Skip to main content
SpringerLink
Log in

Barrett’s Esophagus

Is Screening and Surveillance Justified?

  • Current Opinion
  • Published:
Disease Management & Health Outcomes

Abstract

Barrett’s esophagus is a condition that develops in approximately 10–15% of patients with chronic gastroesophageal reflux disease and is the only known major risk factor for esophageal adenocarcinoma. The incidence of esophageal adenocarcinoma has increased by 350% over the last 3 decades and the reasons for this dramatic increase are unclear. At the time of cancer diagnosis up to 50% of patients will have advanced regional or distant metastatic disease, with little or no chance of cure. The overall 5-year survival rate with advanced disease remains poor at <10%. Several studies have demonstrated an early stage of diagnosis and a marked improvement in the survival of patients with esophageal cancer detected by routine endoscopic surveillance in patients known to have pre-existing Barrett’s esophagus. The aim of endoscopic surveillance in patients with Barrett’s esophagus is the early diagnosis of esophageal cancer, when it is still potentially curable. The desired outcome is to further decrease the mortality rate associated with esophageal adenocarcinoma and identify and screen populations at risk for the development of dysplasia arising from Barrett’s esophagus. This is the principle of the current screening and surveillance guidelines set out by several societies, including the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the European Society of Gastrointestinal Endoscopy. However, as most patients with Barrett’s esophagus do not develop adenocarcinoma, the cost effectiveness of endoscopie screening and surveillance strategies is questionable. To date, no prospective, randomized trials have been performed to evaluate the effectiveness of surveillance, the survival benefit in patients undergoing surveillance or the subsequent impact on healthcare costs. In this article, we focus on the basic principles and reasoning underlying the surveillance guidelines for Barrett’s esophagus. In particular, that the disease is clinically important and has a high prevalence; the transition to adenocarcinoma could have a high death and/or disability rate; early diagnosis of adenocarcinoma should reduce mortality; and the screening method should be easily applied, safe, relatively inexpensive, and applicable to a large number of patients. We then review arguments for and against screening and surveillance as they apply to these principles and discuss the current literature that reviews the effectiveness of such surveillance strategies, including an outline of cost analysis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I

Similar content being viewed by others

References

  1. Spechler SJ. Barrett’s esophagus. N Engl J Med 2002; 346(11): 836–42

    Article  PubMed  Google Scholar 

  2. Spechler SJ. Screening and surveillance for complications related to gastroesophageal reflux disease. Am J Med 2001; 111 Suppl. 8A: 130S–6S

    Article  PubMed  Google Scholar 

  3. Gopal DV, Powers J. Barrett’s esophagus and esophageal adenocarcinoma: a practical approach to diagnosis and management. Ann Long-Term Care 2002; 10(10): 27–31

    Google Scholar 

  4. Gopal DV, Lieberman DA, Magaret N, et al. Risk factors for dysplasia in patients with Barrett’s Esophagus (BE): results from a multicenter consortium. Dig Dis Sci 2003; 48(8): 1537–41

    Article  PubMed  Google Scholar 

  5. Dulai G, Guha S, Kahn K, et al. Screening for Barrett’s esophagus may not reduce morbidity and mortality due to esophageal adenocarcinoma. Gastroenterology 2002; 122: 26–33

    Article  PubMed  Google Scholar 

  6. Gopal DV. Another look at Barrett’s esophagus: current thinking on screening and surveillance strategies. Postgrad Med 2001; 110(3): 57–68

    Article  PubMed  CAS  Google Scholar 

  7. O’Connor JB, Falk GW, Richter JE. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: report on the Cleveland Clinic Barrett’s Esophagus Registry. Am J Gastroenterol 1999; 94(8): 2037–42

    PubMed  Google Scholar 

  8. Cameron AJ, Lomboy CT. Barrett’s esophagus: age, prevalence, and extent of columnar epithelium. Gastroenterology 1992; 103(4): 1241–5

    PubMed  CAS  Google Scholar 

  9. Lagergren J, Bergstrom R, Lindgren N, et al. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999; 340(11): 825–31

    Article  PubMed  CAS  Google Scholar 

  10. Sampliner RE, The Practice Parameters Committee of the American College of Gastroenterologists: practice guidelines on the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 1999; 92(4): 582–5

    Google Scholar 

  11. Alikhan M, Rex D, Khan A, et al. Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice. Gastrointest Endosc 1999; 50: 23–6

    Article  PubMed  CAS  Google Scholar 

  12. Sagan C, Flejou JF, Diebold MD, et al. Reproducibility of histologic criteria of dysplasia in Barrett’s mucosa [in French]. Gastroenterol Clin Biol 1994; 18(1.2): D31–4

    PubMed  CAS  Google Scholar 

  13. Reid BJ, Haggitt RC, Rubin CE, et al. Observer variation in the diagnosis of dysplasia in Barrett’s esophagus. Hum Pathol 1988; 19(2): 166–78

    Article  PubMed  CAS  Google Scholar 

  14. Sampliner RE, The Practice Parameters Committee of the American College of Gastroenterology: updated guidelines for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2002; 97(8): 1888–95

    Article  PubMed  Google Scholar 

  15. Dulai GS. Surveying the case for surveillance. Gastroenterology 2002; 122: 820–3

    Article  PubMed  Google Scholar 

  16. Shaheen NJ, Provenzale D, Sandler RS. Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence. Am J Gastroenterol 2002; 97(6): 1319–27

    Article  PubMed  Google Scholar 

  17. Barr H. Protagonist: endoscopie surveillance of patients with Barrett’s oesophagus. Gut 2002; 51(3): 313–4

    Article  PubMed  CAS  Google Scholar 

  18. Streite Jr JM, Andrews Jr CW, Ellis Jr FH. Endoscopie surveillance of Barrett’s esophagus: does it help? J Thorac Cardiovasc Surg 1993; 105(3): 383–7

    Google Scholar 

  19. Morales TG, Sampliner RE. Barrett’s esophagus: update on screening, surveillance and treatment. Arch Intern Med 1999; 59: 1411–6

    Article  Google Scholar 

  20. Buttar NS, Wang KK, Leontovich O, et al. Chemoprevention of esophageal adenocarcinoma by Cox-2 inhibitors in an animal model of Barrett’s esophagus. Gastroenterology 2002; 122(4): 1101–12

    Article  PubMed  CAS  Google Scholar 

  21. Heath EI, Canto MI, Wu TT, et al. Chemoprevention for Barrett’s esophagus trial: design and outcome measures. CBET Research Group. Dis Esophagus 2003; 16(3): 177–86

    Article  PubMed  CAS  Google Scholar 

  22. Kaur BS, Khamnehei N, Iravani M, et al. Rofecoxib inhibits cyclooxygenase 2 expression and activity and reduces cell proliferation in Barrett’s esophagus. Gastronenterology 2002 Jul; 123(1): 60–7

    Article  CAS  Google Scholar 

  23. Corley DA, Levin TR, Habel LA, et al. Surveillance and survival in Barrett’s adenocarcinomas: a population-based study. Gastroenterology 2002; 122: 633–40

    Article  PubMed  Google Scholar 

  24. Provenzale D, Schmitt C, Wong JB. Barrett’s esophagus: a new look at surveillance based on emerging estimates of cancer risk. Am J Gastroenterol 1999; 94(8): 2043–53

    Article  PubMed  CAS  Google Scholar 

  25. Streite Jr JM, Ellis Jr FH, Tilden RL, et al. Endoscopie surveillance of Barrett’s esophagus: a cost-effectiveness comparison with mammographie surveillance for breast cancer. Am J Gastroenterol 1998; 93(6): 911–5

    Google Scholar 

  26. Soni A, Sampliner RE, Sonnenberg A. Screening for high-grade dysplasia in gastroesophageal reflux disease: is it cost-effective? Am J Gastroenterol 2000; 95(8): 2086–93

    Article  PubMed  CAS  Google Scholar 

  27. Sonnenberg A, Soni A, Sampliner RE. Medical decision analysis of endoscopie surveillance of Barrrett’s oesophagus to prevent esophageal adenocarcinoma. Aliment Pharmacol Ther 2002; 16: 41–50

    Article  PubMed  CAS  Google Scholar 

  28. Gopal DV, Jobe BA. Screening for Barrett’s esophagus may not reduce morbidity and mortality due to esophageal adenocarcinoma. Evid Based Oncol 2002; 3: 144–5

    Article  Google Scholar 

  29. Macdonald CE, Wicks AC, Playford RJ. Final results from 10 year cohort of patients undergoing surveillance for Barrett’s oesophagus: observational study. BMJ 2000; 321: 1252–5

    Article  PubMed  CAS  Google Scholar 

  30. Playford RJ. Antagonist: endoscopie surveillance of patients with Barrett’s oesophagus. Gut 2002; 51(3): 314–5

    Article  PubMed  CAS  Google Scholar 

  31. Eckardt VF, Kunzler G, Bernhard G. Life expectancy and cancer risk in patients with Barrett’s esophagus: a prospective controlled investigation. Am J Med 2001; 111: 33–7

    Article  PubMed  CAS  Google Scholar 

  32. Gudlaugsdottir S, van Blankenstein M, Dees J, et al. A majority of patients with Barrett’s oesophagus are unlikely to benefit from endoscopie cancer surveillance. Eur J Gastroenterol Hepatol 2001; 13: 639–45

    Article  PubMed  CAS  Google Scholar 

  33. Mandal A, Playford RJ, Wicks AC. Current practice in surveillancestrategy for patients with Barrett’s oesophagus in the UK. Aliment Pharmacol Ther 2003; 17: 1319–24

    Article  PubMed  CAS  Google Scholar 

  34. Gross CP, Canto MI, Hixson J, et al. Management of Barrett’s esophagus: a national study of practice patterns and their cost implications. Am J Gastroenterol 1999; 94(12): 3440–7

    Article  PubMed  CAS  Google Scholar 

  35. Falk GW, Ours TM, Richter JE. Practice patterns for surveillance of Barrett’s esophagus in the United States. Gastrointest Endosc 2000; 52(2): 197–203

    Article  PubMed  CAS  Google Scholar 

  36. Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop. Gastroenterology 2004; 127(1): 310–330

    Article  PubMed  Google Scholar 

  37. Reavis KM, Morris CD, Gopal DV, et al. Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma that typical gastroesophageal reflux symptoms. Ann Surg 2004 Jun; 239(6): 849–58

    Article  PubMed  Google Scholar 

  38. Eloubeidi MA, Homan RK, Martz MD, et al. A cost analysis of outpatient care for patients with Barrett’s esophagus in a managed care setting. Am J Gastroenterol 1999; 94(8): 2033–6

    Article  PubMed  CAS  Google Scholar 

  39. Arguedas MR, Eloubeidi MA. Barrett’s oesophagus: a review of costs of the illness. Pharmacoeconomics 2001; 19(10): 1003–11

    Article  PubMed  CAS  Google Scholar 

  40. Inadomi JM, Sampliner R, Lagergren J, et al. Screening and surveillance for Barrett esophagus in high risk groups: a cost utility analysis. Ann Intern Med 2003; 138(3): 176–86

    PubMed  Google Scholar 

  41. Fennerty MB. Endoscopic diagnosis and surveillance of Barrett’s esophagus. Gastrointest Endosc Clin N Am 2003; 13: 257–67

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This review is supported in part by the National Institute of Health grants K23DK066165-01 (BAJ) and R03CA105959 (BAJ). The authors have no conflicts of interest that are directly relevant to the content of this review.

Author information

Authors and Affiliations

  1. Section of Gastroenterology & Hepatology, University of Wisconsin, Hospital & Clinics, H6/516, 600 Highland Ave, Madison, Wisconsin, 53792, USA

    Deepak V. Gopal (assistant professor), Mark Reichelderfer & Eric A. Gaumnitz

  2. Department of Pathology & Laboratory Medicine, University of Wisconsin, Hospitals & Clinics, Madison, Wisconsin, USA

    Josephine Harter

  3. Department of Surgery, Oregon Health & Sciences University & Portland VA Medical Center, Portland, Oregon, USA

    Blair A. Jobe

Authors
  1. Deepak V. Gopal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark Reichelderfer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eric A. Gaumnitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Josephine Harter
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Blair A. Jobe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deepak V. Gopal.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gopal, D.V., Reichelderfer, M., Gaumnitz, E.A. et al. Barrett’s Esophagus. Dis-Manage-Health-Outcomes 12, 353–361 (2004). https://doi.org/10.2165/00115677-200412060-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00115677-200412060-00002

Keywords

Search

Navigation