Careful Scrutiny of Early Endoscopy Results Critical for Assessment in Barrett's Esophagus

Madhav Desai, MD, MPH, Fellow Physician, Department of Gastroenterology, Hepatology & Motility, University of Kansas Medical Center, Kansas City, and colleagues recently conducted a study to determine the prevalence patterns of Barrett's esophagus (BE)-associated dysplasia detected via index endoscopy in the past 25 years (Gastrointest Endosc. 2019;89[2]:257-263).

Results from the study suggest that high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) prevalence have significantly increased in this time, despite a decrease in BE length during the same period. According to Dr Desai and colleagues, this increase corresponds with that of the detection of visible lesions, and suggests that careful inspection at the index examination is vital.

In an interview with Oncology Learning Network, Dr Desai discussed his team’s findings in detail, and highlighted their next steps for this research effort.

What existing data led you to evaluate the prevalence patterns of Barrett's esophagus (BE)-associated dysplasia and esophageal adenocarcinoma (EAC) in the past 25 years?

Esophageal cancer is the 18th most common cancer with only a 19% 5-year survival rate. Incidence of EAC is rapidly rising with change in population habits, urbanization, and increasing average body size. BE is the only known precursor of EAC, making it a target for close surveillance with intent to detect EAC at early stage when it may be amenable to be eradicated easily.

Recent data has shown that incidence of EAC will continue to rise through 2030, especially for males, with estimated EAC incidence of 6 to 8 per 100,000 individuals. Incidence and prevalence of BE is also rising in parallel, with an estimated prevalence of 6% in the United States.

Recent studies have shown another concerning finding, which is that most patients with BE are diagnosed with early EAC within the first year of diagnosis of BE, and most of EAC patients had underlying BE that was not diagnosed too long ago. This poses several questions for medical community.

We currently do not know if detection of dysplasia and EAC in BE patients undergoing index endoscopy contributes to this rise, perhaps suggesting our efforts are improving in recent years (ie, how good we are at finding prevalent cases).

We examined this issue closely by evaluating BE registries from multiple tertiary care centers across the United States. looking at their initial endoscopy exams to understand changing trends and patterns of BE-associated dysplasia and EAC in past 25 years.

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

We examined a large cohort of BE patients who underwent index endoscopy for BE exam over a span of 25 years (1990-2016) and analyzed outcomes for time trends over 25 years with comparisons across 5-year cohorts.

A total of 3643 patients were included in the analysis with index endoscopy showing nondysplastic BE in 70.1%, low-grade dysplasia (LGD) in 11.5%, HGD in 5.4%, and EAC in 5.1% of patients.

Interestingly, we noted that, over time, there was an increase in the mean age of BE patients (51.7 ± 29 years vs 62.6 ± 11.3 years) and proportion of males diagnosed with BE (84% vs 92.6%) but a decrease in the mean BE length (4.4 ± 4.3 cm vs 2.9 ± 3.0 cm) as time progressed (1990-1994 to 2010-2016).

In addition, we surprisingly observed that the presence of LGD on index endoscopy remained stable from 1990 to 2016. However, a significant increase in the diagnosis of HGD (148%), EAC (112%), and HGD/EAC was noted on index endoscopy in the past 25 years (P <.001).

There was also a significant increase in the detection of optically visible lesions on index endoscopy during the same time period (5.1% in 1990-1994, 6.3% in 2005-2009, and 16.3% in 2010-onwards).

What are the possible real-world applications of these findings in clinical practice?

This study puts forth several real-world lessons for clinicians and treating physicians as well as gastroenterologists.

First and most important is that gastroesophageal reflux should be taken seriously; your patient could have underlying BE, which needs to be screening or diagnosed in appropriate scenarios.

Second, when a patient is referred for endoscopy for possible BE, the endoscopist is expected to do a meticulous job examining this area for any suspicious lesions that need to be sampled for evaluation for early dysplasia or cancer cells. Symptoms of acid reflux that are not improving and a history of long-standing acid reflux are a couple of scenarios wherein clinicians should be aware of the possible presence of underlying BE changes requiring further attention.

The findings noted in our study confirm previous research on the rising incidence of BE-related dysplasia and cancer, as well as the fact that we are getting better at detection of these changes, especially in exert hands in tertiary care centers.

Community gastroenterologists are frontrunners for this and should find cases of BE when possible and refer them to BE experts for further management in certain situations. Our group has also recently published data regarding the neoplasia detection rate in BE patients, establishing the role of quality endoscopy for BE patients.

Do you and your co-investigators intend to expand upon this research? If so, will you be incorporating any new end points or patient populations?

Certainly. This study and others like it open door for quality in endoscopy and assessment of our current efforts.

We hope to continue looking into factors to improve our quality to serve patients better and detect any abnormal cells and cancer at the earliest time possible. At the same time, our final goal should be for primordial and primary prevention of BE.

We plan to conduct future studies looking at establishing quality benchmarks in BE endoscopy, including neoplasia detection rate and BE inspection time for a quality exam, as they are not currently well-established.