An Article in The Times 27/1/2015

How do GPs differentiate between heartburn and early stomach cancer? The truth is, we can't.

Dr. Mark Porter.

Indigestion that lasts more than three weeks might be a sign of cancer. That's the core message of a new public health campaign launched this week and GPs are bracing themselves for an influx of anxious patients. How, though are we going to reassure them?

Most cases of indigestion/heartburn ( the terms are interchangeable) are nothing to do with cancer. It is most common in adults over 40 and is caused by a weakness in the valve at the top of the stomach that allows acidic gastric juices to travel backwards (reflux) into the lower gullet (oesophagus). While the stomach has a special lining to protect it from acid, the tender gullet doesn't and the resulting inflammation leads to heartburn.

The classic story is of a middle-aged man or woman who gets discomfort behind the breast bone, often worse after meals or when lying in bed. Other common complaints include a tendency to belch, an irritating dry cough and being more aware than normal of cold, hot or strong alcoholic drinks as they are swallowed. By the time most of my patients me they have been suffering for months and sometimes for years.

It is this delay in seeking medical advice that Public Health England hopes to address because a tiny proportion of those who appear to have simple reflux will in fact have cancers of the stomach or oesophagus. In the early stages both types of cancer often mimic reflux and to compound matters their symptoms often respond well to the same antacid medication. And by the time you develop more telltale signs - such as difficulty swallowing, unexplained weight loss, vomiting blood or passing black stools ( a sign of internal bleeding )- it is often too late.

So how do GPs differentiate between someone with simple heartburn and those with an early cancer? The honest truth is we can't. The only way to confirm the diagnosis is to refer everyone who presents with persistent heartburn for an endoscopy ( passing a camera into the gullet and stomach). And without this it all comes down to playing a game of chance where the odds are stacked heavily against cancer. In the past five years I have had two patients with cancer of the gullet but during the same period I have treated hundreds for reflux-related heartburn. It depends how lucky you feel.

I am not being glib, just pragmatic. Despite the best intentions of campaigns such as this the NHS simply couldn't cope with referring everyone with persistent heartburn and no one has yet managed to draw up reliable guidelines to help sort the wheat from the chaff. The National Institute for Health And Care Excellence (Nice) has had a go but remains on the fence, leaving the final decision to GPs whom it suggests should "consider" referring people with reflux for endoscopy. Thanks for that.

These reservations aside, I support the campaign, not least because cancer isn't the only reason why persistent heartburn sufferers should seek medical advice. Your GP will be able to prescribe better medication to control your symptoms and check for underlying factors that may be exacerbating the problem such as anti-inflammatory drugs like aspirin or ibuprofen and the bacterial infection Helicobacter pylori. However, if you are expecting your GP to guarantee that you don't have cancer without doing an endoscopy then I'm afraid you are going to be disappointed.

On a more reassuring note I should add I have been plagued with heartburn for seven years but only recently had an endoscopy (I was given the all-clear). My GP got it right, as most will.

©Dr Mark Porter / The Times 01 2015