Two articles in the April issue of Clinical Gastroenterology and Hepatology show that surveillance intervals might be lengthened or even discontinued for subgroups of patients with Barrett’s esophagus. Stable non-dysplastic Barrett’s esophagus (NDBE) has a low risk of progression to high-grade dysplaisa (HGD) or esophageal adenocarcinoma (EAC), Yonne Peters et al report. In a separate study, Nour Hamade et al report a lower annual rate of progression of short-segment BE to EAC (0.07%/year) than long-segment BE (0.25%/year).
BE is precursor to EAC, which has high mortality. Surveillance of BE is recommended for detection and treatment of dysplasia and early-stage cancers. The evidence for surveillance, however, is based on findings from observational studies—there have been no randomized controlled trials of the effects of surveillance. Surveillance programs are expensive and time consuming. Strategies are needed to determine risk of BE progression and to select appropriate surveillance intervals to improve outcomes of patients.
Peters et al studied outcomes of 12,728 patients with NDBE from a Netherlands nationwide registry of histopathology results. After a mean follow-up period of 4.9 years, 436 patients developed HGD and 304 had EAC, with an incidence of 0.68 per 100 person-years. With each year the patients were found to have no disease progression by endoscopy, the risk of HGD or EAC decreased by 14% (see figure).
In patients with 2 consecutive endoscopies finding no evidence for progression, the rate of HGD or EAC decreased to 0.55 per 100 person-years (incidence rate ratio, 0.72). If surveillance endoscopy was discontinued after 3 negative endoscopies, 32 cases of HGD or EAC would be missed, but 1800 patients would not have to undergo endoscopy.
Peters et al conclude that the risk of malignant progression decreases by 28% in patients with consecutive endoscopies showing persistent NDBE, and risk decreases further with negative results from surveillance endoscopies performed at least 1 year apart.
Hamade et al followed 1883 patients with NDBE from 6 tertiary referral centers in the United States and 1 center in the Netherlands. Among them, 822 had short-segment Barrett’s esophagus (1 to 3 cm) and 1061 had long-segment Barrett’s esophagus (3 cm or more). After a median follow-up time of 6.4 years, the incidence of progression to HGD was 0.22 per 100 person-years in patients with short-segment BE and 0.67 per 100 person-years in those with long-segment BE. The corresponding incidence for EAC was 0.07 and 0.25 per 100 person-years, respectively.
After Hamade et al adjusted for other factors such as age, sex, smoking, body mass index, and hiatal hernia, the risk of progression was 3 times lower in patients with short-segment BE than long-segment BE (hazard ratio, 0.32; 95% CI, 0.18–0.57). Patients with segment length less than 1 cm were excluded from the main analysis, but no events were noted in these patients.
The findings from these studies indicate that it might be possible to reduce the number of surveillance endoscopies by discontinuing surveillance for patients with persistent NDBE or reducing the interval of surveillance in those with short-segment Barrett’s esophagus.
An editorial by Aaron P. Thrift and Andrew T. Kunzmann states these findings provide support for selecting surveillance intervals based on BE segment length, as recommended by British and Australian guidelines. However, it is not clear whether it is better to reduce surveillance intervals for patients with long-segment BE or extend surveillance intervals of patients with short-segment BE.
Thrift and Kunzmann write that incorporating BE segment length and, with further evidence, persistence of NDBE, into analysis of risk of progression are a first step toward better selection of surveillance intervals. However, there are additional factors to consider in determining whether patients with BE are at low, intermediate, or high risk of progression. Additional studies are needed to fully determine the risk of progression to HGD or EAC in patients with BE and to select accurate surveillance intervals.