Impact of Endoscopic Surveillance on Mortality From Barrett's Esophagus–Associated Esophageal Adenocarcinomas

Abstract

Background & Aims Although patients with Barrett's esophagus commonly undergo endoscopic surveillance, its effectiveness in reducing mortality from esophageal/gastroesophageal junction adenocarcinomas has not been evaluated rigorously. Methods We performed a case-control study in a community-based setting. Among 8272 members with Barrett's esophagus, we identified 351 esophageal adenocarcinoma: 70 in persons who had a prior diagnosis of Barrett's esophagus (who were eligible for surveillance); 51 of these patients died, 38 as a result of the cancers (cases). Surveillance histories were contrasted with a sample of 101 living persons with Barrett's esophagus (controls), matched for age, sex, and duration of follow-up evaluation. Results Surveillancei within 3 years was not associated with a decreased risk of death from esophageal adenocarcinoma (adjusted odds ratio, 0.99; 95% confidence interval, 0.36–2.75). Fatal cases were nearly as likely to have received surveillance (55.3%) as were controls (60.4%). A Barrett's esophagus length longer than 3 cm and prior dysplasia each were associated with subsequent mortality, but adjustment for these did not change the main findings. Although all patients should be included in evaluations of effectiveness, excluding deaths related to cancer treatment and patients who failed to complete treatment, changed the magnitude, but not the significance, of the association (odds ratio, 0.46; 95% confidence interval, 0.13–1.64). Conclusions Endoscopic surveillance of patients with Barrett's esophagus was not associated with a substantially decreased risk of death from esophageal adenocarcinoma. The results do not exclude a small to moderate benefit. However, if such a benefit exists, our findings indicate that it is substantially smaller than currently estimated. The effectiveness of surveillance was influenced partially by the acceptability of existing treatments and the occurrence of treatment-associated mortality.

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

“…Importantly, these fi ndings were maintained, although attenuated, aft er attempting to correct for both lead time and length time bias. 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 ( 102 ). Although there are no prospective clinical trial data that demonstrate a benefi t of endoscopic surveillance, the considerable heterogeneity of available evidence makes it prudent to continue to perform endoscopic surveillance of BE patients.…”

The cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia: results from a randomized controlled trial (SURF trial)

“…11 Ablation of LGD may therefore be clinically useful if neoplastic progression can be reduced at an acceptable cost profile. Using a BE disease model, we previously analyzed the cost-effectiveness of ablation treatment for patients with BE with and without dysplasia.…”

Cost–effectiveness analysis of endoscopic eradication therapy for treatment of high-grade dysplasia in Barrett’s esophagus

“…The 2013 British Society of Gastroenterology (BSG) guidelines advise that, in those patients with BE in whom there is no neoplasia, surveillance is recommended for those fit for endoscopy [3]. This is based on existing evidence from published studies which show that surveillance correlates with early-stage cancer diagnosis and likely improved survival from other cancers [4][5][6]. Recent work from the ProBar study group examined data from the Dutch cancer registry.…”