'One and Done' BE Screening Approach May Not Be Enough

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another GI Common Concerns.

When it comes to screening for Barrett esophagus (BE), I've always practiced with a "one and done" strategy. The only exception to this approach is if we suspect that a patient may have erosive esophagitis, which prompts us to go back and ensure there's nothing hidden under the erosive change.

This is in alignment with the most recent iteration of guidelines from the American College of Gastroenterology on the diagnosis and management of BE, which state that a single screening endoscopy should be restricted to those with symptoms of chronic gastroesophageal reflux disease (GERD) and three or more of the following risk factors: over the age of 50 years, Caucasian race, male, smokers, obesity, and/or first-degree relative with BE or esophageal adenocarcinoma.

Although it's tradition that we don't repeat screening for BE, and it's supported by the guidelines, what should we do if patients develop BE after that initial screening is performed?

Recent Data Suggest a Shift in Screening Strategies Is Warranted

The ProGERD study, first reported in 2006 and then again in 2012, assessed for the incidence of BE in approximately 6000 patients with nonerosive disease at clinics in Australia, Switzerland, and Germany. They observed that BE was demonstrated in 0.5% of patients at 2 years and 4.2% at 5 years.

There are some data showing that BE may develop in early to middle adulthood. Therefore, if the one-time endoscopy screening was performed too early, it may not be quite as effective in prevention.

This topic was evaluated in a very interesting and well-designed cost-effectiveness study by Dr Joel Rubenstein and colleagues. They ran three simulation models and found that, in Caucasian male patients with chronic GERD symptoms, a repeat endoscopy from age 45 to 60 actually prevented 23% of cases of esophageal adenocarcinoma and 30% of deaths associated with esophageal adenocarcinoma. Conversely, their data indicated that a repeat endoscopy was not cost-effective in women and, in fact, it may cause net harm in Black women. So, these cost-modeling data certainly suggest that a repeat endoscopy may be worth discussion in specific groups.

A separate study from Dr Joel Rubenstein and colleagues looked at the yield of a repeat endoscopy of BE after a normal index endoscopy. This was a national retrospective analysis of a US Veterans Health Administration database of approximately 71,000 individuals who had a normal index endoscopy performed before the age of 70, followed by a repeat endoscopy between 1 and 16 years later. They then looked at ICD-9 codes to identify new diagnoses of BE, esophageal adenocarcinoma, or esophagogastric junction adenocarcinoma.

What they found was very interesting regarding the duration between an initial and repeat endoscopy. For every 5 years between these procedures, the adjusted odds ratios increased by 1.31 for a new diagnosis of BE, esophageal adenocarcinoma, or esophagogastric junction adenocarcinoma. In fact, they saw the development of all three of these diagnoses in 5.7%, of which 97% were BE, 2% were esophageal adenocarcinoma, and 1% were esophagogastric junction adenocarcinoma.

I was also intrigued by what they found regarding the length of the new BE. For 55%, the length was short segment (< 3 cm), and for 22%, it was long segment (≥ 3 cm). The longest segment was up to 13 cm. It's amazing that this could have been missed on an index exam. But nonetheless, there was an incremental yield as it relates to the durability of the index exam over time and the repeat exam subsequently.

There were also increases noted for the other individual risk factors we previously discussed: Caucasian race, male, smoking history, obesity, and/or first-degree relatives with BE or esophageal adenocarcinoma. For those who had an index exam between the ages of 19 and 29, their adjusted odds ratio for developing these cancers was nearly four times greater. Additionally, a patient who had an index exam in that 19-29 age group had approximately seven times greater incremental yield compared with those with an index exam at age 65.

Time to Reconsider?

Let's back up for a moment and ask, should we continue with a "one and done" approach to BE surveillance? Maybe not.

I would certainly think about having this discussion with your at-risk patients. Consider when they had their index exam and what their other risk factors are, prior to discussing it with them in a modeling strategy.

I think there's strong evidence suggesting that this may be valuable in patients with defined risk.

Even the authors of the yield analysis do not recommend altering clinical guidelines on the basis of their findings. However, I think it should give us pause and provoke possible changes to what we've ascribed to as being tradition in BE surveillance. This new evidence suggests that maybe we should be modifiable to change.

We certainly changed our intervals for colon cancer screening, whereby the age to start has moved to 45 years. Maybe we should be doing a little bit differently with our follow-up of patients defined as being at risk for BE. Let's think about it. I certainly will.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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