Hi, I'm Sachin Mani, a gastroenterologist at the University of Colorado, and in honor of Esophageal Cancer Awareness Month, I'd like to talk to you today about surveillance intervals in patients with known Barrett's esophagus. As we all know, the incidence of esophageal cancer continues to rise over the past few decades, as demonstrated in this most recent analysis using the SEER database. So what is our current approach to prevention of esophageal adenocarcinoma? The first step is to screen individuals at risk for Barrett's esophagus and esophageal adenocarcinoma. Barrett's esophagus, as we know, is the only identifiable premalignant condition for esophageal adenocarcinoma. Once we do make a diagnosis of Barrett's esophagus, these patients are then recommended to undergo surveillance endoscopies with the hope of identifying high-grade dysplasia or early esophageal adenocarcinoma. We know that Barrett's esophagus progresses to cancer in a stepwise and a probabilistic fashion. It goes through these stages of nondysplastic Barrett's esophagus to low-grade dysplasia to high-grade dysplasia, and then to invasive esophageal adenocarcinoma. And despite all the advances that we've made in the field of biomarkers in 2021, the degree of dysplasia is the best biomarker we have to predict progression of Barrett's esophagus to esophageal adenocarcinoma and determine the next best management plan, which is either enrolling patients in surveillance programs or referring these patients for endoscopic eradication therapy. Now, before we talk about surveillance intervals in patients with Barrett's esophagus, it's really important to understand what the natural history is for patients with nondysplastic Barrett's esophagus. And if you focus your attention on all the contemporary studies, studies that have been published over the last decade or so, the message is fairly clear. The risk of progression in patients with nondysplastic Barrett's esophagus is fairly low. The estimate that we share with our patients is 0.25% per year. Or put it differently, 1 in 400 patients with Barrett's esophagus will progress to esophageal adenocarcinoma. It is based on this low risk of progression to high-grade dysplasia or cancer that our U.S. guidelines recommend that we perform surveillance endoscopies in patients with nondysplastic Barrett's esophagus every three to five years. International guidelines actually have taken this a step further and recommend stratifying surveillance intervals based on the length of the Barrett's esophagus. For patients with Barrett's esophagus that measures three centimeters or greater, surveillance endoscopy is recommended in three years. On the other hand, patients with a Barrett's length of less than three centimeters can have their endoscopies pushed out to every five years. This is all based on strong observational data suggesting that the length of the Barrett's segment is one of the strongest predictors for progression to high-grade dysplasia or esophageal adenocarcinoma. It's also important to understand that surveillance intervals has been suggested as a quality metric in the management of patients with Barrett's esophagus. It is suggested that if you've obtained systematic surveillance biopsies in a patient with Barrett's esophagus and if those biopsies do not demonstrate any evidence of dysplasia, it is recommended that these patients are brought back no sooner than three to five years. Not only that, inappropriately frequent endoscopy in patients with nondysplastic Barrett's esophagus has been targeted by the ABIMs choosing wisely campaign as an area of improvement. So let's try and answer this question as a community of endoscopists, how well do we measure up to this quality metric? Results are fairly sobering, as we've shown from this analysis using GI Quick, a national benchmarking registry, which analyzed surveillance endoscopy recommendations in over 58,000 upper endoscopies performed in over 53,000 patients. We showed that nearly 30% of all procedures were actually non-adherent and brought back too soon after making a diagnosis of nondysplastic Barrett's esophagus, resulting in over 42,000 excess endoscopies performed in a 10-year time frame. In a time trend analysis, we've also shown that adherence to this quality measure of performing appropriate surveillance endoscopy at three to five years has improved with time. So when we think about performance of endoscopy and this whole concept of overutilization, we can understand the factors that drive overutilization of endoscopy in patients with nondysplastic Barrett's esophagus. This may be driven by fear of missing cancer, the fear of medical malpractice, litigation, higher financial incentives, underappreciation of harms of endoscopy, and this whole concept of clinicians and our society always wanting to do more rather than waiting. What are some of the factors that can actually shift this pendulum towards appropriate utilization of endoscopy? This has to start with educational programs, shared decision-making, and improved implementation of our clinical care guidelines and quality measures. And finally, there's an urgent need for improved risk stratification for our patients with Barrett's esophagus, and this is likely best accomplished by a combination of clinical factors and biomarkers. There's also a need for validation of our existing prediction tools. Thank you so much for your attention.

surveillance intervals

Barrett's esophagus

esophageal cancer

screening

dysplasia