Should patients with GERD be screened once at least for Barrett's epithelium? A balancing view: To screen or not to screen: scoping out the issues

Professionals' views on the justification for esophageal adenocarcinoma screening: A systematic literature search and qualitative analysis

Screening for early esophageal adenocarcinoma (EAC), including screening for its precursor Barrett's esophagus (BE), has the potential to reduce EAC-related mortality and morbidity. This literature review aimed to explore professionals' views on the justification for EAC screening. A systematic search of Ovid Medline, EMBASE, and PsycInfo, from January 1, 2000 to September 22, 2022, identified 5 original studies and 63 expert opinion articles reporting professionals' perspectives on EAC screening. Included articles were qualitatively analyzed using the framework method, which was deductively led by modernized screening principles. The analyses showed that many professionals are optimistic about technological advancements in BE detection and treatment. However, views on whether the societal burden of EAC merits screening were contradictory. In addition, knowledge of the long-term benefits and risks of EAC screening is still considered insufficient. There is no consensus on who to screen, how often to screen, which screening test to use, and how to manage non-dysplastic BE. Professionals further point out the need to develop technology that facilitates automated test sample processing and public education strategies that avoid causing disproportionately high cancer worry and social stigma. In conclusion, modernized screening principles are currently insufficiently fulfilled to justify widespread screening for EAC. Results from future clinical screening trials and risk prediction modeling studies may shift professionals' thoughts regarding justification for EAC screening.

Incidence of adenocarcinoma among patients with Barrett's esophagus

BACKGROUND

Accurate population-based data are needed on the incidence of esophageal adenocarcinoma and high-grade dysplasia among patients with Barrett's esophagus.

METHODS

We conducted a nationwide, population-based, cohort study involving all patients with Barrett's esophagus in Denmark during the period from 1992 through 2009, using data from the Danish Pathology Registry and the Danish Cancer Registry. We determined the incidence rates (numbers of cases per 1000 person-years) of adenocarcinoma and high-grade dysplasia. As a measure of relative risk, standardized incidence ratios were calculated with the use of national cancer rates in Denmark during the study period.

RESULTS

We identified 11,028 patients with Barrett's esophagus and analyzed their data for a median of 5.2 years. Within the first year after the index endoscopy, 131 new cases of adenocarcinoma were diagnosed. During subsequent years, 66 new adenocarcinomas were detected, yielding an incidence rate for adenocarcinoma of 1.2 cases per 1000 person-years (95% confidence interval [CI], 0.9 to 1.5). As compared with the risk in the general population, the relative risk of adenocarcinoma among patients with Barrett's esophagus was 11.3 (95% CI, 8.8 to 14.4). The annual risk of esophageal adenocarcinoma was 0.12% (95% CI, 0.09 to 0.15). Detection of low-grade dysplasia on the index endoscopy was associated with an incidence rate for adenocarcinoma of 5.1 cases per 1000 person-years. In contrast, the incidence rate among patients without dysplasia was 1.0 case per 1000 person-years. Risk estimates for patients with high-grade dysplasia were slightly higher.

CONCLUSIONS

Barrett's esophagus is a strong risk factor for esophageal adenocarcinoma, but the absolute annual risk, 0.12%, is much lower than the assumed risk of 0.5%, which is the basis for current surveillance guidelines. Data from the current study call into question the rationale for ongoing surveillance in patients who have Barrett's esophagus without dysplasia. (Funded by the Clinical Institute, University of Aarhus, Aarhus, Denmark.).

Gastroesophageal reflux disease and bulimia nervosa--a review of the literature

Bulimia nervosa and other eating disorders have been on the increase for the past half century. Self-induced vomiting is often practiced as a method of weight control in these patients, potentially causing acidic damage to the esophagus of the kind observed in cases of gastroesophageal reflux disease. To ascertain whether patients suffering from bulimia nervosa had an increased rate of reflux-related symptoms, potentially placing them at risk of developing sequelae such as Barrett's esophagus and esophageal adenocarcinoma, a literature review was performed via searches of databases including PubMed, Medline, OVID and PsycINFO and a recursive search of the literature. The search terms were: bulimia nervosa; reflux; esophageal adenocarcinoma; Barrett's esophagus; eating disorders; oral; dental; complications. Several case reports were identified detailing the occurrence of an esophageal tumor in patients with a history of bulimia. This was supported to some degree by studies detailing higher incidences of reflux symptoms in eating disordered patients compared to controls but there was large variability in study design, quality and results. From these results an association is suggested as possible but is far from being proved conclusively. Further investigation is required using larger patient groups, better study design controlling for confounding factors and symptom characterisation.

Clinical use of p53 in Barrett's esophagus

Barrett's esophagus is an established precursor to esophageal adenocarcinoma. Whereas most patients with Barrett's esophagus do not progress to adenocarcinoma, patients with progression have a poor prognosis. Current management strategies use frequent endoscopic surveillance and multiple nontargeted biopsies. This approach, however, may miss dysplastic areas. Furthermore, given the relatively high prevalence of Barrett's esophagus but low incidence of progression, this invasive and expensive approach has not been shown to be cost-effective. Thus, there is intense interest in using biomarkers to identify patients at increased risk of progressing to adenocarcinoma. This has included examination of mutations in the tumor suppressor gene, p53. In this report, we discuss the biology of p53 and the incidence of p53 mutations in Barrett's esophagus and review relevant studies regarding the ability of p53 to predict neoplastic progression. Additionally, we report our results of the expression of p53 by immunohistochemistry in a group of 18 patients that have undergone endoscopic esophageal mucosal resection for dysplasia. Although the presence of a p53 mutation increases the risk of neoplastic progression, the absence of this mutation does not abrogate the risk. Continuing efforts, therefore, are needed to define and prospectively validate a panel of biomarkers to risk-stratify patients with Barrett's esophagus. Determination of p53 mutational status may ultimately be a component of such a panel.

Does screening for Barrett's esophagus and adenocarcinoma of the esophagus prolong survival?

Despite the paucity of data supporting its use, screening upper endoscopy for patients with chronic gastroesophageal reflux disease symptoms to assess for Barrett's esophagus and esophageal adenocarcinoma has become a widely accepted practice. We apply the principles of screening to Barrett's esophagus and esophageal adenocarcinoma. Critical application of the key criteria of screening to this situation demonstrates that several criteria are unfulfilled. Key data are not available with which to judge other criteria. The major fault with screening for Barrett's esophagus is that the at-risk population is too broadly characterized and that too many cancers occur outside of this risk pool. Thus, recommendations for screening cannot be endorsed. Efforts may be better directed at further research identifying groups at risk for esophageal adenocarcinoma, developing more accurate and less-invasive methods of diagnosis, and discovering the underlying factors which continue to drive the increased incidence of this disease.