Damian McNamara

October 24, 2016

LAS VEGAS — A new risk-stratification model could help physicians identify patients with Barrett's esophagus who are at risk for neoplastic progression, according to results from a prospective, multicenter study.

"Although patients undergo regular endoscopic examination, frequent endoscopic surveillance of all Barrett's esophagus patients may be unnecessary, and may expose patients to undue risk and costs," said Sravanthi Parasa, MD, from the University of Kansas Medical Center in Kansas City, Missouri.

"We don't have any validated models so far," Dr Parasa said here at the American College of Gastroenterology 2016 Annual Scientific Meeting. But she and her colleagues decided that the stratification of patients with Barrett's esophagus by risk for progression risk to high-grade dysplasia or esophageal adenocarcinoma "could be an extremely clinically useful."

In the Barrett's Esophagus Study, known as BEST, the team enrolled 2697 patients with Barrett's esophagus histologically confirmed at one of six tertiary care referral centers.

In the study cohort, 84% of patients were men and 87% were white. The mean length of Barrett's esophagus was 3.7 cm, mean age at baseline was 55 years, and mean body mass index was 28 kg/m2.

Seventy percent of the cohort was used to develop the prediction model, and the remaining 30% was used for validation with the Cox proportional hazard model.

During a mean follow-up of 5.9 years,154 patients (5.7%) with Barrett's esophagus progressed to high-grade dysplasia or esophageal adenocarcinoma.

Several progression risk factors emerged. These were assigned points and incorporated in a weighted fashion into the prediction model.

Table. Points Assigned to Risk Factors for Progression

Risk Factor Hazard Ratio Points Assigned
Each 1-cm increase in length of Barrett's esophagus 1.13 1 (to a maximum of 10)
Smoker or smoking history 1.82 5
Male 3.02 9
Diagnosis of low-grade dysplasia 3.50 11

 

A score of 0 to 10 was considered low risk, of 11 to 20 was considered intermediate risk, and of more than 20 was considered high risk.

Risk for progression was higher in the intermediate-risk group than in the low-risk group (hazard ratio [HR], 5.6), and was higher in the high-risk group than in the low-risk group (HR, 18.4).

"In validation, this model had excellent prediction capability," Dr Parasa reported.

This scoring system might be a useful for determining which patients with Barrett's esophagus require no surveillance, which require surveillance, and which require ablation, the researchers note.

After the presentation, a member of the audience asked whether the model is good enough to "tell us that nonsmoking women with nondysplastic, short-segment Barrett's esophagus don't need surveillance."

"They would probably fall into the low-risk group, with a score from 0 to 10, Dr Parasa replied. Once this is validated more widely, "they would not undergo any kind of surveillance because their progression risk is really low and cost-effectiveness might be really poor."

"It's a controversial issue, taking a nonsmoking woman out of surveillance," said Felice Schnoll-Sussman, MD, from Weill Cornell Medicine in New York City.

"We always want to be cautious," she told Medscape Medical News.

"We're always looking for the Holy Grail for this patient population to undergo surveillance in a cost-effective way," said Dr Schnoll-Sussman. "This could potentially stratify patients at highest risk."

Dr Parasa and Dr Schnoll-Sussman have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2016 Annual Scientific Meeting: Abstract 25. Presented October 17, 2016.

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