High Burden, Unclear Benefit of Barrett’s Esophagus Screening in the US

The number of adults in the United States who meet criteria for Barrett’s esophagus (BE) screening is substantial yet highly variable, a new analysis shows.

Using national survey data and current guidance from four major gastroenterology societies, researchers found the US adult population eligible for BE screening ranges from nearly 20 million to roughly 120 million.

"This potentially imposes a considerable resource burden, especially if endoscopic screening is pursued, with unclear benefit," write Apoorva Chandar, MD, with Case Western Reserve University, Cleveland, Ohio, and co-authors.

The study was published online in Gastroenterology.

BE is a pre-malignant precursor of esophageal adenocarcinoma (EAC), which carries a poor prognosis. In an earlier systematic review and meta-analysis, Chandar and his co-authors found that BE screening and endoscopic surveillance may lead to earlier detection of EAC and improved survival. 

Targeted screening for BE, guided by age, race, obesity, smoking, chronic gastroesophageal reflux disease (GERD), and family history of BE or EAC, is recommended in the current clinical guidelines and practice updates from the American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and British Society of Gastroenterology.

However, the population at risk for BE is defined by different combinations of risk factors in the societal guidance statements, which impacts the potential burden of screening, the researchers point out.

To estimate the different potential burdens of BE screening, the researchers turned to 2012 data from the US National Health Interview Survey (NHIS), the most recent year of the annual household survey that included answers to a question about GERD symptoms.

The researchers calculated screen eligibility based on each societal guidance statement.

After weighting the NHIS data, the total noninstitutionalized US population in 2012 was about 235 million, with 44% aged 50 years and older, 48% male, and 76% non-Hispanic White. In other risk factors, 40% had a history of smoking (18% current smoker), and 27% were obese.

Nearly one quarter (23%) of the population reported experiencing symptoms of GERD over the prior 12 months. No data on personal or family history of BE or EAC were available, the authors write.

After applying criteria for BE screening based on the combination of risk factors recommended in each of the four guidance statements, the screen-eligible population ranged from 19.7 million to 120.1 million, representing 8.4%-51.1% of noninstitutionalized US adults.

Three of the four guidance statements required the presence of GERD to consider screening. Focusing only on adults with GERD, the proportion eligible for BE screening ranged from 22.1% (with one additional risk factor) to 13.4% (with at least three additional risk factors), the authors report.

Comparing the guidance in another way, the researchers calculated the resource burden by the number of risk factors in each statement. When BE screening is expanded to all patients regardless of GERD, the proportion of US adults eligible for screening ranged from 78.1% (with at least two risk factors) to 24.7% (with at least four risk factors).

The burden was lower when screening was limited to adults aged 50-75 years. In this scenario, 28.5% of adults with two additional risk factors would be eligible, while 10.3% of adults with GERD and one additional risk factor would be eligible.

The findings highlight the "substantial burden" of screen-eligible population for BE according to current guidance, as well as the variability depending on risk factors used to target screening, the investigators say.

They note that invasive endoscopic screening will impose "significant utilization of healthcare resources" and suggest that noninvasive screening may be preferable.  

The investigators point out that the prevalence of BE, even in adults with multiple risk factors is 5%-10%, and in adults with BE, the risk of neoplasia that warrants intervention is small.

"Further elucidation and refinement of screening criteria, better understanding of risks and benefits of screening and surveillance, and high-performing, scalable, noninvasive modalities for screening are warranted before population implementation of screening for BE," the study team concludes.

Funding for the study was provided by the National Institutes of Health. Chandar reports no relevant financial relationships.

Gastroenterology. Published online March 29, 2023. Full text.

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Cite this: High Burden, Unclear Benefit of Barrett’s Esophagus Screening in the US - Medscape - Apr 06, 2023.