World Journal of Surgery

, Volume 41, Issue 4, pp 1023–1034 | Cite as

Toward More Efficient Surveillance of Barrett’s Esophagus: Identification and Exclusion of Patients at Low Risk of Cancer

  • Mats Lindblad
  • Tim Bright
  • Ann Schloithe
  • George C. Mayne
  • Gang Chen
  • Jeff Bull
  • Peter A. Bampton
  • Robert J. L. Fraser
  • Piers A. Gatenby
  • Louisa G. Gordon
  • David I. WatsonEmail author
Original Scientific Report



Endoscopic surveillance of Barrett’s esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought.


The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals.


During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE <2 cm [IR—0.14% (IRR 8.6, 95% CIs 4.5–12.8)]. Limiting the surveillance cohort after the first endoscopy to individuals with CLE ≥2 cm, or dysplasia, followed by a further restriction after the second endoscopy—exclusion of patients without intestinal metaplasia—removed 296 (46%) patients, and 767 (37%) person-years from surveillance. Limiting surveillance to the remaining individuals reduced the incremental cost-effectiveness ratio from US$60,858 to US$33,807 per quality-adjusted life year (QALY). Further restrictions were tested but failed to improve cost-effectiveness.


Based on stratification of risk, the number of patients requiring surveillance can be reduced by at least a third. At a willingness-to-pay threshold of US$50,000 per QALY, surveillance of higher-risk individuals becomes cost-effective.


Intestinal Metaplasia Surveillance Program QALY Gain Surveillance Interval Index Endoscopy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Barrett’s esophagus


Confidence interval


Columnar-lined esophagus


Esophageal adenocarcinoma


High-grade dysplasia


Intestinal metaplasia


Incremental cost-effectiveness ratio


Incidence rate


Incidence rate ratio


Low-grade dysplasia


Not applicable


Quality-adjusted life year



Dr. Mats Lindblad was supported by Bengt Ihre Gastroenterology Fund and Swedish Society of Medicine Traveling Fund. Professor Watson and Professor Fraser received a Beat Cancer Hospital Research Package Grant which was funded by the Cancer Council of South Australia’s Beat Cancer Project on behalf of its donors and the State Government of South Australia Department of Health, together with the support of the Flinders Medical Centre Foundation, its donors and partners. This Grant funded Dr. Gang Chen’s salary.

Author contributions

Authors ML and DW contributed substantially to the conception and design of the work. ML, TB, AS, JB, GM, PG, RF, PB, and DW contributed to data acquisition. Analysis and interpretation of data was performed by ML, TB, GM, GC, PG, RF, and DW. GC, LG, and GM developed the health economic modeling. ML, TB, GM, GC, RF, PG, and DW have participated in drafting the work or revising it critically for important intellectual content. All authors have approved the version submitted and agree in all aspects of the work.

Compliance with ethical standards

Conflict of interest

There are no competing interests or conflicts of interests to disclose among the authors.


  1. 1.
    Spechler SJ, Souza RF (2014) Barrett’s esophagus. N Engl J Med 371:836–845CrossRefPubMedGoogle Scholar
  2. 2.
    Ronkainen J, Aro P, Storskrubb T et al (2005) Prevalence of Barrett’s esophagus in the general population: an endoscopic study. Gastroenterology 129:1825–1831CrossRefPubMedGoogle Scholar
  3. 3.
    Wani S, Falk GW, Post J et al (2011) Risk factors for progression of low-grade dysplasia in patients with Barrett’s esophagus. Gastroenterology 141:1179–1186CrossRefPubMedGoogle Scholar
  4. 4.
    Coleman HG, Bhat S, Johnston BT et al (2012) Tobacco smoking increases the risk of high-grade dysplasia and cancer among patients with Barrett’s esophagus. Gastroenterology 142(2):233–240CrossRefPubMedGoogle Scholar
  5. 5.
    Pohl H, Pech O, Arash H et al (2016) Length of Barrett’s oesophagus and cancer risk: implications from a large sample of patients with early oesophageal adenocarcinoma. Gut 65:196–201CrossRefPubMedGoogle Scholar
  6. 6.
    Levine DS, Haggitt RC, Blount PL et al (1993) An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett’s esophagus. Gastroenterology 105:40–50CrossRefPubMedGoogle Scholar
  7. 7.
    Association American Gastroenterological, Spechler SJ, Sharma P et al (2011) American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology 140:1084–1091CrossRefGoogle Scholar
  8. 8.
    Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology (2008) Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 103:788–797CrossRefPubMedGoogle Scholar
  9. 9.
    Hirota WK, Zuckerman MJ, Adler DG et al (2006) ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 63:570–580CrossRefPubMedGoogle Scholar
  10. 10.
    Shaheen NJ, Weinberg DS, Denberg TD et al (2012) Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med 157:808–816CrossRefPubMedGoogle Scholar
  11. 11.
    Committee ASoP, Evans JA, Early DS et al (2012) The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest endosc 76:1087–1094CrossRefGoogle Scholar
  12. 12.
    Fitzgerald RC, di Pietro M, Ragunath K et al (2014) British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s esophagus. Gut 63:7–42CrossRefPubMedGoogle Scholar
  13. 13.
    Gordon LG, Mayne GC, Hirst NG et al (2014) Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett’s esophagus. Gastrointest Endosc 79:242–256CrossRefPubMedGoogle Scholar
  14. 14.
    Neumann PJ, Cohen JT, Weinstein MC (2014) Updating cost-effectiveness — The curious resilience of the $50,000-per-QALY threshold. NEJM 371:796–797CrossRefPubMedGoogle Scholar
  15. 15.
    Barbiere JM, Lyratzopoulos G (2009) Cost-effectiveness of endoscopic screening followed by surveillance for Barrett’s esophagus: a review. Gastroenterology 137:1869–1876CrossRefPubMedGoogle Scholar
  16. 16.
    Hirst NG, Gordon LG, Whiteman DC et al (2011) Is endoscopic surveillance for non-dysplastic Barrett’s esophagus cost-effective? Review of economic evaluations. J Gastroenterol Hepatol 26:247–254CrossRefPubMedGoogle Scholar
  17. 17.
    Koop H, Fuchs KH, Labenz J et al (2014) S2 k guideline: gastroesophageal reflux disease guided by the German Society of Gastroenterology: aWMF register no. 021–013. Z Gastroenterol 52:1299–1346CrossRefPubMedGoogle Scholar
  18. 18.
    Bampton PA, Schloithe A, Bull J et al (2006) Improving surveillance for Barrett’s esophagus. BMJ 332:1320–1323CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Devesa SS, Blot WJ, Fraumeni JF Jr (1998) Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 83:2049–2053CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Mats Lindblad
    • 1
    • 4
  • Tim Bright
    • 1
  • Ann Schloithe
    • 1
  • George C. Mayne
    • 1
  • Gang Chen
    • 3
  • Jeff Bull
    • 1
  • Peter A. Bampton
    • 2
  • Robert J. L. Fraser
    • 2
  • Piers A. Gatenby
    • 5
  • Louisa G. Gordon
    • 6
  • David I. Watson
    • 1
    • 3
    Email author
  1. 1.Department of SurgeryFlinders University, Flinders Medical CentreAdelaideAustralia
  2. 2.Department of Gastroenterology and HepatologyFlinders UniversityAdelaideAustralia
  3. 3.Flinders Centre for Innovation in CancerFlinders UniversityAdelaideAustralia
  4. 4.Division of Upper Gastrointestinal Surgery, Centre of Digestive Diseases, KarolinskaUniversity HospitalStockholmSweden
  5. 5.Department of SurgeryRoyal Surrey County HospitalGuildfordUK
  6. 6.Centre for Applied Health EconomicsGriffith UniversityBrisbaneAustralia

Personalised recommendations