Missed Opportunities for Screening and Surveillance of Barrett's Esophagus in Veterans with Esophageal Adenocarcinoma

Abstract

Background: Barrett's esophagus (BE) is the premalignant lesion of esophageal adenocarcinoma (EAC) and is the target of early detection and prevention efforts for EAC.

Aims: We sought to evaluate what proportion and temporal trends of EAC patients had missed opportunities for screening and surveillance of BE.

Methods: Our study included 182 patients with EAC at the Michael E. DeBakey VA Medical Center in Houston, Texas, between 02/2005 and 09/2017. We conducted a retrospective audit of patients' medical records for any previous upper endoscopies (EGDs) for screening or surveillance of BE prior to their EAC diagnosis.

Results: The mean age of the cohort was 67.3 years (SD = 9.5); 99.5% of patients were male, and 85.2% were white. Only 45 patients (24.7%) had EGD at any time prior to the cancer diagnosing EGD, of whom 29 (15.9% of all EAC cases) had an established BE diagnosis. In the 137 patients with no prior EGD, most (63.5%) had GERD or were obese or ever smokers. There were no changes in patterns over time. For the 29 patients with prior established BE, 22 (75.8%) were diagnosed with EAC as a result of surveillance EGD. Patients with prior established BE were more likely to be diagnosed at 0 or I stage (p < 0.001) and managed with endoscopic or surgical modalities (p < 0.001) than patients without prior BE.

Conclusions: Despite having established risk factors for BE, the majority of EAC patients had no prior EGD to screen for BE. BE screening may represent the largest missed opportunity to reduce EAC mortality.

Keywords: Barrett’s esophagus; Esophageal adenocarcinoma; Esophagogastroduodenoscopy (EGD); GERD; Guidelines; Quality improvement; Screening and surveillance.

Figure 1:

Flow Diagram of EAC patients. Abbreviations: EAC: Esophageal adenocarcinoma. EGD: Esophagogastroduodenoscopy. BE: Barrett’s esophagus. Definitions: ¹:Previous EGD: Any prior EGD for any indication including screening and surveillance for BE. ²:Established BE: Patients with confirmed histological diagnosis of BE at least 6 months prior to the EAC diagnosis. ³:Proper surveillance: If the patient underwent appropriate surveillance EGD for BE based findings from previous endoscopies. ⁴:Patients had established BE, but they had the EGD performed to evaluate new symptoms (i.e. dysphagia, weight loss) rather than for BE surveillance. ⁵:Improper surveillance: Patients with established BE who did not have appropriate surveillance EGD for BE based on findings from previous endoscopies.

Figure 2:

Missed Opportunities for Screening and Surveillance for BE among patients diagnosed with EAC during 2005–2017. Abbreviations: EAC: Esophageal adenocarcinoma. EGD: Esophagogastroduodenoscopy. BE: Barrett’s esophagus. Definitions: ¹:High risk group: Male patients over the age of 50 with GERD and at least one of the other risk factors like obesity, smoking use (active or former) or Caucasian ethnicity. ²:Coexistent BE: Patients with confirmed histological diagnosis of BE at the time of EAC diagnosis. ³:Established BE: Patients with confirmed histological diagnosis of BE at least 6 months prior to the EAC diagnosis. ⁴:Proper surveillance: If the patient underwent appropriate surveillance EGD for BE based findings from previous endoscopies.