Low Prevalence of Endoscopic Screening for Barrett's Esophagus in a Screening-Eligible Primary Care Population

Abstract

INTRODUCTION:Despite societal recommendations supporting Barrett's esophagus (BE) screening, it is unknown what proportion of eligible patients is screened in primary care. We assessed the proportion of BE screening- eligible patients evaluated in the primary care setting receiving upper esophagogastroduodenoscopy (EGD) and identified factors associated with undergoing EGD.METHODS:This was a retrospective study of BE screening-eligible patients, as defined by the American College of Gastroenterology's BE guidelines, in a multipractice healthcare network consisting of 64 internal medicine practices and 94 family medicine (FM) practices. The proportion undergoing EGD, prevalence of BE and esophageal adenocarcinoma (EAC) in this group, and patient and provider factors associated with undergoing EGD were assessed. Multivariable logistic regression was performed to identify independent predictors of undergoing EGD.RESULTS:Of 1,127 screening-eligible patients, the mean age was 65.2 ± 8.6 years; 45% were obese; and 61% were smokers. Seventy-three percent were seeing FM; 94% were on proton pump inhibitors; and 44% took ≥1 gastroesophageal reflux disease (GERD) medication. Only 39% of patients (n = 436) had undergone EGD. The overall prevalence of BE or EAC was 9.9%. Of 39 (9%) referred for BE screening as the primary indication, BE/EAC prevalence was 35.1%. Factors associated with increased odds of having EGD were symptomatic GERD despite treatment (odds ratio [OR] 12.1, 95% confidence interval [CI] 9.1‐16.3), being on ≥1 GERD medication (OR 1.4, 95% CI 1.0‐1.9), and being an FM patient (OR 1.5, 95% CI 1.1‐2.1).DISCUSSION:In this large, primary care population, only 39% of screening-eligible patients underwent EGD. Most of the examinations were triggered by refractory symptoms rather than screening referrals, highlighting a need for improved dissemination and implementation of BE screening.

Construction of the Interaction Network of Hub Genes in the Progression of Barrett’s Esophagus to Esophageal Adenocarcinoma

“…The development of NE-BE-EAC is a long process. 25 Although, BE is a precancerous lesion of EAC, not all BE will progress to EAC. Then, finding biomarkers that can predict whether BE will become cancerous or not has a very important diagnostic value.…”

“…There is growing evidence that the progression of BE to EAC is a multistep process that includes the development of non-developmental abnormal BE to low-grade atypical hyperplasia, then to high-grade atypical hyperplasia, and ultimately to EAC. [25][26][27] However, the molecular mechanism by which BE becomes cancerous is largely unknown. In BE is the only recognized precancerous lesion of EAC, and almost all EAC originates from BE.…”

Gastroesophageal Reflux Disease Is Not a Great Screening Criterion: Time to Move on to Other Strategies for Controlling the Burden of Esophageal Adenocarcinoma

“…The study by Eluri et al (7) adds context to previous studies of EGD findings among patients referred for GERD, showing that those with symptoms refractory to therapy are not at increased risk of BE or erosive esophagitis, and atypical symptoms believed to be due to GERD, such as cough and globus, in addition to psychiatric distress may be inversely associated with finding esophageal pathology (8,9). Studying the referral patterns in a large primary care multipractice network, Eluri et al (7) demonstrated that, by and large, the patients being referred for EGD are the wrong ones if we are trying to address the burden of EAC. We are being sent patients with refractory symptoms (who are less likely to actually have GERD) or patients with alarm symptoms (who are unlikely to benefit from endoscopic therapy for early neoplastic lesions) rather than the patients with typical GERD symptoms who have responded to therapy.…”

“…In this issue of the Red Journal, Eluri et al (7) performed a retrospective analysis of primary care patients within a multipractice network finding that only 39% of patients with GERD meeting guideline criteria for screening had undergone EGD. Only 9% of those were specifically referred for screening purposes.…”

“…The other 30% had EGD for diagnostic purposes, primarily GERD symptoms not responding to therapy, and also for alarm symptoms, including dysphagia, abdominal pain, and bleeding. Eluri et al (7) excluded patients with prior BE diagnosis, esophagectomy, and antireflux surgery, which could have biased the estimate of the proportion referred for screening downward, but such patients only accounted for fewer than 1% of patients, so the magnitude of such bias was not very large. They also used an algorithm for defining patients with GERD which likely selected for patients with severe symptoms and missed some patients with GERD symptoms who were well controlled with medication or patients who self-medicated with over-the-counter medication without discussing their symptoms with their PCP.…”