Former Texas Gov. Ann Richards's brief battle with esophageal cancer has raised new questions about whether more people should be screened for the deadly disease.

Esophageal cancer is one of the fastest-rising forms of cancer, but it is rarely detected early, when it is most curable. Most patients live less than a year after being diagnosed -- just 15 percent survive for at least five years. Gov. Richards lived for just six months after her diagnosis.

The form of cancer that killed Gov. Richards -- squamous cell -- often is associated with a history of heavy alcohol and tobacco use. Gov. Richards was a recovering alcoholic and former smoker. The fastest-rising form of esophageal cancer -- adenocarcinoma -- is strongly linked with years of chronic heartburn and acid-reflux disease.

But whether people should be screened for the disease remains a matter of heated debate in the medical community because it isn't clear whether screening would be cost effective or make a meaningful difference in long-term survival rates. The medical community routinely screens for a range of diseases in high-risk populations, but there's no routine screening for people at high risk for "one of the deadliest tumors known -- esophageal cancer," says Scott Swanson, chief of thoracic surgery at Mount Sinai School of Medicine in New York. "We need to consider (screening) for high-risk groups."

The best way to screen for esophageal cancer is with an endoscopy. During an endoscopy, the patient is sedated while a lighted tube is put down the throat to look for changes in the esophagus that might signal cancer. The procedure costs about $1,000 and is typically covered by insurance. Although an endoscopy is considered a safe procedure, there are always risks associated with anesthesia and a slight risk of bleeding or infection after the procedure. The main concern about screening endoscopy is cost and that fact that the vast majority of screening endoscopies wouldn't find cancer, but would tax the resources of an already overburdened health-care system.

Currently there are more than 14,000 cases of esophageal cancer each year. Considering that there are 40 million current smokers, 100 million former smokers and an estimated 40 million people who suffer weekly bouts of heartburn, the question is who among these groups is at highest risk for esophageal cancer and should be screened.

There are no simple answers. But we do know risk for the squamous-cell esophageal cancer is dramatically higher with long-term use of both tobacco and alcohol. It's six times more likely to occur in African-American men than in whites.

We also know that people with chronic heartburn -- or gastroesophageal reflux disease, known as GERD -- are at higher risk for esophageal cancer. Many doctors believe patients with a history of chronic heartburn for five years or more should be screened for precancerous changes in the lining of the esophagus -- a condition known as Barrett's esophagus. It has been estimated that from 5 percent to 10 percent of Barrett's patients will go on to develop cancer. Eating a diet low in fruits and vegetables, or weighing 20 to three pounds more than your ideal weight, also has been linked with increased risk for esophageal cancer.

Most doctors agree that patients already diagnosed with Barrett's should get regular screenings for cancer. The more difficult question is who among GERD sufferers should undergo screening endoscopy. Some researchers have suggested a one-time screening for anyone who has chronic reflux, particularly if the problem is serious enough to warrant long-term drug therapy. Others believe only those at highest risk should be screened -- men older than 40 who have suffered reflux symptoms at least twice a week for five years. Patients who develop GERD for the first time after age 65 also should consider screening.

One answer to the screening question is to perform a screening endoscopy at the same time a patient is undergoing a screening colonoscopy, which typically happens around the age of 50. The patient already is sedated and the gastroenterologist who performs the colonoscopy also typically specializes in endoscopy. Some studies have shown that Barrett's is detected in as many as one out of four patients screened this way.

Finding esophageal cancer early makes a dramatic difference in survival because patients can qualify for surgical removal of the esophagus and sometimes the surrounding lymph nodes. An April study published in the Journal of the American College of Surgeons reviewed the medical records of 263 patients who underwent the surgery from 1992 through 2002. The overall survival rate during the last five years of the study was 50.4 percent, and jumped to 81 percent for patients who were diagnosed at Stage I.

The results show patients can benefit from early detection, says Jeffrey H. Peters, surgery-department chairman at the University of Rochester Medical Center and a study co-author. "I believe we should be screening high-risk populations," says Dr. Peters. "The principle is clear -- the earlier you pick up a cancer the more likely you are to cure it. There's very little debate about that."