Barrett's esophagus surveillance in a prospective Dutch multi‐center community‐based cohort of 985 patients demonstrates low risk of neoplastic progression

Abstract

Background and Aims: Barrett's esophagus (BE) is accompanied by an increased risk of developing esophageal cancer. Accurate risk-stratification is warranted to improve endoscopic surveillance. Most data available on risk factors is derived from tertiary care centers or from cohorts with limited surveillance time or surveillance quality. The aim of this study was to assess endoscopic and clinical risk factors for progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in a large prospective cohort of BE patients from community hospitals supported by an overarching infrastructure to ensure optimal surveillance quality.Methods: A well-defined prospective multicenter cohort study was initiated in six community hospitals in the Amsterdam region in 2003. BE patients were identified by PALGA search and included in a prospective surveillance program with a single endoscopist performing all endoscopies at each hospital. Planning and data collection was performed by experienced research nurses who attended all endoscopies. Endpoint was progression to HGD/EAC.Results: Nine hundred eighty-five patients were included for analysis. During median follow-up of 7.9 years (IQR 4.1-12.5) 67 patients were diagnosed with HGD (n = 28) or EAC (n = 39), progression rate 0.78% per patient-year. As a clinical risk factor age at time of endoscopy was associated with neoplastic progression (HR 1.05; 95% CI 1.03-1.08). Maximum Barrett length and low-grade dysplasia (LGD) at baseline were endoscopic predictors of progression (HR 1.15; 95% CI 1.09-1.21 and HR 2.36; 95% CI 1.29-4.33).This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Impact of expert center endoscopic assessment of confirmed low grade dysplasia in Barrett’s esophagus diagnosed in community hospitals

“…Two prior studies demonstrated that LGD diagnosed by a community pathologist, was downgraded to NDBE in 73 %–85 % after review by a BE expert pathologist. After downstaging to NDBE, the risk of progression to HGD/EAC was < 1 % per patient-year 4 5 . In contrast, for confirmed LGD, the risk of malignant progression increased to 9 %–13 % per patient-year 6 7 .…”

Today’s Mistakes and Tomorrow’s Wisdom in Development and Use of Biomarkers for Barrett’s Esophagus

“…Increasing age has been showed to be associated with an increased risk of progression in a recent meta-analysis; however, this association did not remain statistically significant in a more restricted analysis including only studies that reported multivariate analysis adjusted for age, sex, dysplasia, and BE length [3]. Additionally, the value of age is a questionable risk factor, since the low progression rate of 0.12–0.78% per patient-year needs to be weighted carefully against the invasiveness and costs of endoscopic surveillance in elderly and frail BE patients [4, 5].…”

“…LGD and p53 Immunohistochemistry Whereas patients with nondysplastic (ND) BE carry a very low risk for progression (0.12-0.78%/year), the progression rate increases substantially in the presence of a histologic diagnosis of LGD [4,5]. However, the diagnosis of LGD is challenging due to several reasons.…”

Artificial intelligence in Barrett's oesophagus and the need for shared and combined data

“…These biopsy protocols essentially reflect the subtlety of a relevant proportion of the lesions 3 . Limited adherence to ‘blind chase’‐biopsy protocols and varying dysplasia detection rates, 3 the relevance of (verified) low‐grade dysplasia, 4 and debates around the efficiency of current surveillance protocols 2,3 have sparked efforts towards improved risk‐stratification protocols 2,5 and ‘optical biopsy’ to reduce the biopsy‐load in BE surveillance and improve its quality.…”

“…Barrett's oesophagus (BE) confronts endoscopists with labour‐intensive surveillance protocols 1 in the context of relatively low‐prevalence cohorts 2 . These biopsy protocols essentially reflect the subtlety of a relevant proportion of the lesions 3 .…”