The risk of oesophageal adenocarcinoma in a prospectively recruited Barrett’s oesophagus cohort

Abstract

Background: Varying rates of oesophageal adenocarcinoma (OAC) complicating Barrett's oesophagus (BO) have been reported. Recent studies and meta-analyses suggest a lower incidence, questioning the value of endoscopic surveillance. Aim: We aimed to retrospectively examine the rate of OAC, risk factors and causes of death in a prospectively recruited BO cohort. Methods: Data from patients with BO from a cohort from 1982-2007 were studied. Patients were subdivided into surveyed, failed to attend surveillance and unfit for surveillance. Standardised mortality ratios (SMR) were calculated for common causes of death. Cox proportional hazards models were used to determine which factors were associated with progression to OAC. Results: In total, 671 BO patients (61% male) were studied; 37 (76% male) were diagnosed with OAC. OAC incidence was 0.47% per annum and stable across three decades (1982-1991 0.56%, 1992-2001 0.46%, 2002-2012 0.41% (p ¼ 0.8)). All-cause mortality was increased for the whole cohort (SMR 163(95% CI 145-183)). Mortality from OAC appeared higher in patients who failed to attend surveillance (SMR 3216(95% CI 1543-5916)) compared with surveyed (SMR 1753(95% CI 933-2998)) and those unfit for surveillance due to co-morbidity (SMR 440(95% CI 143-1025)). Multivariable analysis identified low-grade dysplasia ), p ¼ 0.005) and length of BO (HR 1.2(95% (1.1-1.3)), p < 0.001)) as associated with OAC. Conclusions: Progression to OAC appeared stable over three decades at 0.47% per annum. Patients with BO had a modest increase in all-cause mortality and a large increase in OAC mortality, particularly if fit for surveillance. Low-grade dysplasia and the length of the BO segment were associated with developing OAC.

The Effect of Endoscopic Surveillance in Patients With Barrett’s Esophagus: A Systematic Review and Meta-analysis

“…Our initial search strategy yielded 1,747 studies, with 19 articles eligible for inclusion in both the final qualitative and quantitative analysis (Figure 1). 12, 13, 15, 16, 22–36 Given the heterogeneous study designs used in studies, we divided the studies into 4 different groups, namely, Group 1: Randomized controlled trial design, Group 2: Case-control study with matched control groups assessing EAC-related mortality, Group 3: Cohort study with well-defined BE surveillance and non-surveillance groups, and 4. Group 4: Cohort studies comparing outcomes of patients with EAC having prior BE (diagnosed ≥6 months before the diagnosis of EAC) to patients presenting with symptomatic EAC without a prior history of BE.…”

“…In total, we found 6 studies that fit these criteria. 22–24, 29, 31, 35 All studies in this group were retrospective cohort studies. Details of individual studies, including demographics, are provided in Table 1 and Supplementary Table 1 The “case” cohorts in these studies were patients with established BE receiving regularly scheduled surveillance (i.e.…”

“…Studies received a score on the Newcastle-Ottawa scale between 4 and 9. Of the 17 cohort studies, nine received a score of “7” or higher, 22–25, 29, 31–34 with two receiving a score of “9”. 24, 25 Reasons for lower quality ratings included cohorts that were not representative of the general BE population and lack of adjustment for potential confounders.…”

“…There were 4 studies 22, 23, 31, 35 comparing regular BE surveillance to incomplete or no surveillance that provided unadjusted data on EAC-related mortality. Meta-analysis of these studies showed that regular BE surveillance was associated with a significantly reduced EAC-related mortality compared to the incomplete/no surveillance groups (RR = 0.60; 95% CI = 0.50–0.71; Figure 2).…”

Whole Genome Methylation Analysis of Nondysplastic Barrett Esophagus that Progresses to Invasive Cancer

“…Patients within the surveillance program had endoscopy and biopsy every 2 years. 32 Biopsies were taken at the time of the initial surveillance endoscopy and at all subsequent endoscopies including immediately before treatment as part of their staging. They were also required to have still been alive and to have had a NDBE biopsy within 2 years of this study.…”