Effect of Barrett's esophagus surveillance on esophageal preservation, tumor stage, and survival with esophageal adenocarcinoma

Variation in proliferative and cell cycle markers in Barrett's esophagus in relation to circumferential and axial location in the esophagus

BACKGROUND

Adenocarcinoma in Barrett's esophagus (BE) occurs more frequently between 12 and 3 o'clock at the gastroesophageal junction (GEJ).

METHODS

BE patients were prospectively recruited from December 2013 to July 2016. Expression of p53, Ki-67, cyclin-D1, COX-2 and p21 was assessed in quadrantic biopsies from the proximal and distal margins of the BE segments. Cell cycle marker association with current or subsequent dysplasia or adenocarcinoma was examined.

RESULTS

110 patients: median age 64 (IQR, 56-71) years; median BE segment length C4M6; and a median follow-up of 4.7 (IQR, 3.6-5.7) years. In total 13 (11.8%) had evidence of dysplasia or neoplasia (2.7% indefinite for dysplasia, 5.5% low grade, 1.8% high grade and 1.8% adenocarcinoma) at index endoscopy. Six (7%) developed dysplasia or neoplasia (1 low grade, 2 high grade and 3 adenocarcinoma) during follow-up. Ki-67 expression was highest at 3 o'clock, and overall was 49.6% higher in the 12-6 o'clock position compared to 6-12 o'clock [odds ratio (OR), 1.42 (95% confidence interval (CI), 1.00-2.12)]. A similar pattern was found with p21 [1.82 (1.00-3.47)]. There was increased expression of several markers in distal BE biopsies; cyclin-D1 [1.74 (1.29-2.34)]; Cyclo-oxygenase 2 [2.03 (1.48-2.78]) and p21 [2.06 (1.16-3.68)]. Expression of Ki-67 was lower in distal compared to proximal biopsies [0.58 (0.43-0.78)]. P53 expression had high specificity (93.8%) for subsequent low-grade dysplasia, high-grade dysplasia or adenocarcinoma.

CONCLUSION

Increased cellular proliferation was seen at 12-6 o'clock at the GEJ. Cell-cycle marker expression was increased at the GEJ compared to the proximal BE segment. These findings mirror reflux esophagitis and suggest ongoing reflux contributes to the progression of dysplasia and malignancy in BE.

Missed Opportunities: the Timing and Frequency of Screening Colonoscopy in Patients That Develop Esophageal Adenocarcinoma

INTRODUCTION

Screening colonoscopy (SC) is widely accepted and has been shown to decrease the rate of colorectal cancer death. Guidelines and acceptance of screening for Barrett's esophagus (BE) are less established despite the fact that esophageal adenocarcinoma (EA) remains the fastest increasing cancer in the USA. The aim of this study was to assess the timing and frequency of SC in patients ultimately found to have EA and to evaluate the presence of symptoms and risk factors that might have prompted an esophagogastroduodenoscopy (EGD) and potentially earlier diagnosis of the EA.

METHODS

A retrospective chart review was performed to identify all patients who were referred to a single center with esophageal cancer between July 2016 and November 2022. Patients with any histology other than adenocarcinoma were excluded.

RESULTS

There were 221 patients referred with EA. Of these, a SC had been done prior to the diagnosis of EA in 108 patients (49%): 96 men and 12 women. A total of 203 SC had been done (range 1-7 per patient), and 47% of patients had more than 1 SC. The median interval from the last SC to the diagnosis of EA was 2.9 years. At the time of SC, gastroesophageal reflux disease (GERD) symptoms or chronic acid suppression medication use was reported by 81% of patients, and 80% had an American Society of Gastrointestinal Endoscopy (ASGE) indication for a screening EGD. Only 19 patients (18%) that had a SC had an EGD at any time prior to the diagnosis of EA, and in these patients, 74% had erosive esophagitis or BE. The EA in most patients was stage III or IV and associated with lymph node metastases.

CONCLUSIONS

Nearly one-half of patients ultimately diagnosed with EA had one or more SCs, and most of these patients had GERD symptoms, were using acid suppression medications or had an ASGE indication for a screening EGD. Despite this, only 18% had an EGD prior to the EA diagnosis. The addition of an EGD at the time of SC in these patients may have allowed the detection of BE or EA at an early, endoscopically curable stage and represents a missed opportunity to intervene in the natural history of this disease.

Gastroesophageal Reflux Disease and Barrett Esophagus in the Elderly

As our population continues to age, the early diagnosis and optimal management of patients with gastroesophageal reflux disease becomes paramount. Maintaining a low threshold for evaluating atypical symptoms in this population is key to improving outcomes. Should patients develop complications including severe esophagitis, peptic stricture, or Barrett esophagus, then a discussion of medical, endoscopic, and surgical treatments that accounts for patient's comorbidities and survival is important. Advances in screening, surveillance, and endoscopic treatment of Barrett esophagus have allowed us to dispel concerns of futility and treat a larger subset of the at-risk population.

Impact of Barrett's esophagus surveillance on the prognosis of esophageal adenocarcinoma: A meta-analysis

OBJECTIVE

Whether endoscopic surveillance would improve the outcomes of esophageal adenocarcinoma in patients previously diagnosed with Barrett's esophagus remains unclear. This meta-analysis aimed to assess the survival advantages of endoscopic surveillance for patients with Barrett's esophagus.

METHODS

Databases including PubMed, the Web of Science, and the Cochrane Library were examined systematically from their inception to July 2017, for articles related to the survival outcomes of esophageal adenocarcinoma in patients with Barrett's esophagus under endoscopic surveillance. Adjusted hazard estimates were adopted to determine overall results with 95% confidence intervals (CIs), using the fixed-effect model. We conducted subgroup and sensitivity analyses using the "metan" command in Stata software to assess the stability of the overall results. Begg's test, Egger's test and the funnel plot were used to evaluate the presence of publication bias.

RESULTS

A total of eight studies (two case-control and six cohort studies) were finally included in our current study. Compared with patients with esophageal adenocarcinoma that was not detected by surveillance, a significant 29% reduction in mortality from esophageal adenocarcinoma was observed among patients under endoscopic surveillance (adjusted hazard ratio [HR] 0.71, 95% CI 0.66-0.77). This effect was presented in both the USA (adjusted HR 0.71, 95% CI 0.65-0.78) and Europe (adjusted HR 0.71, 95% CI 0.60-0.83). We found no evidence of publication bias.

CONCLUSIONS

Our meta-analysis supports the concept that endoscopic surveillance for patients with Barrett's esophagus could improve the prognosis of esophageal adenocarcinoma. More well-designed prospective studies are needed to confirm this association.

An improved surgical procedure to establish a gastroesophageal reflux model with a high incidence of Barrett's esophagus in rats

Barrett's esophagus (BE) is a complication of gastroesophageal reflux disease and is a precursor lesion of esophageal adenocarcinoma. In existing BE models, the incidence of BE is typically low and induction is usually time consuming. In the present study, a gastroesophageal reflux model with a high incidence of BE in rats. Rats were divided into a model group and a sham operation group, and anesthetized with an inhalation anesthesia machine. Stomach-jejunal anastomosis (SJA) and esophagus-jejunal anastomosis (EJA) were simultaneously performed in the model group. The distance between the Treitz ligament and the gastro-jejunal anastomosis was shortened to 3 cm. The distance between the SJA and the EJA was prolonged to 1–1.5 cm. However, 15/40 rats in the model group succumbed to post-surgical complications (mortality rate was 37.5%). The weight of surviving rats in the model group was significantly lower compared with the sham group rats post-surgery. Erosions and ulcers were common of the surviving rats in the model group, with an incidence of 80% (20/25). Squamous cell dysplasia was identified in 40% (10/25) of rats in model group. The modified model was well established within 16 weeks. Notably, the modified surgical procedure used enhanced the incidence of BE in rats from 47% in the EJGJ model (as establish by Zhang) to 100%. To conclude, this model can be used as a reliable animal model for basic research on BE.

How to get the most out of costly Barrett's oesophagus surveillance

Current endoscopic surveillance protocols for Barrett's oesophagus have several limitations, mainly the poor cost-effectiveness and high miss rate. However, there is sufficient evidence that patients enrolled in a surveillance program have better survival chances of oesophageal cancer due to earlier tumor stages at diagnosis compared to patients with de novo diagnosed oesophagus cancer. Risk stratifications aim to identify patients at highest risk of developing adenocarcinoma of the oesophagus; most of them base on the length of the Barrett's segment and the presence of dysplasia. This review discusses prognostic factors and provides practical guidance on how to improve the efficacy and outcome in Barrett's surveillance programs.

Point-Counterpoint: Screening and Surveillance for Barrett's Esophagus, Is It Worthwhile?

The exponential rise in incidence of esophageal adenocarcinoma (EAC), paired with persistently poor survival, continues to drive efforts to improve and optimize screening and surveillance practices. While advancements in endoscopic therapy have generated a shift in management and significantly improved the outcomes of patients with early-stage EAC, the majority of prevalent EAC continues to be diagnosed at advanced stages, remaining ineligible for curative therapy. Barrett's esophagus (BE) screening, when applied to high-yield target populations, using minimally or noninvasive accurate tests, followed by endoscopic surveillance to detect prevalent or incident dysplasia/EAC (which can then be treated successfully) is the cornerstone of the current BE management paradigm. While supported by some empiric evidence and attractive, this approach faces a number of challenges, which are also balanced by numerous recent advances in these areas. In this manuscript, we review the rationale, supportive evidence, current challenges, and recent progress in BE screening and surveillance.

The Effect of Endoscopic Surveillance in Patients With Barrett's Esophagus: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Guidelines recommend endoscopic surveillance of patients with Barrett's esophagus (BE) to identify those with dysplasia (a precursor of carcinoma) or early-stage esophageal adenocarcinoma (EAC) who can be treated endoscopically. However, it is unclear whether surveillance increases survival times of patients with BE. We performed a systematic review and meta-analysis to qualitatively and quantitatively examine evidence for the association of endoscopic surveillance in patients with BE with survival and other outcomes.

METHODS

We searched publication databases for studies reporting the effects of endoscopic surveillance on mortality and other EAC-related outcomes. We reviewed randomized controlled trials, case-control studies, studies comparing patients with BE who received regular surveillance with those who did not receive regular surveillance, and studies comparing outcomes of patients with surveillance-detected EAC vs symptom-detected EACs. We performed a meta-analysis of surveillance studies to generate summary estimates using a random effects model. The primary aim was to examine the association of BE surveillance on EAC-related mortality. Secondary aims were to examine the association of BE surveillance with all-cause mortality and EAC stage at time of diagnosis.

RESULTS

A single case-control study did not show any association between surveillance and EAC-related mortality. A meta-analysis of 4 cohort studies found that lower EAC-related and all-cause mortality were associated with regular surveillance (relative risk, 0.60; 95% CI, 0.50-0.71; hazard ratio, 0.75; 95% CI, 0.59-0.94). Meta-analysis of 12 cohort studies showed lower EAC-related and all-cause mortality among patients with surveillance-detected EAC vs symptom-detected EAC (relative risk, 0.73; 95% CI, 0.57-0.94; hazard ratio, 0.59; 95% CI, 0.45-0.76). Lead- and length-time bias adjustment substantially attenuated/eliminated the observed benefits. Surveillance was associated with detection of EAC at earlier stages. A randomized trial is underway to evaluate the effects of endoscopic surveillance on mortality in patients with BE.

CONCLUSIONS

In a systematic review and meta-analysis of the effects of surveillance in patients with BE, surveillance as currently performed was associated with detection of earlier-stage EAC and may provide a small survival benefit. However, the effects of confounding biases on these estimates are not fully defined and may completely or partially explain the observed differences between surveyed and unsurveyed patients.

Genomic similarity between gastroesophageal junction and esophageal Barrett's adenocarcinomas

The current high mortality rate of esophageal adenocarcinoma (EAC) reflects frequent presentation at an advanced stage. Recent efforts utilizing fluorescent peptides have identified overexpressed cell surface targets for endoscopic detection of early stage Barrett's-derived EAC. Unfortunately, 30% of EAC patients present with gastroesophageal junction adenocarcinomas (GEJAC) and lack premalignant Barrett's metaplasia, limiting this early detection strategy. We compared mRNA profiles from 52 EACs (tubular EAC; tEAC) collected above the gastroesophageal junction with 70 GEJACs, 8 normal esophageal and 5 normal gastric mucosa samples. We also analyzed our previously published whole-exome sequencing data in a large cohort of these tumors. Principal component analysis, hierarchical clustering and survival-based analyses demonstrated that GEJAC and tEAC were highly similar, with only modest differences in expression and mutation profiles. The combined expression cohort allowed identification of 49 genes coding cell surface targets overexpressed in both GEJAC and tEAC. We confirmed that three of these candidates (CDH11, ICAM1 and CLDN3) were overexpressed in tumors when compared to normal esophagus, normal gastric and non-dysplastic Barrett's, and localized to the surface of tumor cells. Molecular profiling of tEAC and GEJAC tumors indicated extensive similarity and related molecular processes. Identified genes that encode cell surface proteins overexpressed in both Barrett's-derived EAC and those that arise without Barrett's metaplasia will allow simultaneous detection strategies.

The Epidemiology of Esophageal Adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has increased in many Western countries and is higher in men than women. Some risk factors for EAC have been identified-mainly gastroesophageal reflux disease, Barrett's esophagus, obesity, and tobacco smoking. It is not clear whether interventions to address these factors can reduce risk of EAC, although some evidence exists for smoking cessation. Although consumption of alcohol is not associated with EAC risk, other exposures, such as physical activity, nutrition, and medication use, require further study. Genetic variants have been associated with risk for EAC, but their overall contribution is low. Studies are needed to investigate associations between risk factors and the molecular subtypes of EAC. The prognosis for patients with EAC has slightly improved, but remains poor-screening and surveillance trials of high-risk individuals are needed.

Yesterday and today of Barrett's esophagus: Historical evolution and research hotspots

It has been more than 60 years since the concept of Barrett's esophagus (BE) was put forward, and over these a few decades, we have made great progress in the diagnosis and treatment of BE. BE does not cause clinical symptoms, but it attracts wide attention, because it is an important precursor lesion of esophageal adenocarcinoma. The purpose of this article is to review the process of the recognition of BE and the current research hotspots as well as to discuss the current status of esophageal adenocarcinoma screening in BE patients. We aim to provide clinicians with an overview of the ins and outs of the disease, which will help them improve the diagnosis and treatment of BE in clinical practice and provide patients with beneficial treatment.

Impact of surveillance for Barrett's oesophagus on tumour stage and survival of patients with neoplastic progression

OBJECTIVE

Endoscopic surveillance for Barrett's oesophagus (BO) is under discussion given the overall low incidence of neoplastic progression and lack of evidence that it prevents advanced oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the impact of endoscopic BO surveillance on tumour stage and survival of patients with neoplastic progression.

DESIGN

783 patients with BO of at least 2 cm were included in a multicentre prospective cohort and followed during surveillance according to the American College of Gastroenterology guidelines. Cases of high-grade dysplasia and OAC were identified during follow-up. OAC staging was performed according to the 7th UICC-AJCC classification. Survival data were collected and crosschecked using death and municipal registries. Data from patients with OAC in the general population were obtained from the Dutch cancer registry. We compared survival of patients with BO with neoplastic progression during surveillance with those of patients without neoplastic progression and patients with OAC in the general population.

RESULTS

53 patients with BO developed high-grade dysplasia or OAC during surveillance. Thirty-five (66%) were classified as stage 0, 14 (26%) as stage 1 and 4 (8%) as stage 2. OAC was diagnosed at an earlier stage during BO surveillance than in the general population (p<0.001). Survival of patients with BO with neoplastic progression was not significantly worse than those of patients without neoplastic progression and similar to survival of patients with stage 0 or stage 1 OAC in the general population.

CONCLUSIONS

OAC is detected at an earlier stage during BO surveillance than in the general population with good survival rates.

Quality indicators for the management of Barrett's esophagus, dysplasia, and esophageal adenocarcinoma: international consensus recommendations from the American Gastroenterological Association Symposium

The development of and adherence to quality indicators in gastroenterology, as in all of medicine, is increasing in importance to ensure that patients receive consistent high-quality care. In addition, government-based and private insurers will be expecting documentation of the parameters by which we measure quality, which will likely affect reimbursements. Barrett's esophagus remains a particularly important disease entity for which we should maintain up-to-date guidelines, given its commonality, potentially lethal outcomes, and controversies regarding screening and surveillance. To achieve this goal, a relatively large group of international experts was assembled and, using the modified Delphi method, evaluated the validity of multiple candidate quality indicators for the diagnosis and management of Barrett's esophagus. Several candidate quality indicators achieved >80% agreement. These statements are intended to serve as a consensus on candidate quality indicators for those who treat patients with Barrett's esophagus.

Animal Models of Barrett's Esophagus and Esophageal Adenocarcinoma-Past, Present, and Future

Esophageal adenocarcinoma is the fastest rising cancer in the United States. It develops from long-standing gastroesophageal reflux disease which affects >20% of the general population. It carries a very poor prognosis with 5-year survival <20%. The disease is known to sequentially progress from reflux esophagitis to a metaplastic precursor, Barrett's esophagus and then onto dysplasia and esophageal adenocarcinoma. However, only few patients with reflux develop Barrett's esophagus and only a minority of these turn malignant. The reason for this heterogeneity in clinical progression is unknown. To improve patient management, molecular changes which facilitate disease progression must be identified. Animal models can provide a comprehensive functional and anatomic platform for such a study. Rats and mice have been the most widely studied but disease homology with humans has been questioned. No animal model naturally simulates the inflammation to adenocarcinoma progression as in humans, with all models requiring surgical bypass or destruction of existing antireflux mechanisms. Valuable properties of individual models could be utilized to holistically evaluate disease progression. In this review paper, we critically examined the current animal models of Barrett's esophagus, their differences and homologies with human disease and how they have shaped our current understanding of Barrett's carcinogenesis.

Barrett's esophagus: recent insights into pathogenesis and cellular ontogeny

Esophageal adenocarcinoma (EAC) has increased 6-fold in its incidence in the last 2 decades. Evidence supports the hypothesis of stepwise progression from normal squamous epithelium → reflux esophagitis → metaplasia (Barrett's esophagus, BE) → dysplasia → adenocarcinoma. The precursor, BE, stands as the bridge connecting the widespread but naive reflux disease and the rare but fatal EAC. The step of metaplasia from squamous to intestine-like columnar phenotype is perhaps pivotal in promoting dysplastic vulnerability. It is widely accepted that chronic inflammation because of gastroesophageal reflux disease leads to the development of metaplasia, however the precise molecular mechanism is yet to be discovered. Additionally, how this seemingly adaptive change in the cellular phenotype promotes dysplasia remains a mystery. This conceptual void is deterring further translational research and clouding clinical decision making. This article critically reviews theories on the pathogenesis of Barrett's esophagus and the various controversies surrounding its diagnosis. We further discuss unanswered questions and future directions, which are vital in formulating effective preventive and therapeutic guidelines for Barrett's esophagus.

BOB CAT: A Large-Scale Review and Delphi Consensus for Management of Barrett's Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia

OBJECTIVES

Barrett's esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD).

METHODS

We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations.

RESULTS

In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients.

CONCLUSIONS

In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.

Surveillance of Barrett's esophagus and mortality from esophageal adenocarcinoma: a population-based cohort study

OBJECTIVES

Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC.

METHODS

All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up.

RESULTS

In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64-0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16-0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58-0.76).

CONCLUSIONS

Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.

Gastroesophageal reflux disease, proton-pump inhibitor use and Barrett's esophagus in esophageal adenocarcinoma: Trends revisited

PURPOSE

Screening for esophageal adenocarcinoma (EAC) has not become policy in part over concerns in identifying the high-risk group. It is often claimed that a significant proportion of patients developing EAC do not report preexisting reflux symptoms or prior treatment for gastroesophageal reflux disease (GERD). As such, our aim was to assess the prevalence of GERD symptoms, proton pump inhibitor (PPI) use and Barrett's esophagus (BE) and their impact on survival in patients undergoing esophagectomy for EAC.

METHODS

The study population consisted of 345 consecutive patients who underwent esophagectomy for EAC between 2000 and 2011 at a university-based medical center. Patients with a diagnosis of esophageal squamous cell carcinoma and those who underwent esophagectomy for benign disease were excluded. The prevalence of preoperative GERD symptoms, defined as presence of heartburn, regurgitation or epigastric pain, PPI use (>6 months) and BE, defined by the phrases "Barrett's esophagus," "intestinal epithelium," "specialized epithelium," or "goblet cell metaplasia" in the patients' preoperative clinical notes were retrospectively collected. Overall long-term and stage-specific survival was compared in patients with and without the presence of preoperative GERD symptoms, PPI use, or BE.

RESULTS

The majority of patients (64%; 221/345) had preoperative GERD symptoms and a history of PPI use (52%; 179/345). A preoperative diagnosis of BE was present in 34% (118/345) of patients. Kaplan-Meier survival analysis revealed a marked survival advantage in patients undergoing esophagectomy who had preoperative GERD symptoms, PPI use or BE diagnosis (P ≤ .001). The survival advantage remained when stratified for American Joint Committee on Cancer stage in patients with preoperative PPI use (P = .015) but was less pronounced in patients with GERD symptoms or BE (P = .136 and P = .225, respectively).

CONCLUSION

These data show that the oft-quoted statistic that the majority of patients with EAC do not report preexisting GERD or PPI use is false. Furthermore, a diagnosis of BE is present in a surprisingly high proportion of patients (34%). There is a distinct survival advantage in patients with preoperative GERD symptoms, PPI use, and BE diagnosis, which may not be simply owing to earlier stage at diagnosis. Screening may affect survival outcomes in more patients with EAC than previously anticipated.

Diagnosis and treatment of Barrett's oesophagus

INTRODUCTION

Barrett's oesophagus (BO) is a common premalignant condition, which carries a risk of progression to oesophageal adenocarcinoma. Recent advances include quantifying the risk of neoplasia progression, novel diagnostic tools and development of new endoscopic techniques to treat early Barrett's cancer.

SOURCES OF DATA

A selective search was performed on recent advances in BO and this was supplemented with guidelines from the American and British Society of Gastroenterology.

AREAS OF AGREEMENT

All cases of dysplasia should be confirmed by a second expert histopathologist. Endoscopic therapy is the preferred option for high-grade dysplasia and intra-mucosal (T1a) carcinoma using endomucosal resection (EMR) and/or radiofrequency ablation. EMR also provides accurate staging information and any remaining Barrett segment should be ablated to reduce the risk of metachronous lesions.

AREAS OF CONTROVERSY

The cell of origin for BO is not certain. The merits and cost effectiveness of endoscopic screening and surveillance still remain controversial. The risk of neoplasia progression in low-grade dysplasia is inconsistently reported. The role of chemoprevention remains unclear.

GROWING POINTS

The use of radical endotherapy in early Barrett's neoplasia is promising with some data supporting long-term durability.

AREAS TIMELY FOR DEVELOPING RESEARCH

The development of non-endoscopic diagnostic tools and radical endotherapy to treat early cancer strengthens the argument for surveillance and suggests the possibility of screening in the near future. Identification of a biomarker may help to select high-risk patients.