Screening for Barrett’s esophageal saves lives and prolongs survival

Barrett’s esophagus is the condition in which the normal squamous lining of the distal esophagus is replaced with a metaplastic, intestinal, columnar epithelium. While not proven in cost models, screening and surveillance of patients with gastroesophageal reflux disease for Barrett’s esophagus is supported by current data.

Adenocarcinoma of the esophagus is one of the most rapidly increasing cancers in Western populations. In the United States, new cases of esophageal adenocarcinoma in white men increased continuously between 1975 and 1995. The incidence increase from 0.7 to 3.4 cases per 100,000 per year over these two decades. The National Program of Cancer Registries currently collects data regarding the incidence of cancer diagnosis in 45 states in the United States. For the years 1993 to 1997, the risk of being diagnosed with cancer of the esophagus per 100,000 people was 6.7 for men and 1.8 for women. This risk is larger than the risk for gall bladder and liver cancer for both men and women but is similar to the risk of stomach (9.7), pancreatic (9.9), and brain (6.7) cancers for men. Barrett’s esophagus is the major, and perhaps only, risk factor for the development of adenocarcinoma of the distal esophagus. Although the risk of cancer for a given patient with Barrett’s esophagus is relative low (0.3 percent per year), it is still many times greater than the risk for the general population (0.006 percent per year).

Gastroesophageal reflux disease is the primary pathologic factor for the development of Barrett’s esophagus. Barrett’s esophagus is more common in patients with long-term symptoms and is present in 10-15 percent of patients with chronic gastroesophageal reflux disease. Barrett’s esophagus is even more common in older patients with symptoms.

The outcome for patients who have cancer detected in a surveillance program is better than that for those who are diagnosed because of esophageal symptoms. In one study, the chance of having nodal involvement was much lower (6 percent compared with 63 percent) and two-year survival was much better (86 percent compared with 43 percent) when cancer was discovered in a surveillance program.

Future research is likely to identify subsets of patients with Barrett’s esophagus at higher risk as well as interventions (perhaps chomeprophylaxis) that may be applied to decrease the risk of cancer for these patients. Current screening and surveillance programs have not demonstrated effectiveness in preventing esophageal cancer; in fact, the incidence of disease continues to increase. It is likely that these programs have not enrolled a majority of symptomatic patients at risk for Barrett’s esophagus. In addition, several new studies have demonstrated that many patients with few or no gastroesophageal reflux disease symptoms may have Barrett’s esophagus. This may be particularly important for older patients.

In summary, many questions about Barrett’s esophagus remain, but the risk of cancer caused by this disorder must be appreciated. Current guidelines that emphasize screening for patients with long-term symptomatic gastroesophageal reflux disease should be followed. Future developments such as ultrathin endoscopy without sedation may lead to more cost-effective screening to stratify risk is commendable, but it is not appropriate to ignore the possibility of Barrett’s esophagus for a patient with long-term gastroesophageal reflux symptoms.