Editorial: Best Practices in Surveillance of Barrett's Esophagus

Abstract

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...

Biomarker identification and trans-regulatory network analyses in esophageal adenocarcinoma and Barrett’s esophagus

“…Additionally, histology depends on a biopsy taken during an endoscopic procedure, and this introduces additional inter- and intra-observer variability[21]. Due to the limitations of endoscopic surveillance and histological examination, developing biomarkers that could identfify the neoplastic progression is crucial[10]. The discovery of molecular changes during BE and EAC progression may identify biomarkers that can be used for early diagnosis and prognostic prediction[22].…”

“…Due to the limitations of endoscopic surveillance and the lack of clinical risk stratification strategies available to identify BE patients who are at a higher risk of progressing to EAC, more attention has been paid to improving endoscopic techniques and to the discovery of molecular biomarkers for EAC and BE[10,11]. Panels of markers have been developed and used to explore the relationships among normal esophagus (NE), BE, and EAC, yet the molecular drivers are still not clear, and no biomarkers are currently utilized for clinical application[11].…”

Barrett’s esophagus: current standards in advanced imaging

“…The Seattle protocol (four-quadrant biopsies using the "turn and suction technique" at 1-2 cm intervals along the entire length of the Barrett's segment) remains the standard of care for tissue sampling (14). Any suspicious areas (nodularity, erythema, erosion, ulceration) should be biopsied and samples placed in separate jars as these mucosal abnormalities can be associated with dysplasia (15).…”

“…Several other imaging modalities have been investigated for use in BE but most are not ready for clinical application at this time (14).…”

A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett’s Esophagus

“…Current practice guidelines recommend endoscopic surveillance of BE with acquisition of tissue samples by the Seattle protocol (4-quadrant random biopsies every 1–2 cm and targeted biopsies of visible lesions), with the objective of detecting dysplasia/ EAC at an early and potentially curable stage [3–9]. However, this strategy is limited by its high significant risk for sampling error, as dysplasia/EAC may be highly focal and only less than 5% of the surface area of the BE segment is sampled, resulting in an expensive, time-consuming, and relatively low-yield process [10, 11]. Furthermore, there is variability among endoscopists with respect to adherence to the recommended intervals for surveillance and compliance with obtaining biopsies using the Seattle protocol [12].…”