Data from prospective studies published after 2002 may better predict prognosis for Barrett’s esophagus patients.6-9 Even lower rates of progression to esophageal carcinoma (<0.5% a year or <1/220 patient-years) have been reported in these studies drawing from the general population rather than referred patients, likely stemming from differences in gender mix, patient age, and risk factors.
In addition to grade of dysplasia, the length of the dysplastic Barrett’s esophagus segment is emerging as a potentially predictive risk factor. While the ACG cautions that esophageal cancer has been reported in patients with so-called “short segment” Barrett’s esophagus (SSBE) (≤3 cm),1 recent prospective studies have shown an increased risk of carcinoma development with long segment Barrett’s esophagus (LSBE).7-9 Weston et al7 reported a 2.4% progression rate to HGD or esophageal carcinoma with SSBE and no dysplasia compared with 6.8% with LSBE (P=.002). If patients had LGD, the rate of progression to esophageal carcinoma with SSBE was 5.3% and jumped to 35% in patients with LSBE (P<.001). Conio et al8 reported that 4 of 5 cases of esophageal carcinoma noted through surveillance had LSBE. Hage et al9 reported a significantly increased risk of progression to HGD or esophageal carcinoma with long segment disease (P<.02).
While currently still considered investigational, DNA content flow cytometry may be a future tool used in risk stratification. Reid et al10 report a 5-year cumulative risk of esophageal carcinoma of 1.7% in Barrett’s esophagus patients with negative, low-grade or indefinite grades of dysplasia. Subsequent application of flow cytometry allowed for further stratification of these low-risk patients. Those with neither aneuploidy nor an increased 4N had a 5-year cumulative risk of cancer of 0% while the risk for those with abnormalities on cytometry increased to 28% (relative risk=19; P<.001).
TABLE
Grade of dysplasia and recommendations for Barrett’s esophagus surveillance as proposed by the ACG
| DYSPLASIA | DOCUMENTATION | FOLLOW-UP ENDOSCOPY |
|---|---|---|
| None | Two EGDs with biopsy | 3 years |
| Low-grade | Highest grade on repeat | 1 year until no dysplasia |
| High-grade | Repeat EGD with biopsy to rule out cancer/document high-grade dysplasia; expert pathologist confirmation | Focal: every 3 months |
| Multifocal: intervention | ||
| Mucosal irregularity: EMR | ||
| ACG, American College of Gastroenterology; EGD, esophagogastroduodenoscopy; EMR, endoscopic mucosal resection. Intervention: ie, esophagectomy. Ablative therapies only in the setting of a clinical trial or for those unable to tolerate surgery. | ||
Recommendations from others
The French Society of Digestive Endoscopy has published guidelines on monitoring Barrett’s esophagus.3 Their recommendations differ only slightly from the ACG in advocating a slightly increased frequency of EGD surveillance based on degree of dysplasia, and utilizing the length of the dysplastic segment in decision-making. Neither the American Academy of Family Physicians nor the US Preventive Services Task Force make any specific recommendations about Barrett’s esophagus surveillance.