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Screening and Surveillance of Barrett Esophagus Might Not Be Justifiable

A large, population-based study adds to a growing body of evidence that the incidence of cancer or dysplasia in patients with BE is lower than previously suggested.

Barrett esophagus (BE) is a precancerous condition, and endoscopic biopsies to screen for high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) are recommended based on previously reported incidence rates of HGD and EAC of 0.5% and 0.9%, respectively. However, recent study findings suggest that incidence rates are lower than previously reported, thereby questioning the need for surveillance.

To estimate the incidence of HGD or EAC in patients with BE in a population-based cohort, researchers analyzed data from pathology and cancer registries on 11,028 patients in Denmark who had been diagnosed with BE through endoscopic biopsy. Patients were excluded from the analysis if HGD or EAC was identified at the index exam or if EAC was diagnosed within the first year of the study.

During a median 5.2 years of follow-up, the incidence of EAC was 1.2 cases per 1000 person-years and was three times higher in men than women (1.5 vs. 0.5). The incidence rate of HGD or EAC combined was 2.6 cases per 1000 person-years, yielding a standardized incidence ratio of 21.1. Diagnosis of low-grade dysplasia at baseline or during follow-up increased the risk for HGD or EAC fivefold.

Comment: Although this study reaffirms that BE is a significant risk factor for development of EAC, the absolute risk of 0.12% is considerably lower than earlier estimates of 0.8% and, more recently, 0.5%, which have been used as a basis for current screening and surveillance recommendations. These risk estimates have been progressively decreasing as issues of publication bias, duplicate counting, and inclusion of prevalent cancers have been taken into account. Another recent, large population-based study estimated incidence of EAC at 0.13% (J Natl Cancer Inst 2011; 103:1049). On the basis of these estimates, the relative risk for EAC in patients with BE compared with the general population drops from a previously cited range of 30 to 40 to approximately 11. With regard to surveillance, a prior study estimated that the annual incidence of EAC must be >1.9% per year for surveillance of nondysplastic BE at 5-year intervals (the current recommendation is 3 years) to be cost-effective (Ann Intern Med 2003; 138:176). Furthermore, current data demonstrate a normal life expectancy for patients with BE, among whom cause of death is rarely attributed to EAC, regardless of surveillance (Gastroenterology 2004; 127:310). For these reasons, the rationale for current screening and surveillance recommendations should be questioned. The overall low rate of progression from nondysplastic BE to HGD or cancer reinforces the current expert consensus that routine endoscopic ablation of nondysplastic BE is not justifiable.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology October 21, 2011

Citation(s):

Hvid-Jensen F et al. Incidence of adenocarcinoma among patients with Barrett's esophagus. N Engl J Med 2011 Oct 13; 365:1375.

• Medline abstract (Free)

Kahrilas PJ. The problems with surveillance of Barrett's esophagus. N Engl J Med 2011 Oct 13; 365:1437.

• Medline abstract (Free)

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