Clinical Question: What is the yield of regular endosopic surveillance in patients with newly diagnosed Barrett's esophagus?
Setting: Outpatient (specialty)
Study Design: Cohort (prospective)
Synopsis: Barrett's esophagus is thought to be a step in the progression from normal epithelium to low-grade dysplasia, high-grade dysplasia and, finally, esophageal adenocarcinoma. Barrett's esophagus is associated with symptomatic gastroesophageal reflux disease (GERD) and affects approximately 1 percent of patients older than 60 years, although evidence from other studies suggests that it may be almost as common in patients without GERD. Current guidelines from the American College of Gastroenterology recommend routine endoscopic surveillance of patients with Barrett's esophagus, although there is no evidence from randomized trials that this surveillance improves patient-oriented outcomes.
This Italian study identified 177 patients with newly diagnosed Barrett's esophagus. Three of the patients were excluded because they had high-grade dysplasia, and eight were lost to follow-up, leaving 166 for the final study group. The mean age of the patients was 59.9 years; 81 percent were men, 76 percent had symptoms of GERD, and 16 had low-grade dysplasia. The mean segment length of Barrett's esophagus was less than 3 cm (associated with lower cancer risk) in 35 percent of patients and 3 cm or longer in the remaining patients.
The patients underwent surveillance for a mean of 5.5 years, with a range of 0.5 to 13.3 years, and the average patient had three endoscopies. Interestingly, 12 of the 16 patients initially diagnosed with low-grade dysplasia had normal subsequent biopsies; one progressed to esophageal adenocarcinoma. Five cases of esophageal adenocarcinoma were diagnosed during the study, a rate of one per 220 patient-years. Four of five patients with esophageal adenocarcinoma had long-segment (at least 3 cm) Barrett's esophagus. All but one of the patients died during the study period; the remaining patient had advanced disease when the study ended. Progression to high-grade dysplasia was rare, occurring in only three patients.
Bottom Line: Esophageal cancer is rare in patients with Barrett's esophagus, and survival or cure is even more uncommon. This trial does not support a policy of aggressive case finding and surveillance in these patients, particularly in those with short-segment (less than 3 cm) Barrett's esophagus. (Level of Evidence: 1b)