Surveillance of Barrett's Esophagus Patients in an Expert Center is Associated With Low Disease-Specific Mortality

Abstract

Introduction: Specialist guidelines recommend endoscopic surveillance for Barrett's esophagus to reduce mortality related to esophageal adenocarcinoma, but the setting for optimal Barrett's esophagus monitoring is unclear. We assessed progression rate and disease-specific mortality in a large cohort of patients followed up at a single Barrett's esophagus expert center.

Methods: For this prospective longitudinal single center cohort study, we recruited patients with a previous diagnosis of Barrett's esophagus between 2004 and 2022. Endoscopists were trained in Barrett's esophagus surveillance standards and image-enhanced techniques, and biopsies were reviewed by expert pathologists. Exclusion criteria were a single surveillance endoscopy, high-grade dysplasia, or esophageal adenocarcinoma at or within 12 months from index endoscopy and patients with < 12 months follow-up. The primary outcome was the neoplastic progression rate of Barrett's esophagus with intestinal metaplasia to high-grade dysplasia/esophageal adenocarcinoma. Secondary outcomes included cancer stage and disease-specific mortality, risk factors for progression and progression rate in patients with Barrett's esophagus with only gastric metaplasia or irregular z-line and intestinal metaplasia (IZL-IM).

Results: A total of 1932 patients were recruited, of which 969 were included in the primary analysis with a median follow-up of 5.8 years. Of these, 109 developed high-grade dysplasia or esophageal adenocarcinoma with a progression rate of 1.63%/year. Overall, 48 patients received an esophageal adenocarcinoma diagnosis, of which 89,5% (43/48) had stage 1%, and 0.3% patients (3/969) had disease-specific mortality. Multivariate analysis showed that age, alcohol consumption, esophagitis, Barrett's esophagus length, hiatus hernia length, low-grade dysplasia and neutrophil/lymphocyte ratio were risk factors for progression. The rate of progression in patients with Barrett's esophagus-gastric metaplasia or IZL-IM was 0.06%/year.

Conclusions: Endoscopic surveillance in an expert Barrett's esophagus center leads to a high neoplastic progression rate, and a low rate of disease-specific mortality. Further research to correlate disease-specific mortality and cancer stage with dysplasia detection rate is warranted to develop diagnostic quality indicators specific for Barrett's esophagus.

Keywords: Barrett's esophagus; esophageal adenocarcinoma; high‐grade dysplasia; intestinal metaplasia.

FIGURE 1

Patient flowchart. Of the 1932 patients who consented to the Cambridge Barrett's registry, 782 did not meet the inclusion criteria for this study. The 181 Barrett's esophagus with gastric metaplasia only (BE‐GM) and irregular Z‐line with IM (IZL‐IM) were only included in the secondary analysis. 109 patients with BE (11.2%) progressed during the study period to HGD/EAC. A single patient with minimal Barrett's disease progressed to cancer. EAC, esophageal adenocarcinoma; EGD, Esophago‐gastroduodenoscopy; EET, endoscopic eradication therapy; GM, gastric metaplasia; IMC, intramucosal cancer.

FIGURE 2

Kaplan–Meier estimates of the probability of progression to HGD or EAC among the different BE subgroups. Vertical marks indicate the time of censoring. The estimate of the hazard ratio was based on a Cox model stratified according to the length of BE and presence of intestinal metaplasia (IM) and adjusted for age and gender. There was an indication of non‐proportional hazards for the longer segment BE groups (BE 3–9 cm and BE ≥ 10 cm). BE‐GM or irregular Z‐line (IZL) with IM was used as a reference.