Incidence of Esophageal Adenocarcinoma and Causes of Mortality After Radiofrequency Ablation of Barrett’s Esophagus

Abstract

Background & Aims Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, predictors of EAC, and EAC-specific and all-cause mortality rates. Methods We assessed outcomes in a multicenter study of RFA for BE. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (both all-cause and EAC-specific) rates were calculated, and adjusted all-cause mortality rates were assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality. Results Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years (PY)), and 9 (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in non-dysplastic BE (NDBE) was 0.5/1000 PY. Overall, 157 (3%) patients died during follow-up (all-cause mortality 11.2/1000 PY). On multivariate logistic regression, baseline BE length (OR 1.1 per cm) and baseline histology (ORs of 5.8 and 50.3 for low grade dysplasia and high grade dysplasia (HGD) respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extra-esophageal cancers (15%). No deaths were associated with RFA. Conclusion In this multicenter registry of RFA for BE, death from EAC was rare. The incidence of EAC was markedly lower than natural history studies, with the greatest absolute benefit seen in HGD.

Etiology and Prevention of Esophageal Cancer

“…Early detection and treatment of preneoplastic lesions also led to a reduction in the incidence of ESCC [89]. Similar to this, multiple studies have shown that treatment of dysplasia in BE patients - for example, with radiofrequency ablation (RFA) - reduces the risk of EAC [90,91,92]. RFA is an FDA-approved endoscopic technique in which diseased tissue is exposed to heat energy and destroyed.…”

“…This technique has been proven to be safe and durable at least through medium-term follow-up [93,94]. In a multicenter RFA study in the USA, among 4,982 patients with RFA treatment, the incidence of EAC was markedly lower than in other studies of disease progression [91]. A general consensus has been reached among gastroenterologists in Europe and the USA that endoscopic resection and ablation is the most effective therapy for high-risk BE [95].…”

The Rationale and Efficacy of Primary and Secondary Prevention in Adenocarcinomas of the Upper Gastrointestinal Tract

“…As recommended by national and European guidelines, the current gold standard for mucosal ablation is radiofrequency ablation, but for small segments argon plasma coagulation can be used [41,42]. This strategy is both safe and effective resulting in minimally invasive treatment at early stage and thus fewer patients dying from OAC [43][44][45][46]. Treatment of LGD can be recommended under certain conditions, since it can be associated with significant progression rates.…”

Barrett’s esophagus: best practices for treatment and post-treatment surveillance

“…A study with data from the U.S. national RFA registry published in 2015 showed that after initiating treatment with RFA in patients with BE, the risk of incident EAC or death from EAC is small (7.8/1,000 person-years and 0.7/1,000 person-years, respectively), with lower EAC incidence rates compared to estimates derived from natural history studies when stratified by baseline histology and degree of dysplasia (54).…”

“…A randomized, sham-controlled trial of RFA in BE noted presence of SSIM in 25% of cases prior to ablation, which decreased to 5% 12 months after ablation (10). A study published in 2015 from the U.S. RFA registry (54) demonstrated that SSIM was associated with an increased risk of EAC, but all subsquamous cancers occurred prior to CE-IM. After CE-IM, SSIM was much less common, suggesting that RFA may eradicate SSIM and prevent subsquamous cancers.…”