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Making People Better

Dr. Brian Smith helps people with acid reflux disease reduce their risk of cancer.

Dr. Brian Smith was always the analytical, problem-solving type. As a young man growing up in Southern California, he had a natural affinity for math that led him to attend college at the University of California, Santa Barbara, with plans to become an engineer.

“Unlike a lot of doctors, I didn’t come from a medical family,” he says. “In fact, I was the first in my family to even go to college.”

It was a basic anatomy class that introduced Smith to medicine, opening up an intriguing world of complexity and problem-solving potential. After college he attended medical school in Guadalajara, Mexico, where he met his wife.

“It was a new country, a new culture, and the final years were conducted entirely in Spanish, which has been really beneficial,” Smith says. “My experience there definitely inspired my desire to care for underserved populations.”

After returning home from Mexico, Smith re-assimilated into the American medical system with a fifth year of study at New York Medical College. He then matched at Harbor UCLA Medical Center for residency, where he found a mentor in Dr. Bruce Stabile, the surgery department chairman. “He singlehandedly changed my career trajectory. I was a general surgeon, and he taught me a lot about research, about cancer and about surgical oncology,” Smith says. “He also taught me to be a scholar—to look at my own outcomes and try to learn from them; always asking, ‘How can we make them better?’”

Solutions for chronic heartburn

Today Smith does double duty, working both as a general surgeon serving military veterans at the VA Long Beach Healthcare System where he serves as the Chief of Surgical Services, and as a UC Irvine Health gastrointestinal specialist at the H.H. Chao Comprehensive Digestive Disease Center. “There are all kinds of issues that affect the GI tract. It really lets you think and use your head,” he says. “I’ve always been drawn to that.”

One of the biggest puzzles Smith is working on is whether reducing chronic acid reflux can curb the incidence and risk of esophageal cancer. Acid reflux—or heartburn—is one of the most common medical conditions in the country. More than 20 percent of Americans suffer from the chronic form of reflux called gastroesophageal reflux disease (GERD), which can persist for years, sometimes silently.

I'm improving patients' quality of life—they can stop taking meds, they can eat what they want, and they can lie flat and sleep well at night.

GERD is not only painful and debilitating to some people who suffer from it, but it can also lead to esophageal cancer. The burning sensation of reflux happens because corrosive stomach acid back-washes into the esophagus, altering the inside of the lower esophagus. When the lining of the esophagus is constantly bathed in stomach acid over many years, it can undergo a cellular change to protect itself, mutating to become more like stomach tissue. This condition—called Barrett’s esophagus—lays the groundwork for cancer.

“Once you have Barrett’s, there’s some data showing that risk increases by about half a percent per year,” Smith says. “So if that goes on for 30 years, you’re looking at a 15 percent chance of getting cancer.”

And for those who develop esophageal cancer, the chances for survival are daunting. “Esophageal cancer kills about 15,000 people per year out of about 16,000 who get it. Almost all patients die from it,” Smith says. Even worse, esophageal cancer is one of only a few types of cancers for which the incidence rates are rising.

A focus on innovation

For all these reasons, finding a way to stop reflux early on is a high priority, and Smith and his UC Irvine Health colleagues are currently investigators in a multi-center trial for a new medical device called the LINX® Reflux Management System. “We’re comparing the effectiveness of this new device to proton pump inhibitor (PPI) medications to see which is better at controlling reflux,” he says.

LINX is a surprisingly simple solution to a persistent and complex problem. It’s a small titanium collar which holds beads of rare-earth magnets that the surgeon attaches like a bracelet around the bottom of the esophagus. The magnets are strong enough to hold the esophagus shut yet weak enough that swallowed food can push them open and pass through into the stomach before closing themselves back down.

Currently, the primary surgical option for GERD is a procedure called fundoplication that uses part of the stomach to tighten the same area of the esophagus. “LINX is easier to install and it gives the same results without the side effects of fundoplication,” Smith says.

The goal of the trial is to see if LINX works better than PPIs, which have been an effective and widespread GERD treatment for decades. “One problem is PPIs can obscure reflux,” Smith says. “Patients may feel better even as some acid continues to reach the esophagus, which can still lead silently to Barrett’s and possibly cancer.”

Recent studies also have shown potential connections between PPIs and problems like bone density loss, chronic kidney failure, and increased risk of infection.

“It will take years of treating reflux aggressively to look back and see if decreasing reflux actually helps reduce cancer rates,” Smith says.“But it the meantime, I’m improving patients’ quality of life—they can stop taking meds, they can eat what they want, and they can lie flat and sleep well at night. Reflux interventions are quite possibly the most impactful work I do, and I really believe there is a benefit to long-term cancer risk reduction as well.”