Screening for Barrett's Esophagus

David A. Johnson, MD


June 16, 2011


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Who and When to Screen?

Hello, I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to GI Common Concerns -- Computer Consult.

Today, I wanted to talk to you about a question that I get all the time in clinical practice: Who and when should I screen for Barrett's esophagus?

National guidelines have been published repeatedly on this, and the American Gastroenterological Association (AGA) guidelines[1] suggest that screening for Barrett's esophagus, a premalignant condition of the esophagus, is appropriate for people with long-standing heartburn symptoms (typically more than 5 years) or the need for ongoing medications for that same period of time. That definition has been fairly uniform as far as the patients who are referred to gastroenterologists like myself for evaluation of possible Barrett's esophagus.

It's fairly easy to get the patient to weigh in on this by saying that we are going to screen you for a precancerous condition. They obviously are very vested in their interest, and they always come in and have their screening.

Now, are we really doing them a favor? I want to review some very recent recommendations that have come out in the last several months and profile a study from a couple of years ago that puts another twist on this perspective.

Risk Factors for Barrett's Esophagus

First, a recent multidisciplinary review conducted by the AGA[1] provided consensus recommendations against screening the general population for Barrett's esophagus and included the recommendations that were best supported for patients who have multiple risk factors.

What are these risk factors? Men, white, older than 50 years, hiatal hernia, increasing body mass index (BMI), or in particular, an abdominal fat distribution that we know has propensity for increased carcinogenesis in a variety of cancers, and also for Barrett's esophagus.

A recommendation that all patients be screened for Barrett's esophagus was evaluated using a very interesting computer Markov model. This study[2] came from the University of Michigan and was published a few months ago. In this particular study, they used Markov modeling and looked at esophageal adenocarcinoma (EAC) incidence rates and compared these with risks for other cancers.

In a 35-year-old man with at least weekly heartburn symptoms, the incidence of esophageal cancer was 1 per 100,000 person-years, in contrast to the man who was age 70, for whom the incidence was 60.8 per 100,000 person-years. That sounds like a lot, but it is still 3.5 times less than the incidence of colon cancer in the same population. We are talking about a relative risk here, which compared with colon cancer, is considerably lower by several orders of magnitude.

If a woman has weekly heartburn symptoms (the typical indication for screening for Barrett's esophagus), and is age 60, the incidence of esophageal carcinoma for that patient is 3.9 per 100,000 person-years. For a man with the same frequency of symptoms, the number goes up to 34.6 adenocarcinomas per 100,000 patient-years. For men, that makes sense; for women, that is still pretty low.

Let me put it another way. Screening women for EAC associated with Barrett's esophagus is like screening men for breast cancer. Think about that. When you start to apply this relative risk, how many men do you screen for breast cancer in your practice?

As we talk about allocation of healthcare resources, it certainly makes very little sense to talk about application of healthcare resources for patients who have immeasurably low risks relative to their risks for cancer and cancer-related death.

The Downside of Screening

To take it a step further, a diagnosis of Barrett's esophagus does not do your patients any favors. Although we rush them in for a nice diagnosis to say, "yes, you have this precancerous condition," we actually have hurt them with respect to obtaining insurance.

In a very elegant study that was completed about 6 years ago, Shaheen and colleagues[3] at the University of North Carolina looked at 20 different insurance plans (10 in North Carolina and 10 on the West Coast) and found that making a diagnosis of Barrett's esophagus increased the insurance premium by at least 100% in all the patients and, in many cases, made the patients no longer insurable. That does not make any sense, because we have already said that the relative risk for adenocarcinoma and progression in Barrett's esophagus is very low.

Summary: Screening Recommendations

Let's come back to reality. We are in an era of healthcare economics, but we are trying to do the right thing for our patients.

The relative risk for Barrett's esophagus is very small as it relates to adenocarcinoma. I would agree with the consensus document from the AGA[1] that says that we should offer screening to patients with multiple risk factors: white men, older than 50 years, hiatal hernia, abdominal obesity, and perhaps BMI elevation, which has also been linked with Barrett's esophagus. In the absence of those risk factors, screening for Barrett's esophagus should not be offered, at least from a healthcare economics standpoint.

Hopefully, national societies will take a deeper look at this gender bias because offering screening to women who [have] frequent heartburn may not only cause them to lose their insurance, but a diagnosis of Barrett's esophagus itself can also have a negative impact on quality of life. There is a fear factor going forward for the rest of their lives. We don't want to do that. Do we screen our male patients for breast cancer? We don't do that either.

These are things to think about when you try to benefit the patient. Let's take a deep breath and remember rule number 1 in medicine: Do no harm.

We may be shuttling patients into a surveillance program that, first, they do not need and, second, that they may not be able to have insurance and have it paid for. We need to take a step back and reevaluate what we are really doing in our screening for Barrett's esophagus.

The next time you have conversations with patients, keep this in perspective. The medical liability risk is very small and the standards need to be changed in a more definitive way. More appropriate outcome studies will hopefully give us better direction. In the meantime, pause and remember rule number 1. Let's do better screening and allocation of our healthcare resources.

I look forward to our next discussion on GI Common Concerns -- Computer Consult. Thanks for listening. I'm Dr. David Johnson. See you next time.