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Surveillance of Nondysplastic Barrett Esophagus Is Not Supportable

Summary and Comment |
August 26, 2013

Surveillance of Nondysplastic Barrett Esophagus Is Not Supportable

  1. David A. Johnson, MD

The latest observational study showed no mortality benefit. It's time to question this practice.

  1. David A. Johnson, MD

Despite routine recommendation of endoscopic surveillance in patients with Barrett esophagus (BE), few studies have documented its benefit in reducing dysplasia or cancer. Observational studies suggest that endoscopic surveillance might detect curable dysplasia in BE and might allow for discovery of less advanced cancers than those found in symptomatic patients. In the current case-control study, researchers assessed whether endoscopic surveillance in patients with BE was associated with reduced cancer mortality.

In a population of 8272 health care plan members who had been diagnosed with BE, investigators identified 38 case patients who died from esophageal adenocarcinoma and had received a diagnosis of BE at least 6 months prior to cancer diagnosis.

Surveillance within 3 years was not associated with a decreased risk for death from esophageal adenocarcinoma (odds ratio, 0.99; 95% confidence interval, 0.36–2.75). Mortality did not differ by surveillance status. Although BE length ≥3 cm and prior dysplasia were each associated with increased risk for mortality, adjustment for these factors did not change the main findings.

Comment

No study has established the reliability of surveillance in detecting curable dysplasia, whereas a number of reports have documented the development of incurable malignancies in some patients despite adherence to endoscopic surveillance programs. A previous report estimated that the annual incidence of EAC would need to be >1.9% for surveillance of nondysplastic Barrett esophagus at 5-year intervals to be cost-effective (Ann Intern Med 2003; 138:176). The most recent annual incidence estimates for HGD or EAC are between <0.1% and 0.2% (NEJM JW Gastroenterol Oct 21 2011 and NEJM JW Gastroenterol Aug 19 2011). Additionally, data from academic centers show overutilization of surveillance endoscopy (NEJM JW Gastroenterol Mar 30 2012). The time has come to question the standard practice of routine endoscopic surveillance (much less screening) for patients with nondysplastic Barrett esophagus.

  • Disclosures for David A. Johnson, MD at time of publication Consultant / Advisory board Abbott; Centacor; CRH Medical; Medscape; Pfizer; Takeda Pharmaceuticals Speaker's bureau Takeda Pharmaceuticals Editorial boards ACG Universe; MedScape Gastroenterology

Citation(s):

Reader Comments (1)

CHARLES LOEWE Physician, Gastroenterology, Florida Digestive Health Specialists

i agree fully having been in GE for 30 yrs and being a therapeutic endoscopist and ablationist using all modalities! I also do not advocate ablation of NDBE unless patient is at a very high risk!

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