Clinical Question: Which men with Barrett’s esophagus are at greatest risk of progression to high-grade dysplasia or cancer?
Setting: Outpatient (specialty)
Study Design: Cohort (prospective)
Synopsis: The authors identified 550 patients who underwent endoscopy for any reason and were diagnosed with Barrett’s esophagus between 1990 and 2003. The study took place at a Veterans Affairs hospital, 99 percent of participants were men, and 93 percent were white. Patients ranged in age from 28 to 86 years (mean age = 63 years). At the initial endoscopy, 77 percent had no dysplasia, 18 percent had low-grade dysplasia, and 5 percent had unifocal high-grade dysplasia. Helicobacter pylori infection was absent in 345 patients, present in 72 patients, and a history of H. pylori eradication was identified in 60 patients. Patients with cancer, dysplasia-associated lesion or mass, or intramucosal cancer at enrollment were excluded (n = 28).
Of the 550 patients initially identified, 28 had a diagnosis of malignancy, 173 had no follow-up endoscopy, 15 died from other causes, and 10 were lost to follow-up, leaving 324 for the study. It is unknown whether outcomes were assessed blindly. Patients with newly diagnosed low-grade dysplasia or unifocal high-grade dysplasia had optimized medical therapy and were re-endoscoped at 12 to 24 weeks (for patients with low-grade dysplasia) or four to eight weeks (for patients with high-grade dysplasia). Patients with persistent high-grade dysplasia had surveillance at three- to six-month intervals, while those with low-grade dysplasia or regression to normal had surveillance at six- to 12-month intervals. Although patients were followed for up to 130 months based on the Kaplan-Meier curves, the mean or median duration of follow-up or the number of follow-up endoscopies was not given.
Results were presented in several ways. Independent risk factors for high-grade dysplasia or cancer at the initial endoscopy were increased age, greater length of Barrett’s esophagus (especially greater than 6 cm), and never having been diagnosed with H. pylori infection. The independent risk factors for progression of Barrett’s esophagus to high-grade dysplasia or cancer were length, initial histology, histology at follow-up, and H. pylori status. The risk was low for patients with no dysplasia on the initial endoscopy (i.e., 2.4 percent if the length is less than 6 cm; 6.8 percent if the length is more than 6 cm) or with low-grade dysplasia only (i.e., 5.3 percent with length of less than 6 cm). All other groups had at least a 35 percent risk of progression.
Bottom Line: Patients with no dysplasia on the initial endoscopy or with low-grade dysplasia only and Barrett’s esophagus length of less than 6 cm have a very low risk of progression to high-grade dysplasia or malignancy. (Level of Evidence: 2b)