Sanjeev Slehria, MD, Prateek Sharma, MD

Disclosures

Curr Opin Gastroenterol. 2003;19(4) 

In This Article

Screening and Surveillance

Do all esophageal adenocarcinomas arise from Barrett esophagus? This is an important question because this would impact screening programs. Intestinal metaplasia of the distal esophagus is frequently not detected in patients with esophageal adenocarcinoma because of the overlying bulk of the tumor. To clarify this issue, investigators from Germany studied whether preoperative chemotherapy could unmask the underlying Barrett mucosa in patients with esophageal adenocarcinoma.[14**] Before chemotherapy, biopsies revealed Barrett esophagus in only 59 of 79 patients with esophageal adenocarcinoma. Following neoadjuvant chemotherapy, Barrett mucosa was unmasked and documented by biopsies or in the resected specimen in 18 of 20 patients with no Barrett prior to chemotherapy. This study highlights that Barrett esophagus can frequently be masked by tumor overgrowth in patients with advanced esophageal adenocarcinoma and that most of these cancers are associated with Barrett esophagus.

Small retrospective studies have shown that endoscopic surveillance can detect curable cancers in patients with Barrett esophagus and that the cancers identified are far less advanced than cancers identified in patients with symptoms of dysphagia and unexplained weight loss. However, these results do not convincingly support that surveillance is beneficial, and no prospective trials or population-based studies have been performed.

In a cohort of 589 patients with esophageal or gastric cardia adenocarcinoma, investigators reported the presence of Barrett esophagus, detection of cancer by endoscopic surveillance, cancer stage, mortality, and potential confounders .[15**] Barrett esophagus was diagnosed in 135 of 589 adenocarcinoma patients, with Barrett esophagus diagnosed in 23 patients more than 6 months before cancer was diagnosed. Among these 23 patients, 73% of the surveillance-detected cancer patients were alive at the end of follow-up and had low-stage disease, compared with none of the patients whose cancers were not surveillance detected. This small population-based study showed that surveillance-detected Barrett adenocarcinomas were associated with low-stage disease and improved survival. Conversely, only 3.9% had Barrett diagnosed before their cancer, indicating that most patients with Barrett esophagus go unrecognized. A systematic review was performed to determine the prior prevalence of Barrett esophagus in patients with esophageal adenocarcinoma who were undergoing resection.[16] In a review of the literature from 1966 to 2000, the overall percentage of patients undergoing resection who had a prior diagnosis of Barrett esophagus was less than 5%. This and other studies have provided evidence that Barrett esophagus probably goes undiagnosed in a large proportion of patients and that our current screening and surveillance practices have been limited to a small percentage of patients with Barrett esophagus. Additional studies are needed to evaluate whether screening and surveillance programs would decrease mortality among all patients with Barrett esophagus.

Previous studies have suggested that patients with Barrett esophagus have decreased health-related quality of life compared with population controls. Practice guidelines recommend surveillance for Barrett esophagus because of the risk of esophageal cancer. However, the quality of life of patients undergoing Barrett surveillance is unknown. The Quality of Life in Reflux and Dyspepsia is a validated disease-specific instrument with 25 questions in five domains (emotions, vitality, sleeping, eating/drinking, physical/social functioning). Fifteen patients with Barrett esophagus undergoing surveillance were administered the Quality of Life in Reflux and Dyspepsia.[17] This population of Barrett esophagus patients had significantly higher Quality of Life in Reflux and Dyspepsia scores than previously reported in patients referred for endoscopy, suggesting that patients do have concerns regarding surveillance for "cancer."

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