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Patients with at least five biopsies showing nondysplastic Barrett’s esophagus were statistically as likely to progress to high-grade dysplasia or esophageal adenocarcinoma as patients with a single such biopsy, according to a multicenter prospective registry study reported in the June issue of Clinical Gastroenterology and Hepatology (doi: org/10.1016/j.cgh.2017.02.019).
The findings, which contradict those from another recent multicenter cohort study (Gastroenterology. 2013;145[3]:548-53), highlight the need for more studies before lengthening the time between surveillance biopsies in patients with nondysplastic Barrett’s esophagus, Rajesh Krishnamoorthi, MD, of Mayo Clinic in Rochester, Minn., wrote with his associates.
Barrett’s esophagus is the strongest predictor of esophageal adenocarcinoma, but studies have reported mixed results as to whether the risk of this cancer increases over time or wanes with consecutive biopsies that indicate nondysplasia, the researchers noted. Therefore, they studied the prospective, multicenter Mayo Clinic Esophageal Adenocarcinoma and Barrett’s Esophagus registry, excluding patients who progressed to adenocarcinoma within 12 months, had missing data, or had no follow-up biopsies. This approach left 480 subjects for analysis. Patients averaged 63 years of age, 78% were male, the mean length of Barrett’s esophagus was 5.7 cm, and the average time between biopsies was 1.8 years, with a standard deviation of 1.3 years.
A total of 16 patients progressed to high-grade dysplasia or esophageal adenocarcinoma over 1,832 patient-years of follow-up, for an overall annual risk of progression of 0.87%. Two patients progressed to esophageal adenocarcinoma (annual risk, 0.11%; 95% confidence interval, 0.03% to 0.44%), while 14 patients progressed to high-grade dysplasia (annual risk, 0.76%; 95% CI, 0.45% to 1.29%). Eight patients progressed to one of these two outcomes after a single nondysplastic biopsy, three progressed after two such biopsies, three progressed after three such biopsies, none progressed after four such biopsies, and two progressed after five such biopsies. Statistically, patients with at least five consecutive nondysplastic biopsies were no less likely to progress than were patients with only one nondysplastic biopsy (hazard ratio, 0.48; 95% CI, 0.07 to 1.92; P = .32). Hazard ratios for the other groups ranged between 0.0 and 0.85, with no significant difference in estimated risk between groups (P = .68) after controlling for age, sex, and length of Barrett’s esophagus.
The previous multicenter cohort study linked persistently nondysplastic Barrett’s esophagus with a lower rate of progression to esophageal adenocarcinoma, and, based on those findings, the authors suggested lengthening intervals between biopsy surveillance or even stopping surveillance, Dr. Krishnamoorthi and his associates noted. However, that study did not have mutually exclusive groups. “Additional data are required before increasing the interval between surveillance endoscopies based on persistence of nondysplastic Barrett’s esophagus,” they concluded.
The study lacked misclassification bias given long-segment Barrett’s esophagus, and specialized gastrointestinal pathologists interpreted all histology specimens, the researchers noted. “The small number of progressors is a potential limitation, reducing power to assess associations,” they added.
The investigators did not report funding sources. They reported having no conflicts of interest.
Current practice guidelines recommend endoscopic surveillance in Barrett’s esophagus (BE) patients to detect esophageal adenocarcinoma (EAC) at an early and potentially curable stage.
As currently practiced, endoscopic surveillance of BE has numerous limitations and provides the impetus for improved risk-stratification and, ultimately, the effectiveness of current surveillance strategies. Persistence of nondysplastic BE (NDBE) has previously been shown to be an indicator of lower risk of progression to high-grade dysplasia (HGD)/EAC. However, outcomes studies on this topic have reported conflicting results.
Where do we stand with regard to persistence of NDBE and its impact on surveillance intervals? Future large cohort studies are required that address all potential confounders and include a large number of patients with progression to HGD/EAC (a challenge given the rarity of this outcome). At the present time, based on the available data, surveillance intervals cannot be lengthened in patients with persistent NDBE. Future studies also need to focus on the development and validation of prediction models that incorporate clinical, endoscopic, and histologic factors in risk stratification. Until then, meticulous examination techniques, cognitive knowledge and training, use of standardized grading systems, and use of high-definition white light endoscopy are critical in improving effectiveness of surveillance programs in BE patients.
Sachin Wani, MD, is associate professor of medicine and Medical codirector of the Esophageal and Gastric Center of Excellence, division of gastroenterology and hepatology, University of Colorado at Denver, Aurora. He is supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program and is a consultant for Medtronic and Boston Scientific.
Current practice guidelines recommend endoscopic surveillance in Barrett’s esophagus (BE) patients to detect esophageal adenocarcinoma (EAC) at an early and potentially curable stage.
As currently practiced, endoscopic surveillance of BE has numerous limitations and provides the impetus for improved risk-stratification and, ultimately, the effectiveness of current surveillance strategies. Persistence of nondysplastic BE (NDBE) has previously been shown to be an indicator of lower risk of progression to high-grade dysplasia (HGD)/EAC. However, outcomes studies on this topic have reported conflicting results.
Where do we stand with regard to persistence of NDBE and its impact on surveillance intervals? Future large cohort studies are required that address all potential confounders and include a large number of patients with progression to HGD/EAC (a challenge given the rarity of this outcome). At the present time, based on the available data, surveillance intervals cannot be lengthened in patients with persistent NDBE. Future studies also need to focus on the development and validation of prediction models that incorporate clinical, endoscopic, and histologic factors in risk stratification. Until then, meticulous examination techniques, cognitive knowledge and training, use of standardized grading systems, and use of high-definition white light endoscopy are critical in improving effectiveness of surveillance programs in BE patients.
Sachin Wani, MD, is associate professor of medicine and Medical codirector of the Esophageal and Gastric Center of Excellence, division of gastroenterology and hepatology, University of Colorado at Denver, Aurora. He is supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program and is a consultant for Medtronic and Boston Scientific.
Current practice guidelines recommend endoscopic surveillance in Barrett’s esophagus (BE) patients to detect esophageal adenocarcinoma (EAC) at an early and potentially curable stage.
As currently practiced, endoscopic surveillance of BE has numerous limitations and provides the impetus for improved risk-stratification and, ultimately, the effectiveness of current surveillance strategies. Persistence of nondysplastic BE (NDBE) has previously been shown to be an indicator of lower risk of progression to high-grade dysplasia (HGD)/EAC. However, outcomes studies on this topic have reported conflicting results.
Where do we stand with regard to persistence of NDBE and its impact on surveillance intervals? Future large cohort studies are required that address all potential confounders and include a large number of patients with progression to HGD/EAC (a challenge given the rarity of this outcome). At the present time, based on the available data, surveillance intervals cannot be lengthened in patients with persistent NDBE. Future studies also need to focus on the development and validation of prediction models that incorporate clinical, endoscopic, and histologic factors in risk stratification. Until then, meticulous examination techniques, cognitive knowledge and training, use of standardized grading systems, and use of high-definition white light endoscopy are critical in improving effectiveness of surveillance programs in BE patients.
Sachin Wani, MD, is associate professor of medicine and Medical codirector of the Esophageal and Gastric Center of Excellence, division of gastroenterology and hepatology, University of Colorado at Denver, Aurora. He is supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program and is a consultant for Medtronic and Boston Scientific.
Patients with at least five biopsies showing nondysplastic Barrett’s esophagus were statistically as likely to progress to high-grade dysplasia or esophageal adenocarcinoma as patients with a single such biopsy, according to a multicenter prospective registry study reported in the June issue of Clinical Gastroenterology and Hepatology (doi: org/10.1016/j.cgh.2017.02.019).
The findings, which contradict those from another recent multicenter cohort study (Gastroenterology. 2013;145[3]:548-53), highlight the need for more studies before lengthening the time between surveillance biopsies in patients with nondysplastic Barrett’s esophagus, Rajesh Krishnamoorthi, MD, of Mayo Clinic in Rochester, Minn., wrote with his associates.
Barrett’s esophagus is the strongest predictor of esophageal adenocarcinoma, but studies have reported mixed results as to whether the risk of this cancer increases over time or wanes with consecutive biopsies that indicate nondysplasia, the researchers noted. Therefore, they studied the prospective, multicenter Mayo Clinic Esophageal Adenocarcinoma and Barrett’s Esophagus registry, excluding patients who progressed to adenocarcinoma within 12 months, had missing data, or had no follow-up biopsies. This approach left 480 subjects for analysis. Patients averaged 63 years of age, 78% were male, the mean length of Barrett’s esophagus was 5.7 cm, and the average time between biopsies was 1.8 years, with a standard deviation of 1.3 years.
A total of 16 patients progressed to high-grade dysplasia or esophageal adenocarcinoma over 1,832 patient-years of follow-up, for an overall annual risk of progression of 0.87%. Two patients progressed to esophageal adenocarcinoma (annual risk, 0.11%; 95% confidence interval, 0.03% to 0.44%), while 14 patients progressed to high-grade dysplasia (annual risk, 0.76%; 95% CI, 0.45% to 1.29%). Eight patients progressed to one of these two outcomes after a single nondysplastic biopsy, three progressed after two such biopsies, three progressed after three such biopsies, none progressed after four such biopsies, and two progressed after five such biopsies. Statistically, patients with at least five consecutive nondysplastic biopsies were no less likely to progress than were patients with only one nondysplastic biopsy (hazard ratio, 0.48; 95% CI, 0.07 to 1.92; P = .32). Hazard ratios for the other groups ranged between 0.0 and 0.85, with no significant difference in estimated risk between groups (P = .68) after controlling for age, sex, and length of Barrett’s esophagus.
The previous multicenter cohort study linked persistently nondysplastic Barrett’s esophagus with a lower rate of progression to esophageal adenocarcinoma, and, based on those findings, the authors suggested lengthening intervals between biopsy surveillance or even stopping surveillance, Dr. Krishnamoorthi and his associates noted. However, that study did not have mutually exclusive groups. “Additional data are required before increasing the interval between surveillance endoscopies based on persistence of nondysplastic Barrett’s esophagus,” they concluded.
The study lacked misclassification bias given long-segment Barrett’s esophagus, and specialized gastrointestinal pathologists interpreted all histology specimens, the researchers noted. “The small number of progressors is a potential limitation, reducing power to assess associations,” they added.
The investigators did not report funding sources. They reported having no conflicts of interest.
Patients with at least five biopsies showing nondysplastic Barrett’s esophagus were statistically as likely to progress to high-grade dysplasia or esophageal adenocarcinoma as patients with a single such biopsy, according to a multicenter prospective registry study reported in the June issue of Clinical Gastroenterology and Hepatology (doi: org/10.1016/j.cgh.2017.02.019).
The findings, which contradict those from another recent multicenter cohort study (Gastroenterology. 2013;145[3]:548-53), highlight the need for more studies before lengthening the time between surveillance biopsies in patients with nondysplastic Barrett’s esophagus, Rajesh Krishnamoorthi, MD, of Mayo Clinic in Rochester, Minn., wrote with his associates.
Barrett’s esophagus is the strongest predictor of esophageal adenocarcinoma, but studies have reported mixed results as to whether the risk of this cancer increases over time or wanes with consecutive biopsies that indicate nondysplasia, the researchers noted. Therefore, they studied the prospective, multicenter Mayo Clinic Esophageal Adenocarcinoma and Barrett’s Esophagus registry, excluding patients who progressed to adenocarcinoma within 12 months, had missing data, or had no follow-up biopsies. This approach left 480 subjects for analysis. Patients averaged 63 years of age, 78% were male, the mean length of Barrett’s esophagus was 5.7 cm, and the average time between biopsies was 1.8 years, with a standard deviation of 1.3 years.
A total of 16 patients progressed to high-grade dysplasia or esophageal adenocarcinoma over 1,832 patient-years of follow-up, for an overall annual risk of progression of 0.87%. Two patients progressed to esophageal adenocarcinoma (annual risk, 0.11%; 95% confidence interval, 0.03% to 0.44%), while 14 patients progressed to high-grade dysplasia (annual risk, 0.76%; 95% CI, 0.45% to 1.29%). Eight patients progressed to one of these two outcomes after a single nondysplastic biopsy, three progressed after two such biopsies, three progressed after three such biopsies, none progressed after four such biopsies, and two progressed after five such biopsies. Statistically, patients with at least five consecutive nondysplastic biopsies were no less likely to progress than were patients with only one nondysplastic biopsy (hazard ratio, 0.48; 95% CI, 0.07 to 1.92; P = .32). Hazard ratios for the other groups ranged between 0.0 and 0.85, with no significant difference in estimated risk between groups (P = .68) after controlling for age, sex, and length of Barrett’s esophagus.
The previous multicenter cohort study linked persistently nondysplastic Barrett’s esophagus with a lower rate of progression to esophageal adenocarcinoma, and, based on those findings, the authors suggested lengthening intervals between biopsy surveillance or even stopping surveillance, Dr. Krishnamoorthi and his associates noted. However, that study did not have mutually exclusive groups. “Additional data are required before increasing the interval between surveillance endoscopies based on persistence of nondysplastic Barrett’s esophagus,” they concluded.
The study lacked misclassification bias given long-segment Barrett’s esophagus, and specialized gastrointestinal pathologists interpreted all histology specimens, the researchers noted. “The small number of progressors is a potential limitation, reducing power to assess associations,” they added.
The investigators did not report funding sources. They reported having no conflicts of interest.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: Patients with multiple consecutive biopsies showing nondysplastic Barrett’s esophagus were statistically as likely to progress to esophageal adenocarcinoma or high-grade dysplasia as those with a single nondysplastic biopsy.
Major finding: Hazard ratios for progression ranged between 0.00 and 0.85, with no significant difference in estimated risk among groups stratified by number of consecutive nondysplastic biopsies (P = .68), after controlling for age, sex, and length of Barrett’s esophagus.
Data source: A prospective multicenter registry of 480 patients with nondysplastic Barrett’s esophagus and multiple surveillance biopsies.
Disclosures: The investigators did not report funding sources. They reported having no conflicts of interest.