Clinical research study
Barrett's Surveillance Identifies Patients with Early Esophageal Adenocarcinoma

https://doi.org/10.1016/j.amjmed.2009.10.013Get rights and content

Abstract

Background

Barrett's surveillance for dysplasia is recommended, but few studies have documented the benefit of endoscopic surveillance for dysplasia or cancer.

Objectives

Using a retrospective study design, we aim to demonstrate the impact of a Barrett's surveillance program on the stage of esophageal adenocarcinoma and identify factors for progression of metaplasia to cancer.

Subjects

The Institutional Review Board at Veterans Affairs Connecticut Healthcare approved the study. We report a retrospective review of a prospectively followed Barrett's cohort in a surveillance program and compared their outcome with patients with a new diagnosis of esophageal adenocarcinoma, identified at the same center between 1999 and 2005.

Results

There were 248 patients with Barrett's esophagus entered into a surveillance program from 1999 to 2005. During the surveillance period of 987 patient-years, 5 (0.5% patient-year) patients developed esophageal adenocarcinoma. During the same period, 46 patients were diagnosed with new-onset esophageal adenocarcinoma outside of our surveillance program. Only 5% of these patients had a history of gastroesophageal reflux disease. There were 248 patients who underwent a mean number of 2.7 ± 1.7 upper endoscopic procedures, with 26 (10%) patients developing dysplasia. Compared with nonsurveillance, more patients had early stage of cancer in the surveillance group (P <.001). All 5 patients with cancer diagnosed from Barrett's esophagus surveillance endoscopy were alive, compared with 20 of 46 (43%) patients with cancer diagnosed outside of the surveillance program. The length of Barrett's segment >3 cm was found to be associated with development of dysplasia, P = .004 (odds ratio 1.2; 95% confidence interval, 1.07-1.34).

Conclusion

Patients with Barrett's esophagus undergoing endoscopic surveillance benefit from early-stage cancer diagnosis. Progression to adenocarcinoma is low, but long-segment and high-grade dysplasias have an increased risk of cancer. A significant number of patients with newly diagnosed esophageal adenocarcinoma do not complain of gastroesophageal reflux disease and are therefore not investigated for Barrett's esophagus nor entered into surveillance. Patients and physicians can use this information in making a decision about surveillance.

Section snippets

Patient Population

The Institutional Review Board at the Veteran Administration Connecticut Healthcare System approved the study. We performed a retrospective review of consecutive patients with Barrett's esophagus who were prospectively followed in a Barrett's surveillance program and compared their outcome with consecutive patients with a new diagnosis of esophageal adenocarcinoma, identified at the same Veterans Affairs Medical Center between 1999 and 2005. Barrett's esophagus was defined as specialized

Surveillance

There were 248 patients with Barrett's esophagus who entered into a surveillance program from 1999 to 2005. During the surveillance period of 987 patient years, 5 (0.5% patient year) patients developed esophageal adenocarcinoma (surveillance cancers). During the same period and at our institution, 46 patients were diagnosed with new-onset esophageal adenocarcinoma, outside of our surveillance program and without a prior diagnosis of Barrett's esophagus (nonsurveillance cancers). Baseline

Discussion

We present a large single-center study comparing the outcome of Barrett's patients enrolled in a prospective surveillance program, and compared their disease stage and mortality with an unscreened, nonsurveillance patient cohort from the same institution who presented with esophageal adenocarcinoma. We found that patients enrolled in a Barrett's surveillance program benefited from an earlier stage of diagnosis of cancer compared with patients diagnosed with esophageal adenocarcinoma outside of

Conclusion

In this large retrospective cohort of patients with Barrett's esophagus, we observed that regular surveillance identifies patients with earlier stage cancer. The progression to adenocarcinoma in patients with Barrett's esophagus is very low, but patients with high-grade dysplasia have the highest risk of cancer on follow-up. Length of Barrett's segment was found to be a significant risk factor associated with progression to dysplasia. Unfortunately, we also have found that most patients with

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    Funding: None.

    Conflict of Interest: The authors state that they have no conflicts of interest.

    Authorship: All authors had access to the data and contributed to study design, data acquisition, and data analysis. All authors were involved in manuscript writing.

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