Screening and Risk Stratification for Barrett's Esophagus: How to Limit the Clinical Impact of the Increasing Incidence of Esophageal Adenocarcinoma

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Key points

  • Esophageal adenocarcinoma (EAC) is the solid malignancy with the fastest increasing incidence in the Western world over the last 3 decades.

  • Barrett's esophagus (BE) is the only known precursor to EAC and the strongest risk factor for this type of esophageal cancer.

  • Other risk factors for EAC include gastroesophageal reflux disease, obesity, smoking, and male sex.

  • Endoscopic screening for BE has the potential to reduce the clinical impact of the changing epidemiology of EAC, but it is not

Epidemiology of esophageal adenocarcinoma

The epidemiology of esophageal adenocarcinoma (EAC) has changed dramatically over the past 50 years in the Western world. Surgical series reported before the 1980s showed that esophageal squamous cell carcinoma (ESCC), which arises from the native multilayered squamous epithelium, was the most common malignancy in the esophagus.1, 2, 3, 4 However, subsequent Western case series published 10 to 15 years later indicated that the EAC had become the most common esophageal malignancy, exceeding the

Risk factors for EAC

Table 1 lists the clinical and epidemiologic factors that have been studied in relation to the incidence of EAC.

Modification of Risk Factors

The epidemiologic trends of EAC in the Western world, discussed earlier, have raised concern about this disease amongst public health officials and as a result, there has been a call for clinical and research strategies to limit the impact of this disease.70, 71, 72 Because the modifiable risk factors implicated in the pathogenesis are still not completely understood73 and because compliance with healthy-living campaigns is poor, it is difficult to promote strategies to change the risk profile

Screening modalities

Table 2 provides a summary of the diagnostic modalities proposed for BE and EAC screening.

Markers of risk stratification in patients with BE

Once BE is diagnosed, either through screening or as a result of an investigation for upper GI symptoms, surveillance is generally recommended followed by intervention at the point at which HGD or EAC is detected.111 The recent evidence that the cancer risk in patients with BE is lower than previously believed24, 28, 58 has fueled long-standing arguments about whether this approach is justified.108, 112, 113, 114, 115 Most patients with BE never develop cancer, and a recent systematic review

Future perspective

  • The economic implications of endoscopic screening within the general population demand the introduction of cheaper and less invasive tests for an early diagnosis of EAC at a presymptomatic stage and identification of patients at higher risk, such as patients with dysplastic or genetically unstable BE.

  • Novel endoscopic therapies allow ablation of BE with preventive strategies. Although it is difficult to envisage a scenario in which every single patient with BE undergoes endoscopic therapy,

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