Watchful waiting no longer recommended for high-risk Barrett’s oesophagus with advanced precancerous cells

Endoscopic removal of pre-cancerous cells in patients with confirmed, high-risk Barrett’s oesophagus is recommended rather than surveillance, according to a new “Medical Position Statement on the Management of Barrett’s Esophagus”, published by the American Gastroenterological Association (AGA) Institute. The medical position statement was published in Gastroenterology, the official journal of the AGA Institute.

In patients with Barrett’s oesophagus, the normal cells lining the oesophagus are replaced with tissue that is similar to the lining of the intestine. The goal of endoscopic eradication therapy is to permanently eliminate all intestinal-type cells in the oesophagus. A small number of people with Barrett’s oesophagus develop a rare, but often deadly, type of cancer of the oesophagus.

“The AGA’s recommendations for the treatment of patients with Barrett’s oesophagus are based on the best data currently available within the medical literature,” said John M. Inadomi, MD, AGAF, chair of the AGA Clinical Practice & Quality Management Committee. “When considering whether surveillance or endoscopic eradication therapy is the preferred management option for patients with Barrett’s oesophagus, the AGA strongly supports the concept of shared decision-making between the treating physician and patient.”

The AGA recommends endoscopic eradication therapy with radiofrequency ablation (RFA), photodynamic therapy (PDT) or endoscopic mucosal resection (EMR), as follows for various patient groups:

• Patients with confirmed high-grade dysplasia (advanced pre-cancerous cells): endoscopic eradication therapy is recommended.
• Patients with confirmed low-grade dysplasia (beginning pre-cancerous cells): endoscopic eradication therapy is a treatment option and should be discussed with patients as such.
• Patients with Barrett’s oesophagus without abnormal cells: endoscopic eradication therapy is not recommended.

If eradication therapy is not indicated, is not available or is declined by a patient with Barrett’s oesophagus, surveillance by endoscopy should be performed every three months in patients with high-grade dysplasia, every six to 12 months in patients with low-grade dysplasia, and every three to five years in patients with no dysplasia.

“The recommendations in the medical position statement were made under the assumption that a patient’s diagnosis and the presence or absence of low and high grade dysplasia would be accurate to the highest degree possible using the best current standards of practice,” according to Stuart J. Spechler, MD, AGAF, a member of the AGA Institute Medical Position Panel. High grade dysplasia is an abnormal growth that has a high risk for cancer development.

Most patients (70 to 80 per cent) with high-grade dysplasia can be successfully treated with endoscopic eradication therapy. oesophagectomy (surgical removal of all or part of the oesophagus) in patients with high-grade dysplasia is an alternative; however, current evidence suggests that there is less morbidity with ablative therapy.

Other findings of the medical position statement on the management of Barrett’s oesophagus include:

• In patients with multiple risk factors associated with oesophageal cancer (age ≥50 years, male gender, Caucasian, chronic gastrooesophageal reflux disease [GORD], hiatal hernia, elevated body mass index and intra-abdominal distribution of body fat), AGA suggests screening for Barrett’s oesophagus. We recommend against screening the general population with GORD for Barrett’s oesophagus.
• The diagnosis of dysplasia in Barrett’s oesophagus should be confirmed by at least one additional pathologist, preferably one who is an expert in oesophageal histopathology.
• For patients with Barrett’s oesophagus, GORD therapy with medication effective to treat GORD symptoms and to heal reflux is clearly indicated, as it is for patients without Barrett’s oesophagus. However, evidence to support the use of acid-reducing agents, specifically proton pump inhibitors, in patients with Barrett’s oesophagus solely to reduce the risk of progression to dysplasia or cancer is indirect and has not been proven in a long-term controlled trial.
• Given that cardiovascular deaths are more common than deaths from oesophageal cancer among patients with Barrett’s oesophagus, screening for cardiovascular risk factors and interventions is warranted.

It is expected that, each year, every one in 200 patients diagnosed with Barrett’s oesophagus will develop oesophageal cancer, which is a devastating disease. For advanced oesophageal cancers, the current treatment options are limited and odds of survival remain low; it is nearly universally terminal. However, while patients diagnosed with Barrett’s oesophagus, especially those with pre-cancerous cells, feel an increased level of anxiety and emotional burden, the actual risk of death from oesophageal cancer remains low. Patients with Barrett’s oesophagus appear to have an increased risk of death from cardiovascular disease, perhaps due to an association with obesity.

The conclusions of the medical position statement are based on the best available evidence (as the technical review discusses), or in the absence of quality evidence, the expert opinions of the medical position panel convened to critique the technical review and structure the medical position statement.

To develop the guidelines, a set of 10 broad questions were identified by experts in the field to encapsulate the most common management questions faced by clinicians. To review recommendations and grades, view the “American Gastroenterological Association Medical Position Statement on the Management of Barrett’s oesophagus.”

(Source: American Gastroenterological Association: Gastroenterology)