I have come across an interview with a European gastroenterologist (apparently from 2006) where he argues that in cases where a reflux disease does not cause typical symptoms even the presence of a Barrett's esophagus (BO) does not indicate prescription of proton-pump inhibitors (PPIs), because they have (the reduction of stomach acid production caused by them has) not yet been shown to be effective in preventing esophageal carcinoma.

I am wondering whether this is a mainstream or a minority view among specialists and what literature the interviewee may have been referring to. (E.g. this meta-analysis from 2014 apparently concludes with different recommendations.)

  • Excellent question! Can you link to the interview? The use of PPI is a hot topic under extensive debate during the recent years.
    – DoctorWhom
    Aug 19 '19 at 22:27
  • @DoctorWhom Unfortunately, I can't locate it online right now, but I'll give it another try.
    – Drux
    Aug 20 '19 at 2:51
  • When you speak of esophageal carcinoma, are you referring to adenocarcinoma or squamous-cell carcinoma? I ask because adenocarcinoma is associated with Barrett's esophagus more so than squamous-cell.
    – BillDOe
    Aug 20 '19 at 18:54

Are PPIs effective in prevention of esophageal carcinoma in individuals with Barrett's esophagus? The evidence is conflicting; I listed it from yes to no.

Acid-suppressive medications and risk of oesophageal adenocarcinoma in patients with Barrett's oesophagus: a systematic review and meta-analysis (Gut, 2014):

Based on meta-analysis of observational studies, the use of PPIs is associated with a decreased risk of OAC and/or BO-HGD in patients with BO. None of the studies showed an increased risk of OAC. PPI use should be considered in BO, and chemopreventive trials of PPIs in patients with BO are warranted.

GERD and Peptic Ulcers (Indian Health Service, 2018):

...observational data suggest that PPIs are most effective for preventing progression of Barrett’s to cancer

Esomeprazole and aspirin in Barrett's oesophagus (AspECT): a randomised factorial trial (The Lancet, 2018):

Our data indicate that high-dose PPI (40 mg twice-daily) is better than low-dose (20 mg once-daily) for patients with Barrett's oesophagus in terms of delaying death, cancer, and dysplasia.

Chemoprevention of Barrett’s oesophagus: a step closer with PPIs and aspirin (Clinical Oncology, 2018):

On the basis of the findings from AspECT and the evidence from observational studies, we believe that PPI use in clinical practice for chemoprevention in patients with Barrett’s oesophagus is justified...The finding that aspirin was beneficial moves us one step closer to broader recommendations for aspirin use in patient with Barrett’s oesophagus and for prevention of chronic diseases in general.

Aspirin Plus PPI Prevents Esophageal Cancer (Medscape, 2018):

Combined use of aspirin and a high-dose proton pump inhibitor (PPI) protects against the development of esophageal cancer in people who are at elevated risk for the malignancy, according to the results of a major phase 3 chemoprevention trial from the United Kingdom, the Aspirin and Esomeprazole Chemoprevention in Barrett's Metaplasia (AspECT) trial.

Will a Proton Pump Inhibitor and an Aspirin Keep the Doctor Away for Patients With Barrett’s Esophagus? (Gastroenterology, 2019):

Most patients with known Barrett’s esophagus have symptomatic gastroesophageal reflux disease. The study would support using a PPI for acid suppression for such patients. Some patients lack gastroesophageal reflux disease by symptoms, endoscopic findings, or even pH testing; for these patients, the benefit is uncertain or unlikely.

Proton Pump Inhibitors Do Not Reduce the Risk of Esophageal Adenocarcinoma in Patients with Barrett's Esophagus: A Systematic Review and Meta-Analysis (PLosOne, 2017):

No dysplasia- or cancer-protective effects of PPIs usage in patients with BE were identified by our analysis.

Maintenance proton pump inhibition therapy and risk of oesophageal cancer (Cancer Epidemiology, 2018):

In conclusion, the long term use of PPIs is associated with increased risk of oesophageal adenocarcinoma in the absence of other risk factors. Long term use of PPIs should be addressed with caution.

  • This is, of course, anecdotal and applies only to me: I have been taking pantoprazole 20mg twice daily for the past 2 ½ years. I have esophageal cancer (adenocarcinoma) and a PET/CT scan detected evidence of Barrett's esophagus.
    – BillDOe
    Aug 20 '19 at 18:52

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