Consensus Statements for Management of Barrett's Dysplasia and Early-Stage Esophageal Adenocarcinoma, Based on a Delphi Process

Cathy Bennett; Nimish Vakil; Jacques Bergman; Rebecca Harrison; Robert Odze; Michael Vieth; Scott Sanders; Laura Gay; Oliver Pech; Gaius Longcroft-Wheaton; Yvonne Romero; John Inadomi; Jan Tack; Douglas A. Corley; Hendrik Manner; Susi Green; David Al Dulaimi; Haythem Ali; Bill Allum; Mark Anderson; Howard Curtis; Gary Falk; M. Brian Fennerty; Grant Fullarton; Kausilia Krishnadath; Stephen J. Meltzer; David Armstrong; Robert Ganz; Gianpaolo Cengia; James J. Going; John Goldblum; Charles Gordon; Heike Grabsch; Chris Haigh; Michio Hongo; David Johnston; Ricky Forbes-Young; Elaine Kay; Philip Kaye; Toni Lerut; Laurence B. Lovat; Lars Lundell; Philip Mairs; Tadakuza Shimoda; Stuart Spechler; Stephen Sontag; Peter Malfertheiner; Iain Murray; ; Manoj Nanji; David Poller; Krish Ragunath; Jaroslaw Regula; Renzo Cestari; Neil Shepherd; Rajvinder Singh; Hubert J. Stein; Nicholas J. Talley; Jean-Paul Galmiche; Tony C. K. Tham; Peter Watson; Lisa Yerian; Massimo Rugge; Thomas W. Rice; John Hart; Stuart Gittens; David Hewin; Juergen Hochberger; Peter Kahrilas; Sean Preston; Richard Sampliner; Prateek Sharma; Robert Stuart; Kenneth Wang; Irving Waxman; Chris Abley; Duncan Loft; Ian Penman; Nicholas J. Shaheen; Amitabh Chak; Gareth Davies; Lorna Dunn; Yngve Falck-Ytter; John Decaestecker; Pradeep Bhandari; Christian Ell; S. Michael Griffin; Stephenattwood; Hugh Barr; John Allen; Mark K. Ferguson; Paul Moayyedi; Janusz A. Z. Jankowski

Disclosures

Gastroenterology. 2012;143(2):336-346. 

In This Article

Abstract and Introduction

Abstract

Background & Aims Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA.
Methods We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement.
Results Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated.
Conclusions We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

Introduction

Barrett's esophagus (BE) is defined as the replacement of distal esophageal squamous mucosa with metaplastic columnar epithelium.[1] It occurs in 4% of patients undergoing an upper gastrointestinal endoscopy, and in 9% of men over 50 years of age.[2] BE is more common in developed countries, affecting 2% of the population, because it is strongly associated with gastroesophageal reflux disease[3,4] and this disease incidence is increasing in developing countries.[5] The main concern with BE is the associated increased risk for esophageal adenocarcinoma (EA). EA is the fastest growing cause of cancer mortality,[6] and it is estimated that patients with BE have at least a 20-fold increased risk of developing EA.[7–9] Most guidelines[10,11] recommend surveillance endoscopy every 2 to 5 years in patients with BE to detect early, treatable neoplasia and early signs of high-grade dysplasia (HGD). If progression to low-grade dysplasia (LGD), HGD, or EA can be detected early in its course, cancer can either be prevented or treated at a curable stage.[12,13]

There is a lack of agreement concerning optimal management of dysplasia and early EA and, therefore, management practice patterns vary considerably among BE experts. The classification and recognition of dysplasia, both by endoscopy and histology, are variable among and within countries, and between some medical centers. There remains heterogeneity in the management of HGD/early EA throughout the world; the primary alternatives include managing HGD with surveillance alone, endoscopic therapy to remove HGD or early EA, or surgical resection of the BE (esophagectomy).[14] Innovations have taken place in the endoscopic management of EA.[15] In this rapidly changing field, a rational consensus approach to BE patients with LGD, HGD, and early EA is necessary to help inform the practicing clinician. Previously, several consensus papers have had some impact on clinical management[1,10] but have focused on BE in general; the focus of this guideline is LGD, HGD, and early EA.

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