In Barrett Esophagus Surveillance, Slower Is Better

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Colonoscopy has taught us a lot about why slower is better. By increasing the adenoma detection rate, there is evidence of a direct correlation with decreased risk for interval colorectal cancer and improved mortality.

But, when it comes to performing endoscopy in Barrett esophagus, those lines of evidence aren't quite so clear. Now, a provocative and informative study, which was just published from researchers in the United Kingdom, indicates that endoscopy performed in this indication also shows that slower and longer is better.

What We Can Do Better in Endoscopic Surveillance

Endoscopic surveillance of Barrett esophagus is recommended in the most recent guidelines by Dr Nicholas Shaheen and colleagues from the American College of Gastroenterology (ACG), who emphasize that the Seattle protocol should be used. This is a protocol that some of you may not be old enough to remember, given that it came out in 1993. Its aim was to carefully inspect the Barrett segment with biopsies of any endoscopic visible lesions, followed by four-quadrant standard biopsies at most every ≤ 2 cm for high-risk patients. This was then used to dictate how they should be best surveyed based on the early detection of dysplasia.

Unfortunately, the Seattle protocol is not used as it should be. A community-based assessment from the United States suggested that the criteria for Seattle protocol recommendations were met in only 51.2% of cases. It also decreased with increasing length of segment of the Barrett esophagus. As a result, patients were not getting surveyed by this protocol that we regard as the baseline for endoscopy and screening in Barrett esophagus.

This is also observed globally, as a systematic review and meta-analysis of 45 studies found that endoscopic adherence to the Seattle protocol is marginally even less than that, at 49%.

So, as a generality, we don't do what we should be doing as it relates to the Seattle protocol.

How do we even justify that we're doing something?

Surveillance data have not been consistent in regard to decreasing the relative risk for cancer and cancer-related death. Retrospective studies have shown some marginal improvement, but that same finding has not been evident in case-control studies. Taken as a whole, these studies suggest that the mortality benefit for endoscopic surveillance in Barrett esophagus screening is currently very low, as is the quality supporting this evidence, with reported survival benefits probably affected by lead and/or length time biases. This makes it difficult to support what we do from the basis of survival.

The Upsides of Slowing Down

We've learned from performing colonoscopy that it's all about quality, and the same principle applies to what we should be doing in Barrett esophagus.

Data from the previously mentioned UK-based study are derived from a retrospective analysis, but one with a double-blind crossover design. It evaluated high-definition white-light endoscopy with four-quadrant Seattle protocol biopsies, compared with autofluorescence and probe-based confocal endomicroscopy with targeted biopsies.

Investigators looked at 142 patients, with Barrett esophagus classified in different lengths ranging from < 5 cm to > 11 cm. They showed that the median length of time to provide this standard endoscopy was 16.5 minutes.

I've seen schedules where endoscopy is targeted for a 15-minute slot. This includes the exam, sedation, biopsies, postprocedural checks, and reporting time — all the things we do in quality endoscopy. But the time slots are very short. Screening for Barrett esophagus should be longer.

Additional results from this study show that the odds ratio for dysplasia detection increased by 1.1 times. For each 1 cm of Barrett esophagus, the incremental endoscopy time increased by 0.9 minute. So, although it took a little bit longer, it resulted in greater incremental detection yield of both low- and high-grade dysplasia and intramucosal carcinoma. And again, these were all without visible lesions. This shows that going more slowly drives the quality and leads to a better outcome.

The authors suggest that for a Barrett esophagus length of up to 5 cm, a 30-minute slot should be allocated, whereas for a Barrett esophagus length greater than that, you should "double slot" these patients and take approximately 40 minutes.

Insisting on Improvement

It should be noted that this study didn't allow for the use of narrow-band imaging, which should be the standard. The ACG guidelines support strongly that the standard should be the use of electron microscopy, chromoendoscopy, or acetic acid. These are routinely best, perhaps using the chromoendoscopy through narrow-band imaging.

Another thing to call your attention to is a 2016 publication from Dr Prateek Sharma and colleagues, who put together a brilliant categorization called the BING (Barrett's International NBI [narrow-band imaging] Group) criteria. This was developed as a validated, prospective, consensus-driven classification, which should be the standard. It uses morphologic characteristics based on mucosal and vascular patterns, the regularity of which dictate what the classification of the BING criteria should be. It also helps allocate how these patients should be surveyed.

What we see on histologic analysis influences what we do as far as interval surveillance. The ACG guidelines advocate that we can increase these intervals for smaller lengths of Barrett esophagus and tighten them up for longer lengths and more evidence of risk.

We learned a lot from colonoscopy and colon polyps. Are we just starting to learn this on the esophagus? To me, going more slowly when screening for Barrett esophagus is actionable now. It will take more time, so make sure you budget appropriately. We are on the tipping point of showing that we can change outcomes. Use the BING criteria, narrow-band imaging, or some type of chromoendoscopy. And please, the Seattle protocol was not meant to be occasionally used — it should be the standard.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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