2014-04-24 18:54:53 UTC

Should We Screen Women and Non-Caucasians for Barrett’s Esophagus?

May 1, 2014


Julian A. Abrams, MD, MS

Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY

While the rate of rise in incidence of esophageal adenocarcinoma (EAC) has slowed somewhat, this malignancy is still associated with a dismal prognosis. Risk factors for EAC include male gender, Caucasian race, central obesity, smoking and a history of reflux. Barrett’s esophagus (BE), the precursor lesion to EAC, is easily identifiable on routine upper endoscopy and can be monitored for the development of precancerous changes. We generally assume that by performing endoscopic surveillance in our BE patients, we can detect high-grade dysplasia and EAC at early stages, when it is still easily treatable. Therefore, shouldn’t we perform screening endoscopies with the goal of identifying all patients with BE?

While this line of reasoning seems logical, the issue is not at all straightforward, as multiple factors go into the decision to perform any type of screening test. While the incidence of EAC is rising, it is relatively low compared to other GI cancers such as colon or even pancreas. However, mortality in esophageal cancer is extremely high, and thus there may still be significant benefit to detection at early, asymptomatic stages. Another consideration is cost, including medical (from unnecessary tests or treatments), psychological (to the patient) and financial (to the health-care system).

In the GI practice setting, we perform endoscopy not to screen for EAC but rather for Barrett’s esophagus, the precursor lesion. However, the overwhelming majority of BE patients will not progress. I tell my BE patients without dysplasia that, over the next five-to-10 years, they have only a 1 to 2 percent chance of developing esophageal cancer. By performing endoscopic surveillance, we subject our BE patients to numerous costly endoscopies when most will ultimately die from something other than EAC. On the other hand, an endoscopy is a relatively low-risk procedure, and maybe we can catch those unlucky progressors early simply through endoscopic surveillance. Interestingly though, a recent well-conducted study examining data from Northern California showed that BE patients under surveillance did not have a decreased risk of death from EAC compared to those who did not get surveillance.1 In other words, surveillance for patients with BE may have little if any benefit in terms of reducing the number of deaths due to esophageal cancer.

So how does this relate to the initial question: should we screen women and non-Caucasians for BE? As most of us as gastroenterologists have recognized from clinical experience, BE is much more common in Caucasians and males. Let us assume for a moment that endoscopic surveillance is indeed beneficial. In general, cancer prevention efforts should be targeted to those patients at higher risk; there are more than 2,000 cases of male breast cancer per year, but we do not perform screening mammograms in men. The professional societies provide some guidance by suggesting that we screen patients who have risk factors for EAC. Remarkably, nearly 90 percent of all EAC cases occur in men. The incidence of EAC in Caucasians is also two-to-four times higher than in non-Caucasians. While Caucasian males are clearly the highest risk group for EAC, we should not off-hand dismiss females and non-Caucasians from EAC prevention strategies. A 60-year-old female with chronic GERD, central adiposity and a heavy smoking history potentially warrants screening.

Furthermore, screening low-risk groups is reasonable if the cost is minimal and we have a highly effective intervention, in this case to reduce deaths from EAC. Unfortunately, endoscopy is relatively expensive, and the benefit of surveillance (regardless of gender or race) is questionable. If we perform screening endoscopy on all patients, then a very large number of patients would need to be screened to possibly prevent a single death from EAC.

While Caucasian males are clearly the highest risk group for EAC, we should not off-hand dismiss females and non-Caucasians from EAC prevention strategies.

However, our views on screening for BE may change over the next several years. Use of cheaper, less invasive tests such as transnasal endoscopy or a brush cytology capsule on a string would resolve many screening cost issues. There is also a push in the field toward identifying markers of risk stratification for BE, which would allow for interventions aimed at high-risk patients, who, theoretically, would derive the most benefit. The low-risk majority would then need little to no follow-up. If these developments come to fruition, then there may be increased enthusiasm for screening all populations. Until then, we should continue to individualize screening recommendations after assessing the likelihood of BE based on each patient’s risk factors, regardless of sex or race.

Dr. Abrams provides consulting for C2 Therapeutics.


1. Corley DA, Mehtani K, Quesenberry C, et al. Impact of endoscopic surveillance on mortality from Barrett’s esophagus-associated esophageal adenocarcinomas. Gastroenterology 2013;145:312-9 e1.

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