10Should patients with Barrett's oesophagus be kept under surveillance? The case for
Introduction
Oesophageal adenocarcinoma is a lethal disease with a median survival of less than 1 year and limited improvement in mortality over the last 30 years.1 With an estimated incidence of 6500 in the United States, oesophageal adenocarcinoma is not the most prevalent of malignancies but its incidence is increasing more rapidly than that of any other gastrointestinal cancer in the Western world.2, 3, 4, 5, 6
Ideally, strategies directed at preventing deaths from oesophageal adenocarcinoma would be based on preventing the development of oesophageal adenocarcinoma; however, despite progress in our understanding of the mechanisms underlying the development of oesophageal malignancy,2, 7 initial management strategies are still based on early detection of malignancy or its precursors. Predictors of oesophageal adenocarcinoma include gastro-oesophageal reflux disease (GERD), smoking, male gender, age, ethnicity and alcohol. GERD is too common to be used as a basis for screening or surveillance and is not necessarily highly predictive of oesophageal adenocarcinoma; similarly, other risk factors are also too common to be used as a basis for screening.
It is generally accepted that oesophageal adenocarcinoma arises predominantly, if not exclusively, in Barrett's oesophagus8, 9, 10 and that there is a stepwise progression from metaplasia, through dysplasia to invasive carcinoma.7 Indeed, it is arguable that Barrett's oesophagus is, currently, the only clinically useful predictor of oesophageal adenocarcinoma.11 The existence of this relationship is supported, in part, by the observations that Barrett's oesophagus is associated with gastro-oesophageal reflux disease and that Barrett's oesophagus is associated with more severe, more frequent and more prolonged GERD symptoms. Furthermore, there is increased reporting or diagnosis of Barrett's oesophagus12, 13, 14, 15 analogous to the reported increase in prevalence of oesophageal adenocarcinoma.16, 17
Given the presence of a relatively common, lethal disease and the availability of potential markers of disease susceptibility, there is an opportunity for population screening to identify individuals in whom the disease or a marker is present and for continued surveillance of those in whom the disease marker has been identified.
Section snippets
Screening
Screening refers to testing to detect potential disease in a person without signs or symptoms of disease.18 Population screening for oesophageal adenocarcinoma and Barrett's oesophagus is highly controversial although there are cost-modelling studies which suggest that it might be cost-effective under certain circumstances.19, 20, 21 Widespread screening of the general population is not accepted as the overall prevalence of Barrett's oesophagus is only 1.5% in the general population22 rising to
Surveillance
Surveillance refers to periodic testing to detect disease or potential disease in a person at high risk for disease. For patients with Barrett's oesophagus, the aim is early detection of oesophageal adenocarcinoma or high grade dysplasia such that therapeutic intervention will produce an improvement in health outcomes for those undergoing surveillance compared with those who are not.18 Surveillance of patients with Barrett's oesophagus is controversial although the number of individuals
Conclusion
The absence of unequivocal evidence to support surveillance does not constitute proof that surveillance is ineffective and our current state of knowledge should not preclude surveillance. It would be nihilistic not to offer surveillance to Barrett's oesophagus patients but, by the same token, it would unjustified and inappropriate to enrol all Barrett's oesophagus patients in a surveillance program. Ideally, surveillance should be considered for all patients with Barrett's oesophagus and the
Uncited reference
103
References (124)
- et al.
Temporal trends (1973–1997) in survival of patients with esophageal adenocarcinoma in the United States: a glimmer of hope?
Am J Gastroenterol
(2003) - et al.
Seminar: Barrett's metaplasia
Lancet
(2000) - et al.
Barrett's esophagus: development of dysplasia and adenocarcinoma
Gastroenterology
(1989) - et al.
Focus on Barrett's esophagus and esophageal adenocarcinoma
Cancer Cell
(2004) - et al.
Increasing Barrett's oesophagus: education, enthusiasm or epidemiology?
Lancet
(1997) - et al.
Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction
Gastroenterology
(1993) - et al.
Barrett's esophagus: a new look at surveillance based on emerging estimates of cancer risk
Am J Gastroenterol
(1999) - et al.
Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease
Clin Gastroenterol Hepatol
(2004) - et al.
Prevalence of Barrett's esophagus in the general population: an endoscopic study
Gastroenterology
(2005) - et al.
Preoperative prevalence of Barrett's esophagus in esophageal adenocarcinoma: a systematic review
Gastroenterology
(2002)
AGA Chicago Workshop. A critical review of the diagnosis and management of Barrett's esophagus
Gastroenterology
American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma
Gastroenterology
Is there publication bias in the reporting of cancer risk in Barrett's esophagus?
Gastroenterology
Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis
Gastroenterology
Extent of high-grade dysplasia in Barrett's esophagus correlates with risk of adenocarcinoma
Gastroenterology
The diagnosis of low-grade dysplasia in Barrett's esophagus and its implications for disease progression
Am J Gastroenterol
The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: report on the Cleveland Clinic Barrett's Esophagus Registry
Am J Gastroenterol
Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett's multifocal high-grade dysplasia or adenocarcinoma
Am J Gastroenterol
Predictors of progression to cancer in Barrett's esophagus: baseline histology and flow cytometry identify low- and high-risk patient subset
Am J Gastroenterol
Dysplasia as a predictive marker for invasive carcinoma in Barrett esophagus: a follow-up study based on 138 cases from a diagnostic variability study
Hum Pathol
Long-term nonsurgical management of Barrett's esophagus with high grade dysplasia
Gastroenterology
Long-term endoscopic surveillance of patients with Barrett's esophagus. Incidence of dysplasia and adenocarcinoma. A prospective study
Am J Gastroenterol
The perception of cancer risk in patients with prevalent Barrett's esophagus enrolled in an endoscopic surveillance program
Gastroenterology
Essink-Bot MLE for the CYBAR Study Group. Patients with Barrett's esophagus perceive their risk of developing esophageal adenocarcinoma as low
Gastrointest Endosc
Does cancer risk affect health-related quality of life in patients with Barrett's esophagus?
Gastrointest Endosc
Unsedated transnasal endoscopy accurately detects Barrett's esophagus and dysplasia
Gastrointest Endosc
Blinded comparison of esophageal capsule endoscopy versus conventional endoscopy for a diagnosis of Barrett's esophagus in patients with chronic gastroesophageal reflux
Gastrointest Endosc
Surveillance and survival in Barrett's adenocarcinomas: a population based study
Gastroenterology
Screening and surveillance in Barrett's esophagus. A call to action
Clin Gastroenterol Hepatol
The wizards of odds: cost effectiveness model, Barrett's screening and surveillance guidelines
Clin Gastroenterol Hepatol
Screening for high grade dysplasia in gastro-esophageal reflux disease: is it cost effective?
Am J Gastroenterol
Outcome of adenocarcinoma arising in Barrett's esophagus in endoscopically surveyed and non-surveyed patients
J Thorac Cardiovasc Surg
Endoscopic surveillance of Barrett's esophagus: does it help?
J Thorac Cardiovasc Surg
A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD
Gastrointest Endosc
The development and validation of an endoscopic grading system for Barrett's esophagus – the Prague C and M criteria
Gastroenterology
Genetics and prevention of oesophageal adenocarcinoma
Recent Results Cancer Res
Rising incidence of adenocarcinoma of the esophagus and gastric cardia
JAMA
Cancer statistics
CA Cancer J Clin
Changing patterns in the incidence of esophageal and gastric carcinoma in the United States
Cancer
Barrett's esophagus specialist clinic: what difference can it make?
Dis Esoph
Adenocarcinoma complicating columnar epithelium-lined (Barrett's) esophagus
Am J Clin Pathol
The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus
Am J Clin Pathol
Secular trends in the epidemiology and outcome of Barrett's oesophagus in Olmstead county
Gut
Increasing incidence of Barrett's oesophagus in the general population
Gut
Rising incidence of clinically evident Barrett's oesophagus in The Netherlands: a nation-wide registry of pathology reports
Scand J Gastroenterol
Rising incidence of adenocarcinoma of the esophagus and gastric cardia
JAMA
Surveying the case for surveillance
Gastroenterology
Screening and surveillance for Barrett's esophagus in high-risk groups: a cost-utility analysis
Ann Intern Med
The prevalence of Barrett's oesophagus in a cohort of 1040 Canadian primary care patients with uninvestigated dyspepsia undergoing prompt endoscopy
Aliment Pharmacol Ther
Dysplasia and risk of further neoplastic progression in a regional Veterans Administration Barrett's cohort
Am J Gastroenterol
Cited by (8)
Mucosal resection in the upper gastrointestinal tract
2010, Techniques in Gastrointestinal EndoscopyCitation Excerpt :A systematic sequential inject and resect EMR technique with excision of a 2-3 mm cuff of normal tissue at the lesion margins is capable of creating a completely clear mucosal defect without residual adenoma, duplicating the endoscopic appearances, which can be achieved by the far more time-consuming ESD technique (Figure 1). The incidence of adenocarcinoma of the esophagus is increasing more rapidly than any other gastrointestinal cancer in the Western World.36 EMR is the preferred technique for endoscopic resection of Barrett's high-grade dysplasia or early cancer.
Elective surveillance gastroscopy in Barrett's oesophagus: A case study and review of the clinical endoscopist's role
2018, Gastrointestinal NursingYield of Repeat Endoscopy in Barrett’s Esophagus with No Dysplasia and Low-Grade Dysplasia: A Population-Based Study
2016, Digestive Diseases and SciencesThe changing face of esophageal cancer
2010, CancersEndoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: An essential staging procedure with long-term therapeutic benefit
2010, American Journal of Gastroenterology