Abstract

REVIEW

Surveillance in Barrett's Esophagus: A Failed Premise

John M. Inadomi

Background: It is recommended that patients in whom Barrett's esophagus is diagnosed undergo surveillance endoscopy. However, multiple issues regarding the efficacy and feasibility of surveillance remain.
Methods: Quantitative techniques were used to examine surveillance in patients with Barrett's esophagus. A retrospective case-control study was performed to determine whether surveillance endoscopy prolonged survival in a cohort of U.S. veterans diagnosed with esophageal adenocarcinoma. Cost-effectiveness analysis was employed to compare competing strategies of management for patients with Barrett's esophagus to determine whether surveillance strategies using alternative biomarkers could out-perform dysplasia based surveillance, and whether new techniques for eradicating Barrett's metaplasia would constitute cost-effective strategies.
Results: Surveillance did not improve long-term survival among veterans diagnosed with esophageal adenocarcinoma. Lead-time bias has confounded previous reports claiming the efficacy of endoscopic surveillance. Cost-effectiveness analysis revealed that while screening 50-year old Caucasian males with heartburn may be cost-effective, surveillance even at 5 year intervals among patients with Barrett's esophagus without dysplasia exceeded the threshold of cost-effective care. If a biomarker were developed whose sensitivity and specificity to predict cancer development exceeded 80%, this could represent a more viable strategy than dysplasia-based surveillance and overcome the inherent inter- and intra-observer variations in dysplasia diagnosis that currently limit the effectiveness of surveillance programs. Finally, techniques that reduce cancer incidence such as endoscopic mucosal resection or ablation will likely be more cost-effective than current surveillance strategies that rely on early detection of cancer.
Conclusions: Current recommendations for the management of patients with Barrett's esophagus are flawed. Future guidelines should include alternative markers of cancer risk and focus on strategies that reduce cancer incidence instead of cancer detection.