Consensus Statements for Management of Barrett's Dysplasia and Early-Stage Esophageal Adenocarcinoma, Based on a Delphi Process

Abstract

BACKGROUND & AIMS Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett’s esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA. METHODS We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement. RESULTS Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated. CONCLUSIONS We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

Ischemic heart disease, factor predisposing to Barrett’s adenocarcinoma: A case control study

“…Some authorities believe intestinal metaplasia absence is only a reflection of sampling error and that it will invariably be present if meticulously searched [28] . Nevertheless, the risk of non-columnar intestinal metaplasia to progress to AdE is still debatable [29] . By excluding patients without a histological verification of intestinal metaplasia, we limited our BE population and increasing bias due to BE underreporting.…”

The impact of flexible endoscopy in esophageal surgery

“…In the last two decades, efforts have been made to diagnose esophageal cancer at an earlier stage so as to facilitate preservation of the esophagus and improve longterm survival and quality of life (17)(18)(19). With minimally invasive surgical and endoscopic techniques evolving rapidly, there has been a substantial paradigm shift in the management of early stage neoplasia in Barrett's esophagus (BE) comprising high-grade dysplasia (HGD), intramucosal and, in some cases, submucosal carcinoma (20,21). The availability of more therapeutic options interjects an increasing degree of complexity regarding the optimal therapeutic algorithm to be employed.…”

“…In parallel, a consensus statement was created by a group of experts on the management of BE and early cancer including diagnosis, staging and therapeutic approaches (21).…”

“…The depth of treatment is therefore limited to the mucosal layer and the risk of stricture formation is significantly reduced compared to other ablative techniques (21,(25)(26)(27)(28)(29)(30). Success rates in eradicating dysplasia are reported to be over 90% with near complete eradication of intestinal metaplasia in controlled trials.…”

Carcinogenesis of Barrett’s esophagus: a review of the clinical literature

“…Residual SIM carries with it the potential to progress to dysplasia/EAC, but the magnitude of this risk is not well characterized [155,156]. Consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and LGD, HGD, or earlystage EAC have been reported [157]. When treating patients with BE-associated dysplasia or EAC, we should consult these evidence-based consensus statements for the management of such patients.…”