Adults with chronic gastroesophageal reflux disease (GERD) are at increased risk for Barrett's esophagus (BE) — the precursor to esophageal adenocarcinoma (EAC) — but most don't undergo recommended screening, new research shows.
Jennifer Kolb, MD, with UCLA David Geffen School of Medicine, Los Angeles, and colleagues surveyed 472 adults with chronic GERD who qualify for BE screening and had a recent visit with their primary care provider.
In this diverse population of people at risk for BE and EAC, only 13% had ever been advised to undergo endoscopy to screen for BE and only 5% actually had a prior screening, the study notes.
"These results make it clear that screening is rarely done," Kolb told Medscape Medical News.
The results of the survey are published online in the American Journal of Gastroenterology.
Concern High, Understanding Low
Esophageal cancer and BE have increased among middle-aged adults over roughly the past 5 years, and this increase is not because of better or more frequent screening, as reported previously by Medscape Medical News.
In fact, the majority of patients who develop EAC do not have a prior diagnosis of BE, which highlights the failure of current BE screening practices, Kolb and colleagues point out.
Professional gastroenterology society guidelines recommend screening for BE using upper endoscopy for at-risk individuals, which includes those with chronic GERD, along with other risk factors such as age older than 50 years, male sex, white race, smoking, obesity, and family history of BE or EAC.
In the current survey, most individuals said early detection of BE/EAC is important and leads to better outcomes, but most had poor overall knowledge on risk factors and indications for screening.
Only about two thirds of respondents correctly identified BE risk factors, and only about 20% believed BE screening was necessary with GERD, the researchers note.
Roughly two thirds of individuals wanted to prioritize BE screening and felt that getting an upper endoscopy would ease their concern.
Yet, 40% had no prior esophagogastroduodenoscopy (EGD). These individuals were less knowledgeable about BE/EAC risk and screening recommendations and identified more barriers to completing endoscopy.
"While minorities were most concerned about developing Barrett's esophagus and cancer, they reported more barriers to screening compared to White participants," Kolb said.
Addressing Knowledge Gaps
The primary care clinician is often the first line for patients with symptomatic acid reflux and the gateway for preventive cancer screening.
Yet, research has shown that primary care clinicians often have trouble identifying who should be screened for BE, and competing clinical issues make it challenging to implement BE screening.
"As gastroenterologists, we must partner with our primary care colleagues to help increase awareness of this lethal disease and improve recognition of risk factors so that eligible patients can be identified and referred for screening," Kolb said.
Reached for comment, Seth Gross, MD, clinical chief of the division of gastroenterology and hepatology at NYU Langone Health in New York City, said the results "shed light on the fact that patients with GERD don't have the knowledge of when they should get medical attention and possibly endoscopy."
"We may need to do a better job of educating our colleagues and patients to know when to seek specialists to potentially get an endoscopy," Gross said.
About 90% of esophageal cancers are diagnosed outside of surveillance programs, noted Prasad G. Iyer, MD, a gastroenterologist at Mayo Clinic in Rochester, Minnesota.
"Patients didn't even know that they had Barrett's [esophagus], so they were never under surveillance. They only come to attention after they have trouble with food sticking, and they can't swallow solid food," said Iyer, who also wasn't involved in the survey.
"Unfortunately, there are just so many cancers and so many issues that primary care providers have to deal with that I think this may not be getting the attention it deserves," he said.
Access to endoscopy is also likely a barrier, Iyer noted.
"The waiting list may be several months, and I think providers may focus on other things," he said.
Less-Invasive Screening Options
Fear of endoscopy may be another issue.
In their survey, Kolb and colleagues found that 20% of respondents reported fear of discomfort with endoscopy as a barrier to completing screening.
But less invasive screening options are increasingly available or in development.
This includes Cytosponge, a swallowable capsule containing a compressed sponge attached to a string. When withdrawn, the sponge contains esophageal cytology samples that can be used to identify biomarkers for BE.
In a guideline released last spring, the American College of Gastroenterology endorsed Cytosponge as a non-endoscopic BE screening modality, as reported by Medscape Medical News.
"The strength of the recommendation is conditional, but it's the first time where [the ACG] is saying that this may be an option for people," Gross said.
This research was funded by the American College of Gastroenterology. Kolb, Gross, and Iyer report no relevant financial relationships.
Am J Gastroenterol. Published online October 10, 2022. Abstract
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Cite this: Patients at Risk for Barrett's Esophagus Rarely Screened - Medscape - Oct 31, 2022.