viewed as a premalignant condition and treated with an appropriately aggressive approach.

Criticisms of this book are minimal. Several illustrations are faint and sometimes blurred, appearing to be scanned or photographed images that have not reproduced well. The authors are very opinionated, and many readers will not agree with their views, several of which are controversial. Although many of their ideas are indeed provocative and deviate from current consensus, we feel that the authors' vast experience gives their opinions importance — their perspective must be carefully considered. We therefore feel that this book is essential reading for anyone with an interest in esophageal disease, and particularly in GERD and esophageal adenocarcinoma.

Subhas Banerjee, M.D.
Jacques Van Dam, M.D., Ph.D.
Stanford University School of Medicine, Stanford, CA 94305
subhas.banerjee@stanford.edu