Gastroenterology

Gastroenterology

Volume 150, Issue 3, March 2016, Pages 599-607.e7
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Magnitude of Missed Esophageal Adenocarcinoma After Barrett’s Esophagus Diagnosis: A Systematic Review and Meta-analysis

https://doi.org/10.1053/j.gastro.2015.11.040Get rights and content

Background & Aims

A proportion of patients with Barrett’s esophagus (BE) are diagnosed with esophageal adenocarcinoma (EAC) within 1 year of an endoscopic examination that produced negative findings. These cases of missed cancers have not been well studied, despite current surveillance strategies for BE. We performed a systematic review and meta-analysis to determine the magnitude of missed EAC in cohorts of patients with BE.

Methods

We searched MEDLINE, EMBASE, and Web of Science from their inception to May 31, 2015 to identify cohort studies of adults with BE (baseline nondysplastic BE ± BE with low-grade dysplasia) and at least a 3-year follow-up period, providing data on missed and incident EACs (diagnosed within 1 year and diagnosed more than 1 year after the initial endoscopy in which BE was diagnosed, respectively). The main outcome measure was pooled proportion of missed and incident EACs (of all EACs detected after initial endoscopy) among BE cohorts, using a random effects model.

Results

In a meta-analysis of 24 studies reporting on 820 missed and incident EACs, 25.3% were classified as missed (95% confidence interval: 16.4%–36.8%) and 74.7% as incident EACs (95% CI: 63.2%–83.6%), although there was substantial heterogeneity among studies (I2 = 74%). When the analysis was restricted to nondysplastic BE cohorts (15 studies), 23.9% of EACs were classified as missed (95% confidence interval: 15.3%–35.4%; I2 = 0%). In a meta-analysis of 10 studies with follow-up periods of ≥5 years (a total of 239 EACs), 22.0% were classified as missed (95% confidence interval: 8.7%–45.5%), with substantial heterogeneity (I2 = 68%).

Conclusions

Among adults with nondysplastic BE (or BE with low-grade dysplasia) at their index endoscopy and at least a 3-year follow-up period, 25% of EACs are diagnosed within 1 year after the index endoscopy. Additional resources should be allocated to detect missed EAC.

Section snippets

Definitions

EAC reported by studies were divided into 2 categories: missed and incident. EAC diagnosed within 1 year of negative index endoscopy (in which BE was diagnosed) was defined as “missed” EAC because, given the usual time course of progression from NDBE to EAC, it is highly likely that these had been missed at index endoscopy, rather than being a true incident cancer.13 “Incident” EAC patients were those diagnosed more than 1 year after negative index endoscopy. In studies that did not report a

Search Results

A total of 2482 studies were identified using our search strategy, of which 27 studies fulfilled our inclusion criteria and were included in the meta-analysis (Figure 1).2, 3, 9, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 Twenty-four of these studies cumulatively reported 320 missed EAC and 500 incident EAC, and 20 studies reported the combined end points of HGD-EAC with 638 missed HGD-EAC and 863 incident HGD-EAC (Table 1). Twelve studies

Discussion

Surveillance in patients with BE is time- and resource-intensive, and has not yielded a consistent population-level reduction in the incidence of EAC. Several factors may be contributing to this, and we specifically evaluated the problem of missed EAC in patients with BE. Through a systematic review and meta-analysis of 24 cohort studies in adults with BE (baseline NDBE ± BE-LGD) followed for at least 3 years after negative index endoscopy (in which BE was diagnosed), we made several key

Acknowledgments

The authors thank Patricia Erwin, Medical Librarian at Mayo Clinic Library, for her expertise and help in conducting the literature search for this systematic review and meta-analysis.

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    • Cited by (0)

    This article has an accompanying continuing medical education activity on page e14. Learning Objective: After completing this exercise, the learner will be able to discuss the occurrence of high-grade dysplasia and/or esophageal adenocarcinoma in patients undergoing screening for Barrett's esophagus, the occurrence of high-grade dysplasia and/or esophageal adenocarcinoma in patients undergoing surveillance for Barrett's esophagus, and the potential role of adequate visualization and biopsy sampling to minimize missed high grade dysplasia or esophageal adenocarcinoma.

    Conflicts of interest These authors disclose the following: David A. Ahlquist: Exact Sciences. Kenneth K. Wang: Medical Advisory Board and Mauna Kea Technologies. Prasad G. Iyer: Intromedic and Exact Sciences. The remaining authors disclose no conflicts.

    Author names in bold designate shared co-first authorship.

    ∗

    Authors share co-first authorship.

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