Backing Off Surveillance for Barrett's Esophagus Possible

Damian McNamara

May 09, 2017

CHICAGO — For people with Barrett's esophagus who have nondysplastic findings on two consecutive follow-up endoscopies, surveillance for progression can often be relaxed, according to a large nationwide Dutch registry study.

"After two consecutive nondysplastic Barrett's esophagus findings, you can consider a longer interval for surveillance, maybe up to 6 or 7 years," said Yvonne Peters, MD, from the Radboud University Medical Center in Nijmegen, the Netherlands.

Persistent nondysplastic findings reflect a lower-risk population, she explained. "I think surveillance for patients with persistent nondysplasia could be stopped in some cases, so they are not exposed every 3 to 5 years," she added.

As it is performed currently, "surveillance is not effective," she told Medscape Medical News. But "it's really important to identify patients who are likely to progress to adenocarcinoma, as well as those patients who are not likely to progress."

The surveillance strategy should be individualized for each patient, Dr Peters emphasized. People with a longer segment are at higher risk, for example, in part because there is a higher likelihood that biopsy sampling could miss dysplasia. In addition, men tend to progress more than women.

 
After two consecutive nondysplastic Barrett's esophagus findings, you can consider a longer interval for surveillance, maybe up to 6 or 7 years.
 

"Maybe in female patients with 2 to 3 cm length of Barrett's esophagus after two consecutive nondysplastic endoscopies, surveillance can be stopped," she suggested during a presentation that generated a lot of discussion here at Digestive Disease Week 2017.

In their study, Dr Peters and her colleagues evaluated the outcomes of 12,729 people diagnosed with Barrett's esophagus from 2003 to 2012.

During the median follow-up of 5.1 years, 6632 patients underwent one follow-up endoscopy, 3491 underwent two, 1590 underwent three, 654 underwent four, and 362 underwent five. Malignant progression occurred in 437 patients, or 3.4% of the study cohort.

At the first follow-up endoscopy, 93.0% of patients had no evidence of dysplasia, 5.3% had progressed to low-grade dysplasia, and 1.6% had evidence of high-grade dysplasia or esophageal adenocarcinoma.

Rates of Esophageal Adenocarcinoma

Overall, rates of progression to esophageal adenocarcinoma were 0.47 per 100 person-years, and to either high-grade dysplasia or esophageal adenocarcinoma were 0.68 per 100 person-years.

However, for patients with at least two consecutive follow-up endoscopies with nondysplastic findings, those rates were 0.26 and 0.40, respectively, per 100 person-years.

For people with at least five consecutive nonprogressive endoscopies, the relative risk reduction for the development of esophageal adenocarcinoma was 75%, and the progression rate was 0.13 per 100 person-years.

In addition, for every year of follow-up, the risk of developing cancer decreased by 15%. "It will be interesting to see if there is an end point for progression-free survival," Dr Peters said.

Strengths of this study include its population-based cohort of unselected patients, a mean follow-up of 5.1 years, and the large number of patients with one, two, or three surveillance endoscopies. Limitations include the fact that it is a registry-based study with no clinical data, such as body mass index, available.

After the presentation, a member of the audience pointed out that people who had undergone more surveillance endoscopies would likely have undergone the procedure more recently than those who had undergone fewer procedures, and this was a potential source of bias.

"That is a good suggestion," Dr Peters said. "We have not looked at the year of diagnosis."

Another audience member pointed out that research has demonstrated a steady increase in the risk for progression to dysplasia over time. Differences in populations, like veterans, could explain the conflicting findings, said the session moderators.

Findings from this study support those from a study conducted in an American population (Gastroenterology. 2013;145:548-553).

In that study, researchers "found that in patients with consecutive endoscopies showing nondysplastic Barrett's esophagus, there is a much lower risk of esophageal adenocarcinoma than in other patients," said Prashanthi Thota, MD, from the Cleveland Clinic.

In addition to extending the surveillance interval, it would be good to know "if we can stop the surveillance at a certain age," Dr Thota said.

"We generally stop doing colonoscopies at age 75. Between 75 and 85, it's discretionary, depending on the physician and patient," she explained. But for Barrett's esophagus, screening and surveillance do not have any upper age limit. "That's where this information would be useful."

Dr Peters and Dr Thota have disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2017: Abstract 535. Presented May 8, 2017.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Damian McNamara @MedReporter

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