Cases of esophageal cancer developing from a premalignant condition called Barrett’s Esophagus are rare. However, survival of advanced esophageal malignancy is very low, justifying surveillance. Current recommendations on Barrett’s surveillance depend on how far cellular changes have progressed.
Introduction
Barrett’s Esophagus, also called Barrett’s Metaplasia, is a pre-cancerous change in the cells lining the distal portion of the esophagus, usually occurring at the squamo-columnar junction. This is the area where the lining of the stomach, which is cellular tissue resistant to stomach acid damage, meets the tissue of the esophagus, which is not resistant to acid damage.
Frequency of Barrett’s and Cancer
Approximately ten percent of people with persistent and severe acid reflux disease—GERD or Gastroesophageal Reflux Disease—are likely to develop some changes in the esophagus from normal cells to metaplastic cells. Of these, depending on the study, from 0.5 percent to two percent will progress to adenocarcinoma, which is one of the two types of esophageal cancer. The other is squamous cell carcinoma, whose primary risk factors are heavy alcohol and tobacco use or caustic injury from substances such as lye. For a yet unknown reason, esophageal adenocarcinoma is one of the fastest growing cancers in the industrialized world, outpacing even melanoma, breast cancer and prostate cancer.
Diagnosis
Barrett’s Esophagus is diagnosed by biopsies taken during an endoscopy, when a viewing tube is passed down the esophagus. Since the linkage between Barrett’s and esophageal cancer was recognized, there have been debates about how best to manage the condition and how often to retest for changes with more endoscopies and biopsies. As a general rule, current recommendations about Barrett’s surveillance have tended towards longer intervals, as long as there is no progression to dysplasia.
Risk Factors
Some research tried to identify surveillance options by stratifying those at high risk of a malignant change in Barrett’s, focusing on these factors [1]:
- Men over 45 years
- Longer length of Barrett’s segment (over 3 cm)
- Severe reflux more than three times a week
- Chronic heartburn for more than ten years
- Obesity
- Taking drugs that relax the lower esophageal sphincter
- Cured Helicobacter pylori infection
- Family history of Barrett’s
This has been less than satisfactory because Barrett’s progression to esophageal carcinoma is extremely variable, even in individuals with the above criteria.
American College of Gastroenterology Guidelines
The latest revision (2008) of guidelines from the American College of Gastroenterology (ACG) for current recommendations on Barrett’s surveillance are based on the grade of dysplasia, that is, the progressive amount of cellular changes from normal, to metaplasia, to low grade dysplasia and finally high grade dysplasia [2]. The consensus in the U.S. is for follow-up surveillance primarily because there is a very poor five-year survival rate for advanced esophageal cancer.
The guidelines recommend surveillance endoscopy on patients after reflux symptoms are brought under control with proton pump inhibitor drugs. If no evidence of dysplasia is there, then re-check within one year. If there is still no sign of dysplasia, then surveillance every three years is recommended.
If low-grade dysplasia is detected, then there should be a follow-up endoscopy with biopsy within six months. If no further progression exists, then yearly endoscopies are done until no dysplasia is found on two consecutive examinations. When high-grade dysplasia is noted, then follow-up should take place within three months.
In all cases when dysplasia exists, it should be confirmed by an expert pathologist, according to the ACG guidelines
References
[1]. British Medical Journal, Surveillance for Barrett’s Oesophagus , 2001
[2]. Wang, Kenneth K., and Sampliner, Richard E., “Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett’s Esophagus,” American Journal of Gastroenterology, 2008; 103:788-797.
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