Epidemiology and natural history of intestinal metaplasia of the gastroesophageal junction and Barrett's esophagus: a population-based study

Abstract

Objectives: Population-based data on the epidemiology and outcomes of subjects with intestinal metaplasia of the gastroesophageal junction (IMGEJ) and Barrett's esophagus (BE) are limited. The objectives of this study were to (i) estimate the incidence of IMGEJ and BE diagnosed from clinically indicated endoscopy in Olmsted County, MN, over three decades (1976-2006) and prevalence as of 1 January 2007, (ii) compare baseline characteristics of subjects with IMGEJ and BE, and (iii) study the natural history and survival of both cohorts.

Methods: This was a population-based cohort study. The study setting was Olmsted County, MN. Patients with BE (columnar segment >1 cm with intestinal metaplasia) and IMGEJ (intestinal metaplasia in biopsies from the gastroesophageal junction) from 1976 to 2006 in Olmsted County, MN, were identified using Rochester Epidemiology Project resources. Demographic and clinical data were abstracted from medical records and pathology confirmed by gastrointestinal pathologists. The association of baseline characteristics with overall and progression-free survival was assessed using proportional hazards regression models. Outcome measures were baseline characteristics and overall survival of subjects with IMGEJ compared to those with BE.

Results: In all, 487 patients (401 with BE and 86 with IMGEJ) were identified and followed for a median interval of 7 (BE subjects) to 8 (IMGEJ subjects) years. Subjects with BE were older, heavier, reported reflux symptoms more often, and had higher prevalence of advanced neoplasia than those with IMGEJ. No patient with IMGEJ progressed to esophageal adenocarcinoma (EAC) in contrast to BE subjects who had a cumulative risk of progression of 7% at 10 years and increased risk of death from EAC (standardized mortality ratio 9.62). The overall survival of subjects with BE and IMGEJ did not differ from that expected in similar age- and sex-distributed white Minnesota populations.

Conclusions: Subjects with IMGEJ appear to have distinct clinical characteristics and substantially lower cancer progression risk compared to those with BE.

Figure 1

Secular trends in the incidence of Barrett's esophagus (BE) and intestinal metaplasia of the gastroesophageal junction (IMGEJ) over three decades in Olmsted County. (a) Age-adjusted incidence rates for all BE and IMGEJ cases. x Axis displays 5-year time intervals. (b) Secular trends in endoscopy volume per year (indicated on the left y axis) and number of cases of BE and IMGEJ diagnosed per year (indicated on the right y axis) in Olmsted County, MN. EGD, esophagogastroduodenoscopy.

Figure 2

Kaplan–Meier curve illustrating progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in subjects with Barrett's esophagus (BE) (without baseline HGD or EAC) in Olmsted County, MN.

Figure 3

Kaplan–Meier curves illustrating long-term survival of subjects with Barrett's esophagus (BE) and intestinal metaplasia of the gastroesophageal junction (IMGEJ) in Olmsted County, MN. (a) Overall survival of subjects with BE (without high-grade dysplasia (HGD) or carcinoma at baseline or within 6 months of diagnosis) compared to an age- and sex-distributed Minnesota white population. (b) Overall survival of subjects with IMGEJ compared to an age- and sex-distributed Minnesota white population. (c) Comparison of overall survival of subjects with BE and IMGEJ in Olmsted County, MN.