Hello, my name is Dr. Rahul Shimpy, and I'm a member of the ASG Quality Assurance and Endoscopy Committee. In honor of Esophageal Cancer Awareness Month, the committee wanted to share with you each week a video tip related to Barrett's esophagus. I will kick off the series with a tip addressing patients at increased risk for Barrett's esophagus and who we should consider endoscopic screening. Let's start by discussing why we screened for Barrett's esophagus in the first place. There has been an exponential increase in esophageal adenocarcinoma in the Western world over the last few decades. Despite advancements in treatment and detection, esophageal adenocarcinoma still has poor survival, with an overall 5-year survival of less than 20%, much of that owing to the fact that it is often detected as late-stage disease. Barrett's esophagus, which is specialized intestinal-type metoplasia of the distal esophagus, is the only clear precursor lesion to esophageal adenocarcinoma, progressing in a stepwise manner from non-dysplastic Barrett's esophagus to low-grade dysplasia, to high-grade dysplasia, and ultimately to adenocarcinoma. Screening allows for identification of patients with Barrett's esophagus who can undergo endoscopic surveillance in order to detect dysplasia or early-stage adenocarcinoma, and also allows for the detection of prevalent advanced disease. Early-stage adenocarcinoma has markedly improved survival as compared to advanced-stage adenocarcinoma, and both dysplastic Barrett's esophagus and early-stage adenocarcinoma can be treated via endoscopic eradication therapy, with overall excellent outcomes. It is important to acknowledge that there are some controversial aspects to screening for Barrett's esophagus, including a lack of data clearly demonstrating its effectiveness in decreasing either the incidence of esophageal adenocarcinoma or mortality related to esophageal adenocarcinoma. Perhaps non-invasive and more cost-effective modalities, including biomarkers and other non-endoscopic techniques, will allow us to improve the effectiveness of screening for this condition in the future. That said, at this point, endoscopic screening, while imperfect, is the best tool that we have for identifying those patients who have Barrett's esophagus and are thus at increased risk of developing esophageal adenocarcinoma, and screening in selected patients is recommended by multiple societies. These are images from two patients who underwent endoscopic screening and who were found to have Barrett's esophagus. On the left, you see an image from a patient with multiple risk factors for Barrett's esophagus, found to have long-segment Barrett's esophagus during endoscopic screening. On the right, you see an image from a patient presenting for screening who was found to have long-segment Barrett's esophagus and an associated nodular lesion. This lesion was removed via endoscopic mucosal resection and turned out to be a T1A adenocarcinoma. And this patient ultimately had complete remission of his Barrett's esophagus after additional radiofrequency ablation therapy. One of the major challenges in screening for Barrett's esophagus is that the condition itself, the specialized intestinal type metoplasia of the distal esophagus, is asymptomatic. Patients with Barrett's esophagus may have associated symptoms, in particular classic GERD symptoms including heartburn and regurgitation, but these are by no means specific for Barrett's esophagus and often are not present in patients with Barrett's, potentially as a result of the impaired esophageal sensitivity which is thought to be present in some patients with Barrett's esophagus. So, if we can't rely on symptoms alone to identify patients at increased risk for having Barrett's esophagus, how can we identify those patients at increased risk and whom we should consider endoscopic screening? We do this by identifying risk factors that are associated with an increased risk of Barrett's esophagus. It is important to know that GERD symptoms alone, while neither sensitive nor specific for Barrett's esophagus, are an important risk factor. Chronic GERD is strongly associated with Barrett's esophagus, with an odds ratio of 2.9 per a prior meta-analysis. This association with GERD makes sense when you consider that Barrett's esophagus is thought to develop largely as a response to chronic esophageal acid exposure and injury. There are some data showing that more frequent and severe GERD symptoms are associated with a higher risk of having Barrett's esophagus. Age greater than 50 is another risk factor. We know that Barrett's is most frequently diagnosed in the 6th decade of life and that the prevalence of Barrett's increases with increasing age. Family history of either Barrett's esophagus or esophageal adenocarcinoma appears to be a very strong risk factor, with a risk of having Barrett's of up to 30% in first-degree relatives. Sexual or abdominal obesity confers an increased risk of Barrett's esophagus as well. We know that the majority of patients with Barrett's esophagus are white. It's at least twice as common in men as it is in women. And finally, tobacco use is an important risk factor. It appears that smokers have a nearly two-fold increased risk of having Barrett's esophagus over non-smokers. Here's a summary table I've taken from the excellent 2019 ASGE Guideline on Screening and Surveillance of Barrett's Esophagus, summarizing the effect estimates for identified risk factors for Barrett's esophagus. We know that the greater the number of risk factors for Barrett's esophagus an individual has, the greater the chance of that individual having Barrett's esophagus. In fact, in a recent systematic review, it was found that each Barrett's risk factor present increased an individual's risk of having Barrett's esophagus by 1.2%. When you look at this table, you see that amongst all of these risk factors, a family history of Barrett's esophagus or esophial adenocarcinoma stands out as a particularly significant risk factor. All major society guidelines recommend not screening the general population for Barrett's esophagus, instead selectively screening those deemed to be at increased risk of having Barrett's esophagus. There is not complete uniformity among society guidelines with regard to exactly in which patients to consider screening, although all of these guidelines recommend screening in patients with multiple risk factors. And most of these deem chronic GERD an essential risk factor in determining who to screen. The 2019 ASG Barrett Screening and Surveillance Guideline recommends screening in two groups. The first is those with a family history of Barrett's esophagus or esophial adenocarcinoma, who as we have discussed are a high risk group. The second are those patients with GERD and at least one additional risk factor, who are a moderate risk group. Those risk factors again are age over 50, obesity or central adiposity, history of smoking, and male gender. And of course, as with any screening test, you should consider whether an individual patient is a screening candidate in the first place based on comorbidities and projected lifespan. Just as we as gastroenterologists need to ensure that our patients who are seeing us for any reason are up to date on colon cancer screening, we should do the same with Barrett's esophagus. Consider whether your patients are candidates for endoscopic screening for Barrett's esophagus based on their risk factor profiles and offer the appropriate patients a chance to undergo endoscopic screening.

Barrett's esophagus

esophageal adenocarcinoma

screening

early detection

endoscopic screening