barretts esophagus guidelines

the American College of Gastroenterology updated their recommendations for screening for Barrett's Esophagus (see barretts screening dx rx amjgastro2015 in dropbox, or doi: 10.1038/ajg.2015.322)

background: 

    --there is increasing prevalence of GERD in the US and worldwide

    --GERD is associated with 10-15% risk of Barrett's esophagus (BE), ie in 1-2% of the population, with risk factors of male sex, central obesity, intensity/duration of GERD sx, and >50yo. The most profound risk factors are: those with early onset (<30 yo) and weekly symptoms (OR 31.4), and family history of BE or esophageal adenocarcinoma (EAC) (OR 12.23). white men with GERD have 2% chance of BE in the third decade of life, increasing to 9% by 6th decade. men have twice the risk as compared to women for both BE and EAC. alcohol does not increase risk of BE. 

    --BE is associated with EAC, which has also been increasing in incidence. risk factors for EAC in people with BE include: advancing age, increased length of BE segment, central obesity, tobacco use, lack of use of NSAIDs, lack of usage of PPIs, lack of usage of statins

    --the relationship with H pylori and BE is complex. certain strains (eg cytotoxin-associated gene A, or Cag A+) may have a decreased risk. A VA study confirmed a lower risk of BE in those with H pylori, especially in those with gastric atrophy (which might be associated with the increased risk of stomach cancer, however)or use of antisecretory meds [see The American Journal of Gastroenterology 109, 357-368 (March 2014)]. The Cag A+ strain is a more aggressive H pylori strain and decreases gastric acid production more, which may be the reason it may be somewhat protective for developing BE.

    --risk of EAC:

        --for those without dysplasia, 0.2-0.5%/yr

        --with low-grade dysplasia: 0.7%/yr

        --with high-grade dysplasia: 7%/yr

        ​--90% of patients with BE die from causes other than EAC
recommendations:

    --consider in men with >5 year history and/or frequent (weekly or more) symptoms of GERD, and 2 or more risk factors (age >50, white, central obesity with waist circumf >102 cm/40 inches or waist-hip ratio of >0.9, current or past smoking, confirmed family history of BE or EAC in a first-degree relative. (strong recommendation, mod level of evidence)

    --in females (who have half the BE risk), screening not recommended. But, consider in individual cases if multiple risk factors (as above, though in women waist circumf of > 88cm/35 inches or waist-hip ratio of >0.8). (strong recommendation, low level of evidence)

    --do not screen general population [though it is important to remember that 40% of EAC occur in patients without history of GERD]

    --consider life expectancy in decision to screen

    --can do unsedated transnasal endoscopy instead of conventional upper endoscopy

    --if initial endoscopy is negative for BE, no need to repeat. if esophagitis, repeat endoscopy after 8-12 weeks of PPI to ensure healing and exclude underlying BE (conditional recommendation, low level of evidence)

so, a few points:

--the Am Cancer Society's estimated incidence of esophageal cancer in 2015 is: 16980 new cases, with 13570 in men and 3410 in women.

--of the common esophageal cancers, BE is associated with adenocarcinoma and not with squamous cell carcinoma (squamous cell ca in Western countries is largely associated with alcohol and smoking, and its incidence is decreasing in parallel to decreases in these risk factors)

--EAC has an abysmal survival rate when detected late (which is common in those who are symptomatic): those with regional or distant disease have a 5-year survival <20%.

--i personally think there has been supportive data for many years that men >50yo with chronic GERD symptoms should get a one-time endoscopy, so i welcome that recommendation (and in the past, when i have referred patients for EGD, some gastroenterologists would do them and others would not). but there are some unclear parts of the new recommendations:

    --per the letter of their recommendation, a 35 year old white man with central obesity and a 5.1 year history of GERD symptoms once a week should get an endoscopy. i doubt there are data to support that

    ​--though women seem to be spared the higher likelihood of BE or EAC, EAC is still a terrible disease, so i would like to see a clear risk/benefit analysis before not recommending this screen. Prior guidelines from the Am Gastroenterology Assn have just focused on risk factors overall, where male sex is a risk factor, but women would be included in the recommendation for endoscopy if they had other of the risk factors.

   --one overhanging concern with the recommendations is the lack of smoking gun evidence that doing surveillance and treating Barrett’s leads to fewer cases of EAC. Case-control studies are suggestive (though there are some showing no decrease in cases in those undergoing consistent monitoring and treatment of BE), despite the reasonable pathophysiology suggesting an orderly progression from BE to increasing levels of dysplasia to malignancy.

   --bottom line: who knows?? To make an informed decision, we need more data (eg, does screening really work? What are the real risk/benefit analyses for women, assuming screening helps?). at this point, it seems reasonable to me to screen men and women with lots of risk factors one time around age 50 (though I understand that the number of people >50 yo who have central obesity, chronic GERD symptoms, and present/past cigarette smoking is pretty staggering).