Barrett's Esophagus: First-line Endoscopic Therapy Validated

Ricki Lewis, PhD

December 31, 2014

Clinical outcomes for endoscopic therapy for Barrett's esophagus (BE)-related neoplasia improved considerably from 2011 to 2013, according to a study published online December 24 in Gut.

BE-related neoplasia, which refers to high-grade dysplasia and intramucosal cancer, is associated with a 40% to 60% risk of progressing to adenocarcinoma. Five-year survival for patients with esophageal adenocarcinoma in the study population (England and Wales) is 7%. If detected early, the cancer is not likely to have metastasized and is amenable to treatment. Endoscopy has become the approach of choice, note Rehan Haidry, MD, director of endoscopy at University College London Hospital in the United Kingdom, and other members of the UK RFA Registry.

"There has been a paradigm shift in our management of Barrett's high-grade dysplasia and early cancer from surgical treatment to endoscopic treatment," Prateek Sharma, MD, professor of internal medicine at the University of Kansas School of Medicine in Kansas City, told Medscape Medical News. In 2014, the British Society of Gastroenterology recommended endoscopic therapy as first-line treatment for patients with BE-related neoplasia confined to the mucosa.

Endoscopic mucosal resection (EMR) is performed before radiofrequency ablation (RFA). EMR provides a deeper and larger specimen and can thoroughly remove visible lesions. RFA then targets the remaining flat tissue.

Increasing use of EMR followed by RFA to treat BE-related neoplasia reflects both the risks of surgery and the safety and efficacy of endoscopy. Specifically, the morbidity risk of esophagectomy is up to 40%, and the mortality risk is 2% to 4% for all diagnoses, and less than 1% for high-grade dysplasia.

The UK RFA Registry began in 2008 to evaluate RFA/EMR as first-line treatment for BE-related neoplasia. In the current study, the researchers compared clinical outcomes for 266 patients treated from 2008 to 2010 with outcomes for 242 patients treated from 2011 to 2013. The primary outcome was no evidence of dysplasia in a biopsy of the treated segment.

The researchers analyzed prospective data from patients who had EMR to remove visible lesions before trimonthly RFA until either cancer developed or the BE was ablated. The endpoint for patients with short segments of affected esophagus was the first endoscopy after treatment with no evidence of BE or neoplasia. Biopsies were performed a year after the first RFA. The investigators also noted duration of successful treatment and development of adenocarcinoma.

Post-RFA surveillance included biopsy every 3 months for the first year, twice during the second year, and annually after that. Enhanced imaging endoscopy was used to detect recurrences. Additional RFA/EMR was offered to patients with remaining or recurring dysplasia, but not to patients with intestinal metaplasia, which is common.

Outcomes improved markedly during the second 3-year period assessed. Dysplasia resolved in 77% of patients during the first period compared with 92% during the second period, and BE (intestinal metaplasia) resolved in 56% of patients during the first period compared with 83% during the second period (P < .0001). EMR for visible lesions before RFA increased from 48% to 60% (P = .013), and rescue EMR after RFA decreased from 13% to 2% (P < .0001) during the two periods.

Progression to adenocarcinoma during the 12 months after treatment remained similar during the two periods (3.6% vs 2.1%; P = .51). The investigation did not explore a possible relationship between improved reversal rates of dysplasia and decrease in adenocarcinoma incidence.

The researchers attribute the improvement in clinical outcome to increased use of EMR before RFA, because "visible and nodular lesions are more likely to harbour more advanced neoplasia," they write.

"The data from this registry confirm that a large proportion of patients are being treated with endoscopic therapy, and over time, the results are improving. This is probably related to better recognition of subtle neoplastic lesions, early detection, judicious use of EMR, and improved physician techniques. Endoscopic therapy for this patient group should be main line treatment," said Dr Sharma.

Dr Haidry has received grant support from Pentax Medical and Covidien. One coauthor has received grant support from BARRX Medical and Covidien. The other authors and Dr Sharma have disclosed no relevant financial relationships.

Gut. Published online December 24, 2014. Full text

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