Flashback

Flashback to 2011

Publish date: April 21, 2017

 

Barrett’s esophagus, named after Australian-born thoracic surgeon Norman Barrett in the 1950s, is now recognized as an important risk factor for esophageal adenocarcinoma. Estimating the magnitude of this risk has proved challenging; however, as early studies of Barrett’s esophagus tended to overestimate cancer risk because of small sample sizes and selection bias. Accurate risk estimation has profound implications for whether and how to identify and monitor patients with Barrett’s esophagus as part of a cancer-prevention strategy.

The December 2011 issue of GI & Hepatology News highlighted an influential study by Frederik Hvid-Jensen and his colleagues from Aarhus (Denmark) University that harnessed the power of Danish population-based registries to estimate the incidence of esophageal adenocarcinoma and high-grade dysplasia among patients with Barrett’s esophagus. Published in the New England Journal of Medicine (2011;365:1375-83), the study utilized data from Denmark’s national pathology and cancer registries to calculate the incidence of adenocarcinoma among patients with Barrett’s esophagus, compared with the general population. The study was unique in that there was nearly no loss to follow-up and no referral bias because of the nature of the registry.

Dr. Megan A. Adams

Dr. Megan A. Adams

The incidence of esophageal adenocarcinoma among patients with Barrett’s esophagus was found to be only 1.2 cases/1,000 person-years, roughly four to five times lower than some rates previously reported. This conclusion added fuel to an already growing skepticism regarding the utility of aggressive endoscopic surveillance programs and encouraged less intensive surveillance recommendations than espoused by some gastroenterology guidelines at the time. It is worth noting that even our current attenuated strategy of surveillance every 3-5 year remains controversial, given conflicting evidence regarding whether endoscopic surveillance improves overall outcomes to justify the increased costs for surveillance. As elegantly stated by the accompanying editorial, “the problems with the screening and surveillance strategy for patients with Barrett’s esophagus lie not in the logic but in the numbers.”

Megan A. Adams, MD, JD, MSc, is a general gastroenterologist at Veterans Affairs, an investigator in the VA Center for Clinical Management Research, and a lecturer in gastroenterology at the University of Michigan, all in Ann Arbor. She currently serves as chair-elect of the AGA Quality Measures Committee and is an associate editor of GI & Hepatology News.

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