Persistence of Nondysplastic Barrett's Esophagus Identifies Patients at Lower Risk for Esophageal Adenocarcinoma: Results From a Large Multicenter Cohort

Gaddam, Srinivas; Singh, Mandeep; Balasubramanian, Gokulakrishnan; Thota, Prashanthi N.; Gupta, Neil; Wani, Sachin; Higbee, April D.; Mathur, Sharad C.; Horwhat, John D.; Rastogi, Amit; Young, Patrick E.; Cash, Brooks D.; Bansal, Ajay; Vargo, John J.; Falk, Gary W.; Lieberman, David A.; Sampliner, Richard E.; Sharma, Prateek

doi:10.1053/j.gastro.2013.05.040

Cited by 79 publications

(56 citation statements)

References 27 publications

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“…Most recurrent metaplasia and dysplasia, when detected by surveillance, is amenable to endoscopic therapy, including EMR and additional ablation ( 176,177,180 ). However, a few cases requiring esophagectomy for invasive carcinoma have been reported ( 187 ).…”

Section: Management Of Be After Endoscopic Therapymentioning

confidence: 99%

“…Th ough most recurrences are nondysplastic, up to a quarter may be dysplastic, including EAC ( 164,175 ). Variability in reported recurrence rates may be partially explained by diff erences in defi nitions of recurrence among studies: with some studies reporting recurrences located only in the tubular esophagus ( 176 ), whereas others reporting recurrent IM in both the esophagus and the GEJ/cardia ( 177 ). Th e signifi cance of recurrent IM without dysplasia at the GEJ aft er CEIM is currently unclear.…”

Section: Summary Of Evidencementioning

confidence: 99%

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ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus

Shaheen

Falk

Iyer

et al. 2016

American Journal of Gastroenterology

1,335

1,412

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Recent population studies suggest that gastroesophageal refl ux disease (GERD) is increasing in prevalence, both in the United States and worldwide ( 1,2 ). Th e diagnosis of GERD is associated with a 10-15% risk of Barrett's esophagus (BE), a change of the normal squamous epithelium of the distal esophagus to a columnar-lined intestinal metaplasia (IM). Risk factors associated with the development of BE include long-standing GERD, male gender, central obesity ( 3 ), and age over 50 years ( 4,5 ). Th e goal of a screening and surveillance program for BE is to identify individuals at risk for progression to esophageal adenocarcinoma (EAC), a malignancy that has been increasing in incidence since the 1970s ( 6,7 ).Th e purpose of this guideline is to review the defi nition and epidemiology of BE, available screening modalities for BE detection, rationale and methods for surveillance, and available treatment modalities including medical, endoscopic, and surgical techniques. In order to evaluate the level of evidence and strength of recommendations, we used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system ( 8 ). Th e level of evidence ranged from "high" (implying that further research was unlikely to change the authors' confi dence in the estimate of the eff ect) to "moderate" (further research would be likely to have an impact on the confi dence in the estimate of eff ect) to "low" (further research would be expected to have an important impact on the confi dence in the estimate of the eff ect and would be likely to change the estimate) or "very low" (any estimate of eff ect is very uncertain). Th e strength of a recommendation was graded as "strong" when the desirable eff ects of an intervention clearly outweighed the undesirable eff ects and as "conditional" when there was uncertainty about the tradeoff s. We used meta-analyses or systematic reviews when available, followed by clinical trials and cohort and case-control studies. In order to determine the level Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with refl ux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-defi nition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is ...

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Section: Management Of Be After Endoscopic Therapymentioning

confidence: 99%

Section: Summary Of Evidencementioning

confidence: 99%

ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus

Shaheen

Falk

Iyer

et al. 2016

American Journal of Gastroenterology

1,335

1,412

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“…Previous data have suggested that persistence of NDBE may be an indicator of lower risk of progression to high grade dysplasia (HGD)/EAC ( 33 ). If this is true, endoscopic surveillance intervals could be potentially lengthened in patients with persistent NDBE.…”

Section: Is Persistence Of Ndbe Protective Against Progression To Eac?mentioning

confidence: 99%

“…On the contrary, the rate can increase if environmental noxious stimuli continue unabated or due to increase in probability of mutations by sheer number of mitotic cycles over time. Outcome studies on this topic have reported confl icting data ( 33,35,36 ).…”

Section: Is Persistence Of Ndbe Protective Against Progression To Eac?mentioning

confidence: 99%

Editorial: Best Practices in Surveillance of Barrett's Esophagus

Wani

Gaddam

2017

American Journal of Gastroenterology

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Endoscopic surveillance in Barrett's esophagus (BE) has numerous limitations and thus provides several opportunities for improving the effectiveness of our current surveillance strategies. Several risk stratifi cation and prediction tools have been investigated to identify patients at highest risk for progression to esophageal adenocarcinoma (EAC). Persistence of non-dysplastic BE (NDBE) has been proposed as an indicator of lower risk of progression to EAC. This editorial highlights the variable results and methodologies in studies evaluating persistence of NDBE as a risk stratifi cation tool in the surveillance of BE patients and provides guidance for optimizing outcomes in BE patients enrolled in surveillance programs. Am J Gastroenterol 2017; 112:1056-1060 doi: 10.1038/ajg.2017 RATIONALE AND CURRENT STATUS OF SURVEILLANCEAs survival in esophageal adenocarcinoma (EAC) is stage dependent, studies suggest that survival may be enhanced by endoscopic surveillance of Barrett's esophagus (BE), the only identifi able premalignant condition for this lethal cancer that continues to increase in incidence and is associated with a dismal 5-year survival rate. Current practice guidelines recommend endoscopic surveillance of patients with BE in an attempt to detect cancer at an early and potentially curable stage ( 1-3 ). Observational studies suggest that patients with BE in whom EAC was detected in a surveillance program have their cancers detected at an earlier stage with markedly improved 5-year survival compared with similar patients not undergoing routine surveillance ( 4-8 ).Variable results regarding the impact of surveillance in BE patients have been reported from four recent population-based studies. A large Northern Ireland population-based study and a large Dutch population-based study showed that in patients with EAC and a prior diagnosis of BE, survival was improved, and tumor stage and grade was lower compared with patients without a prior diagnosis of BE ( 9,10 ). Similarly, a cohort study of patients with BE diagnosed in the National Veterans Aff airs hospitals showed that surveillance endoscopy was associated with an early stage diagnosis of EAC, longer survival, and decreased overall and cancer-related mortality ( 11 ). On the other hand, a case-control study from the Northern California Kaiser Permanente population found no evidence that endoscopic surveillance improved survival from EAC ( 12 ). Despite these variable results and the lack of data from randomized controlled trials comparing surveillance vs. no surveillance (not likely to be performed in the future), surveillance of BE patients will continue to be recommended in clinical practice.Surveillance intervals are currently determined by the presence and grade of dysplasia. Several contemporary studies have demonstrated a low rate of progression to EAC in patients with non-dysplastic BE and this estimate ranges from 0.1-0.3% per year (13)(14)(15). Also, most patients with BE are likely to die of other causes, the commonest cause of deat...

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“…A recent multicenter study showed that persistence of NDBE, based on multiple surveillance endoscopies, was associated with a gradually lower likelihood of progression to EAC (22).…”

Section: Non Dysplastic Barrett Esophagus (Ndbe)mentioning

confidence: 99%