Disease of the month: Barrett’s Oesophagus

Paul Gyseman looks at the insurance implications of this oesophageal condition and why underwriters need to be alert when assessing the long-term risks of this common disclosure

“What a feeling” sings the female police officer as she directs traffic in the TV advert for Gaviscon.

Well, that ‘feeling’ she is singing about is the relief that certain medications bring to the symptoms of gastro-oesophageal reflux, commonly known as heartburn or indigestion, which cause misery to many people on a daily basis.

Barrett’s oesophagus is a long-term complication of gastro-oesophageal reflux disease (GORD), which is a common disclosure on insurance applications and often mentioned in medical reports.

Cause of illness

Barrett’s oesophagus is generally caused by long-term acid reflux, whereby acid from the stomach regurgitates upwards into the oesophagus.

It was named after thoracic surgeon Norman Barrett who described the condition in 1950.

The beginning of this condition is when the valve that protects the oesophagus from stomach acids becomes weak or gets moved from its position, allowing the acid reflux to occur.

Over time, this reflux causes damage to the lower part of the oesophagus, and subsequently leads to changes to the cellular activity in the oesophagus, making them more like the cells that are found in the stomach and small intestine.

It is estimated that Barrett’s oesophagus affects two per cent of the UK population and is on the increase due to lifestyle factors associated with smoking, drinking and diet.

Many people who suffer from Barrett’s oesophagus do not always report any particular symptoms.

However, those that do get symptoms tend to suffer with heartburn, indigestion, dysphagia (problems with swallowing), ulcers and stricture (narrowing), which can be aggravated by eating certain fatty or spicy foods, alcohol and smoking.

The biggest complication that results from Barrett’s oesophagus is oesophageal cancer, which is why underwriters need to be fully aware of their applicants’ medical history because Barrett’s oesophagus is considered to be a pre-malignant condition.

Being a pre-malignant condition means that at some point it can develop into adenocarcinoma, which is bad news from an insurance perspective.

Men are more likely to develop Barrett’s oesophagus, especially those over 50 and who have central obesity.

There is a link between central obesity – abdominal obesity, colloquially known as belly fat – and Barrett’s oesophagus that is not fully understood, but explains why men have a higher incidence (women tend to have peripheral obesity – hips and thighs – whereas men tend to have central obesity).

So how is Barrett’s oesophagus ­diagnosed? Most people who are diagnosed with Barrett’s oesophagus undergo a procedure known as endoscopy or ­gastroscopy.

These procedures involve passing a small camera down through the mouth and into the oesophagus, stomach and duodenum.

The operator will be able to see if there are any areas of inflammation, ulceration or cancer.

Biopsies will be taken to microscopically look at the cells to establish if there is metaplasia or dysplasia and if so, what type (colonic or gastric) and the grade.

The type of cellular changes will dictate which form of treatment is best to follow.

Over a period of many years, if the chronic acid reflux is allowed to go untreated, the damage to the lining of the oesophagus occurs and the changes to the cells in the oesophageal lining begin (metaplasia).

This “change” is described as being “dysplastic”, which in turn can be either low grade or high grade.

Non or low grade dysplasia is usually monitored closely, whereas high grade dysplasia or carcinoma needs immediate treatment, usually surgery.

Adenocarcinoma of the oesophagus has a very poor prognosis with a mortality rate approaching 85% therefore risk assessment is crucial.

Sufferers of Barrett’s oesophagus are something like five times more likely to develop cancer of the oesophagus.

Smokers have an even higher rate, which is why underwriters need to take account of all relevant risk factors.

There is also a familial component to this condition and numerous studies have indicated that genetics play a part, albeit complex, in the development of Barrett’s oesophagus and adenocarcinoma.

Underwriting implications

Generally speaking, those who suffer with simple GORD are of no major risk and so long as there are no other complicating factors, applications can be accepted at the standard rate of premium for all classes of protection products.

Fully understanding the nature of the treatment and the severity of the ­symptoms helps underwriters in assessing the risks here.

However, Barrett’s oesophagus brings a different risk profile and terms would vary according to age, level of metaplasia/dysplasia, if there has been stricture and whether there were complicating factors such as smoking.

Life cover terms may be available with a range of ratings depending upon the specific circumstances. But in many instances, critical or serious illness will not be available because of the high risk of malignancy, although an exclusion may be available in the best of these cases.

A targeted GPR may be requested as well as the results of endoscopic examination and biopsy, which will bring to the underwriter’s attention the actual level of cellular changes referred to earlier in this article.

A family history of Barrett’s oesophagus in first degree relatives will also be taken into account.

Terms for those with adenocarcinoma are unlikely to be available given the very poor prognosis.

So the female police officer who is singing “What a feeling” knows exactly what the benefits of medication are for the symptoms of acid reflux.

Even if it doesn’t mean sending in the fire brigade to “neutralise that acid”.  

Paul Gyseman is director for underwriting and claims at PruProtect