MEDSCAPE SPECIAL REPORT BARRETT ESOPHAGUS and percentage link to EC

BMGky

This is the cover paragraph with their special report. This article addresses whether there is too much screening--at least, I think that what it is discussing. Again, this is Medscape's material but they indicated it could be shared, printed, emailed, so here it is.


Medscape Special Report – November 9, 2011



Barrett Esophagus
From Medscape Gastroenterology



Expert Commentary and Insight


Barrett Esophagus: Are We Screening Too Often?



Barrett Esophagus and Cancer: Not A Clear Link



Risk for Progression to Cancer in Barrett Esophagus



Esophageal Cancer: New Ideas About Risk and Management
An Expert Interview With Jaffer A. Ajani, MD

Recent News


Cancer Risk in Barrett Esophagus Lower Than Expected



Barrett Esophagus Poses Less Cancer Risk Than Thought

Guidelines for Your Practice


Screening for Barrett Esophagus



Want More Information on Barrett Esophagus? Bookmark the Barrett Esophagus Center for the latest news and perspectives.



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From Medscape Gastroenterology > Johnson on Gastroenterology
Barrett Esophagus: Are We Screening Too Often?
David A. Johnson, MD
Authors and Disclosures
Posted: 11/04/2011
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Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School.

Surveillance and diagnosis are part of the mainstay of evaluation for Barrett's esophagus (BE) in patients with reflux disease. This has been predicated on knowing that BE is a precancerous condition associated with progression to cancer at an estimated incidence of 0.4%-0.5% per year, and to high-grade dysplasia at 0.9% per year. The incidence that we quote to patients is 1.5% yearly progression to high-grade dysplasia cancer.

Those studies were done some time ago, and 2 new, very large epidemiologic studies are changing the waterfront of BE. One was published in the Journal of the National Cancer Institute [1] in July; this study came from Ireland. It was a very large database, including all patients with BE, capturing data from more than 8000 patients. The mean duration of follow-up was 7 years (range: 1-20 years). The de novo progression to cancer from BE (excluding incident cancers) at 1 year was 0.13%. This incidence is very low and very different from 0.4%-0.5% per year, which had estimated the risk to be 30-40 times that of the general population. The risk is now down to 10-11 times the risk in the general population.

The most recent study, published in The New England Journal of Medicine [2] in October, shows essentially the same information, this time coming from a study in Denmark that included all patients with BE, and excluded cancer found within the first year after diagnosis. The mean follow-up was 6 years, and the rate of progression to cancer was 0.12% per year. Progression to cancer was 3 times more common in men than women. The risk in women was inordinately low.

Let me put this in perspective for you. If you look at cost modeling studies that have been done in the past (one that comes to mind is from 2003 in the Annals of Internal Medicine [3]) they found that screening or surveillance of BE was effective from a cost standpoint, at 5-year intervals if the incident cancer risk was ≥ 1.9% per year. At 1.9%, we are talking about 4 times the rates that are being reported now. The incident rate is considerably lower than 0.1%-0.13%, the rate at which it was cost-effective to screen at 5-year intervals. The current guidelines recommend 3-year follow-up for BE. This raises the question: is it cost-effective at the present time, when, because of dollar restrictions we are tossing out things like Pap smears and prostate-specific antigen tests? Surveillance in BE is certainly now subject to cost evaluation.

Throw in the most recent study that comes from a Dr. Wani and colleagues,[4] a 5-site multicenter study that looked at the progression from low-grade dysplasia to cancer. Data were analyzed for 210 patients, and specimens were reviewed by centralized pathologists. The progression rate from low-grade dysplasia to esophageal adenocarcinoma (with a follow-up of 6 years) was 0.44% per year. In progression to cancer risk, this group did not differ from patients who had no low-grade dysplasia at study entry. The study also reiterated that there is terrible concordance for agreement on low-grade dysplasia. The kappa value was 0.14, which indicates poor agreement. Intra-observer variability was very high. This study raises red flags about the paradigm of 6-month evaluations for patients with low-grade dysplasia.

No cancers were evident in the low-grade dysplasia patients within 2 years of the diagnosis of low-grade dysplasia, so it also raises the question, could we potentially lengthen out the surveillance of low-grade dysplasia patients to longer intervals? We return to the bottom line. In the present day, no data suggest that patients with BE die at a higher rate than patients without BE. No data say that patients with BE under surveillance die at a lower rate than patients without surveillance. Even for esophageal adenocarcinomas, the risk for death doesn't seem to be higher in patients with BE under surveillance strategies.

The take-home message is that we need to re-evaluate the evaluation of risk in BE, and guideline committees need to incorporate these data, recognizing that these data are all European, and the biopsy protocols are different in Europe. The definition of intestinal dysplasia is not requisite for the diagnosis of BE in Europe as it is in the United States. These data raise a number of important questions about the relative risk for patients with BE. Do they need surveillance if they don't have dysplasia? Do patients with dysplasia need surveillance at lengthened intervals?

These findings suggest that we should not be ablating patients with low-grade dysplasia or metaplasia outside of research protocols. Certainly in clinical practice, I don't think that should be the standard of care, nor would it be justifiable in the present day based on the cost evaluation and the relative risks for these patients.

There is a lot on the plate for discussion. BE guidelines committees should convene in a more rapid fashion and reassess the relative risk, and provide guidance so we can achieve cost-effective medicine for our patients with BE.

So, let's pause, take a step back, and look at BE with a lot less concern than we used to. There is no question that BE is a precancerous condition and that it is associated with adenocarcinoma of the esophagus. As the biologic behavior of BE has become better understood, the relative clinical significance has dwindled. In your next conversation with your patients with BE, put this into perspective and evaluate the strategies for surveillance. Hopefully, the guidelines will also provide us with some meaningful changes in the not-too-distant future.

I'm Dr. David Johnson. Thanks again for listening.

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dodger21

Concern
My main concern with this report is:
1) they say that adenocarcinoma is on the increase and that is caused by GERD and Barretts. But they are, in the same report, advocating for less screening for Barretts, or those with Barretts not having as regular scopes. I can see this leading to more Stage IV EC sufferers and hardly ever Stage 0 or Stage 1 anymore.

2) it makes me a bit suspicious, in this current world environment, that this report is designed to be a cost cutting exercise.

Money saved by doing less scopes on Barretts patients WILL lead to a yet further increase in EC diagnoses.

BMGky

dodger21 said:

Concern
My main concern with this report is:
1) they say that adenocarcinoma is on the increase and that is caused by GERD and Barretts. But they are, in the same report, advocating for less screening for Barretts, or those with Barretts not having as regular scopes. I can see this leading to more Stage IV EC sufferers and hardly ever Stage 0 or Stage 1 anymore.

2) it makes me a bit suspicious, in this current world environment, that this report is designed to be a cost cutting exercise.

Money saved by doing less scopes on Barretts patients WILL lead to a yet further increase in EC diagnoses.

That is exactly what I
That is exactly what I thought when I read it. I advocate for more screening--mandatory screening at age 50 sort of like colonoscopy, and then every 5 years unless a problem is noted.

It all comes down to economics. So sad.

As to their justification that cutbacks are being made for mammograms and prostate screenings, the OB-GYNs I have spoken with say these economic decisions can mean the lives of some of their young breast cancer patients--that without the early screening, their lives would have been lost.

But as the article intimated, hey! EC is rare so such a cutback is not going to impact a lot of people............ They should say that to the members of this board and see just how devastating an impact EC does have.

Ejlbjc

Dysplacia

My husband had  barretts for  about  six   years.  After  diagnosis he  had  a scope  after  one  year,  then  two  then  three.  The  barretts  went  straight  to adenocarcinoma  cancer  with  no  signs  of  displasia.   You should  review the  data  now  that  insurance/Medicare recommends a three  year scope for  barretts .  My  husband  would  be  dead  if  we  waited  any  longer.   The  solution  is  to  go a less  invasive  scope  like  trans nasal. Esophageal cancer  is  one  of  the  fastest  growing  cancers  in  terms  of  cases  diagnosed.   Now  is  not  the  time to reduce  frequency  of  scopes. He  was  51 at the  time  of  diagnosis. 

Ladylacy

EC

I don't know about all these reports and tests.  My husband was diagnosed with laryngeal cancer.  He underwent radiation, chemo and then had his laryx removed and some nodes which showed no spread of the cancer.  For a year he had his scopes and PET/CT scans every 3 months.  One year later he decided to have a TEP inserted so he could talk, I remember so well the head and neck specialist coming out and saying to me he couldn't do it because he found a small tumor at the cervical of my husband's esophagus and it was biopsied and it was cancer.  Rare spot for a 2nd primary I was told and also told surgery was out of the question due to this cancer being in basically the same spot from the laryngeal cancer.  So he underwent another round of radiation and chemo and was NED for only 6-8 months when it was found that the tumor at the cervical of his esophagus had returned much larger and the cancer had spread to his right lung.  At this point my husband said he was tired of all the treatment and decided not to have any further treatment, only thing offered was chemo and we were told it wouldn't cure only prolong and possibly hasten his time.  He lived another 3 years, 2 1/2 years were good, and he outlived what they said survival rates were for the 2nd primary with or without treatment.

I wonder now if the first radiation caused the 2nd primary cancer.  I also think we all have the genes for cancer and that it is all in the hands of the man upstairs whether we survive or not.  I am not a religious person but still think the man upstairs decides when to call us home regardless of the situation.

I also think that there is a cure for the majority of cancers but the manufacturers of the medication would be out of the big dollars if they produced it and treatment centers, doctors and hospitals would lose big time.   Our government cares less about the people of this country and it doesn't make any difference with either party.  We can spend the money on the illegals, other countries who hate us, we take in refugees, but yet we can't take care of our own.  We have people living on the streets, dying from all types of diseases, going hungry, but yet our government does nothing about it.  Other than to allow illegals and refugess to come into this country and get the benefits that citizens can't get.  Just my opinion.