Abstract
Goals
Determine the rates of follow-up, incident rate of cancer during surveillance, and changes in pathologic grade of patients with Barrett’s esophagus during surveillance in a gastroenterology practice without a formal surveillance program.
Background
Barrett’s esophagus is a pre-malignant condition. Surveillance endoscopy (SE) is recommended in order to detect and treat high-grade dysplasia and esophageal adenocarcinoma early and prevent deaths. SE has not been shown to have mortality benefit and several studies have questioned its cost-effectiveness. Most gastroenterology practices do not have a surveillance program for Barrett’s esophagus. The few that exist are only in very specialized and funded programs. Little information exists on outcomes in patients with Barrett’s esophagus outside of these well-structured surveillance programs.
Study
A retrospective analysis of a cohort of patients with Barrett’s esophagus diagnosed and surveyed between 1995 and 2005 at a Veterans Affairs medical center. Data were collected on age, body mass index, and race. Patients who missed their SE by 6 months or more and those that missed their SE by twice the recommended intervals or more were identified and analyzed for changes in pathologic grades.
Results
A total of 472 patients were diagnosed with Barrett’s esophagus or had SE between 1995 and 2005. Three hundred and five patients only had one endoscopy and biopsy. They did not have follow-up surveillance endoscopies and biopsies. Two patients were excluded from the final analysis: one had an esophagectomy after an index diagnosis of high-grade dysplasia, and one had a diagnosis of esophageal adenocarcinoma 2 days after an initial impression of Barrett’s esophagus. There were 165 patients with Barrett’s metaplasia or dysplasia who had SE more than once and were included in the final analysis. Overall, 53.3% had no change in pathologic grade, 35.2% regressed to a lower pathologic grade, and 11.5% progressed to a higher grade. None (0/165, 0%) progressed to esophageal adenocarcinoma; 3.6% (6/165) progressed to high-grade dysplasia and 11.5% (19/165) regressed to normal mucosa. Forty-four patients missed their SE by 6 months or more. Of these, 50% regressed, 40.9% had no change, and 9.1% progressed. Four patients regressed to normal mucosa, one progressed to high-grade dysplasia and none progressed to esophageal adenocarcinoma. Twenty-three patients missed their SE by twice the recommended intervals or more. Of these, 60.9% regressed, 34.8% did not change, and 4.3% progressed. None progressed to esophageal adenocarcinoma or high-grade dysplasia but three regressed to normal mucosa. After adjusting for age and body mass index, patients with low-grade dysplasia are nearly seven times more likely to miss their endoscopy by twice the recommended intervals or more (OR 6.56, P-value 0.03).
Conclusions
Most veteran patients with Barrett’s esophagus do not undergo surveillance endoscopies. Veteran patients with Barrett’s esophagus undergoing SE rarely progress to high-grade dysplasia or esophageal adenocarcinoma. Veteran patients with Barrett’s esophagus who have longer SE up to twice the recommended intervals because they missed their scheduled SE did not have a worse outcome when compared to the general Barrett’s esophagus surveillance group. Veteran patients with low-grade dysplasia are most likely to miss their SE by twice the recommended intervals or more, though the reason for this is unknown.
Similar content being viewed by others
References
Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103:788–797. doi:10.1111/j.1572-0241.2008.01835.x.
Bresalier R. Barrett’s metaplasia: defining the problem. Semin Oncol. 2005;32:21–24. doi:10.1053/j.seminoncol.2005.07.021.
Ronkainen J, Aro P, Storskrubb T, et al. Prevalence of Barrett’s esophagus in the general population: an endoscopic study. Gastroenterology. 2005;129:1825–1831. doi:10.1053/j.gastro.2005.08.053.
Haggitt RC, Tryzelaar J, Ellis H, et al. Adenocarcinoma complicating columnar epithelium-lined (Barrett’s) esophagus. Am J Clin Pathol. 1978;90:1–5.
Haggitt RC. Barrett’s esophagus, dysplasia, and adenocarcinoma. Hum Pathol. 1994;25:982–993. doi:10.1016/0046-8177(94)90057-4.
Miros M, Kerlin P, Walker N. Only patients with dysplasia progress to adenocarcinoma in BE. Gut. 1991;32:1441–1446. doi:10.1136/gut.32.12.1441.
Streitz JM Jr, Ellis FH Jr, Tilden RL, et al. Endoscopic surveillance of Barrett’s esophagus: a cost-effectiveness comparison with mammographic surveillance for breast cancer. Am J Gastroenterol. 1998;93:911–915. doi:10.1111/j.1572-0241.1998.00275.x.
Eloubeidi MA, Homan RK, Martz MD, et al. A cost analysis of outpatient care for patients with Barrett’s esophagus in a managed care setting. Am J Gastroenterol. 1999;94:2033–2036. doi:10.1111/j.1572-0241.1999.01274.x.
Wright TA, Gray MR, Morris AI, et al. Cost effectiveness of detecting Barrett’s cancer. Gut. 1996;39:574–579. doi:10.1136/gut.39.4.574.
Achkar E, Carey W. The cost of surveillance for adenocarcinoma complicating Barrett’s esophagus. Am J Gastroenterol. 1988;83:291–294.
Provenzale D, Schmitt C, Wong JB. Barrett’s esophagus: a new look at surveillance based on emerging estimates of cancer risk. Am J Gastroenterol. 1999;94:2043–2053. doi:10.1111/j.1572-0241.1999.01276.x.
Provenzale D, Kemp JA, Arora S, et al. A guide for surveillance of patients with Barrett’s esophagus. Am J Gastroenterol. 1994;89:670–680.
Inadomi JM, Sampliner R, Lagergren J, et al. Screening and surveillance for Barrett esophagus in high-risk groups: a cost utility analysis. Ann Intern Med. 2003;138:176–186.
Somerville M, Garside R, Pitt M, et al. Surveillance of Barrett’s oesophagus: is it worthwhile? Eur J Cancer. 2008;44:588–599. doi:10.1016/j.ejca.2008.01.015.
Corley DA, Levin TR, Habel LA, et al. Surveillance and survival in Barrett’s adenocarcinomas: a population-based study. Gastroenterology. 2002;122:633–640. doi:10.1053/gast.2002.31879.
Cooper GS. Endoscopic screening and surveillance for Barrett’s esophagus: can claims data determine its effectiveness? Gastrointest Endosc. 2003;57(7):914–915. doi:10.1016/S0016-5107(03)70029-7.
Dellon ES, Shaheen NJ. Does screening for Barrett’s esophagus and adenocarcinoma of the esophagus prolong survival? J Clin Oncol. 2005;23:4478–4482. doi:10.1200/JCO.2005.19.059.
Shaheen NJ, Dulai GS, Ascher B, et al. Effect of a new diagnosis of Barrett’s esophagus on insurance status. Am J Gastroenterol. 2005;100:577–580. doi:10.1111/j.1572-0241.2005.41422.x.
Falk GW, Ours TM, Richter J. Practice patterns for surveillance of Barrett’s esophagus in the United States. Gastrointest Endosc. 2000;52:197–203. doi:10.1067/mge.2000.107728.
Gross GP, Canto MI, Hixson J, et al. Management of Barrett’s esophagus: a national study of practice patterns and cost implications. Am J Gastroenterol. 1999;94(12):3440–3447. doi:10.1111/j.1572-0241.1999.01606.x.
Rubenstein JH, Saini SD, Kuhn L, et al. Influence of malpractice history on the practice of screening and surveillance for Barrett’s esophagus. Am J Gastroenterol. 2007;102:1–8. doi:10.1111/j.1572-0241.2007.01057.x.
Yousef F, Cardwell C, Cantwell M, et al. The incidence of esophageal cancer and high-grade dysplasia in Barrett’s esophagus: a systematic review and meta-analysis. Am J Epidemiol. 2008;168:237–249. doi:10.1093/aje/kwn121.
Thomas T, Abrams KR, De Caestecker JS, et al. Meta analysis: cancer risk in Barrett’s esophagus. Aliment Pharmacol Ther. 2007;26:1465–1477.
Shaheen NJ, Crosby MA, Bozymski EM, Sandler RS. Is there publication bias in the reporting of cancer risk in Barrett’s esophagus? Gastroenterology. 2000;119:333–338. doi:10.1053/gast.2000.9302.
Sampliner RE. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol. 2002;97:1888–1895. doi:10.1111/j.1572-0241.2002.05910.x.
Deviere J, Buset M, Dumonceau JM, et al. Regression of Barrett’s epithelium with omeprazole. N Engl J Med. 1989;320:1497–1498.
Malesci A, Savarino V, Zentilin P, et al. Partial regression of Barrett’s esophagus by long-term therapy with high-dose omeprazole. Gastrointest Endosc. 1996;44:700–705. doi:10.1016/S0016-5107(96)70055-X.
Weston AP, Badr AS, Hassanein RS. Prospective multivariate analysis of factors predictive of complete regression of Barrett’s esophagus. Am J Gastroenterol. 1999;94:3420–3426. doi:10.1111/j.1572-0241.1999.01603.x.
Wilkinson SP, Biddlestone L, Gore S, et al. Regression of columnar-lined (Barrett’s) esophagus with omeprazole 40 mg daily: results of 5 years of continuous therapy. Aliment Pharmacol Ther. 1999;13:1205–1209. doi:10.1046/j.1365-2036.1999.00593.x.
Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology. 2006;131:1392–1399. doi:10.1053/j.gastro.2006.08.032.
Horwhat JD, Baroni D, Maydonovitch C, et al. Normalization of intestinal metaplasia in the esophagus and esophagogastric junction: incidence and clinical data. Am J Gastroenterol. 2007;102:497–506. doi:10.1111/j.1572-0241.2006.00994.x.
Schnell TG, Sontag SJ, Chejfec G, et al. Long-term non-surgical management of Barrett’s esophagus with high-grade dysplasia. Gastroenterology. 2001;120:1607–1619. doi:10.1053/gast.2001.25065.
El-Serag HB, Aguirre TV, Davis S, et al. Proton pump inhibitors are associated with reduced incidence of dysplasia in Barrett’s esophagus. Am J Gastroenterol. 2004;99:1877–1883. doi:10.1111/j.1572-0241.2004.30228.x.
Hillman LC, Chiragakis L, Shadbolt B, et al. Proton pump inhibitor therapy and the development of dysplasia in patients with Barrett’s oesophagus. Med J Aust. 2004;180(8):387–391.
Overholt BF, Lightdale CJ, Wang KK, et al. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial. Gastrointest Endosc. 2005;62:488–498. doi:10.1016/j.gie.2005.06.047.
Montgomery E. Is there a way for pathologists to decrease interobserver variability in the diagnosis of dysplasia? Arch Pathol Lab Med. 2005;129:174–176.
Yearsley MM, Haggitt RC, Taylor SL, et al. Reinterpretation of high-grade dysplasia in Barrett’s esophagus: a multicenter international phase III trial in 485 patients. Mod Pathol. 2006;19(suppl 19):A569. (Abstract).
Downs-Kelly E, Mendelin JE, Bennett AE, et al. Poor interobserver agreement in the distinction of high-grade dysplasia and adenocarcinoma in pretreatment Barrett’s esophagus biopsies. Am J Gastroenterol. 2008;103:2333–2340. doi:10.1111/j.1572-0241.2008.02020.x.
Hanna S, Rastogi A, Weston AP, et al. Detection of Barrett’s esophagus after endoscopic healing for erosive esophagitis. Am J Gastroenterol. 2006;101:1416–1420. doi:10.1111/j.1572-0241.2006.00631.x.
Corley DA, Kerlikowske K, Verma R, et al. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. Gastroenterology. 2003;124:47–56. doi:10.1053/gast.2003.50008.
Vaughan TL, Dong LM, Blount P, et al. Non-steroidal anti-inflammatory drugs and risk of neoplastic progression in Barrett’s oesophagus: a prospective study. Lancet Oncol. 2005;6:945–952. doi:10.1016/S1470-2045(05)70431-9.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ajumobi, A., Bahjri, K., Jackson, C. et al. Surveillance in Barrett’s Esophagus: An Audit of Practice. Dig Dis Sci 55, 1615–1621 (2010). https://doi.org/10.1007/s10620-009-0917-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-009-0917-y