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Screening and surveillance for Barrett's esophagus—an unresolved dilemma

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 470–471 (2007)Cite this article

The National Cancer Institute estimated that there were 234,000 new cases of prostate cancer, 215,000 new cases of breast cancer, and 148,000 new cases of colorectal cancer in the United States in 2006.1 That same year, there were only 8,000 new cases of esophageal adenocarcinoma, a tumor for which GERD and Barrett's esophagus are major risk factors.2 Although these figures suggest that esophageal adenocarcinoma should be a minor public health concern, at least two factors have focused public attention on this tumor: approximately 20% of adult Americans regularly experience heartburn (which is the major symptom of GERD), and the incidence of esophageal adenocarcinoma has increased approximately six-fold over the past three decades in the United States, a phenomenon that has received much attention in the lay press.3 Heartburn, therefore, regularly reminds more than 40,000,000 Americans that they are at risk for a lethal tumor, the incidence of which is rising rapidly. Physicians must deal with their patients' concerns, even if the level of those concerns might not be justified by the magnitude of the risk.

One unproven (but widely practiced) strategy to decrease deaths from esophageal adenocarcinoma is to use endoscopy to screen individuals with heartburn for Barrett's esophagus, and to perform regular endoscopic surveillance for early, curable neoplasia in patients found to have Barrett's esophagus. Unfortunately, data suggest that a screening program that targets only patients with heartburn can have only a limited impact on cancer mortality; studies of patients with esophageal adenocarcinoma show that ∼40% of patients have no history of heartburn.4 In addition, heartburn is a poor marker for short-segment Barrett's esophagus, which seems to be the precursor of many adenocarcinomas. In one study in which patients who were scheduled for colonoscopy were invited to have an endoscopy to look for Barrett's esophagus, the frequency of short-segment Barrett's esophagus in patients with and without a history of heartburn was nearly identical (5.7% and 5.2%, respectively).5 Furthermore, it is clear that whatever clinicians have been doing to screen for, and manage patients with, Barrett's esophagus, it has not been very effective in preventing deaths from esophageal adenocarcinoma. The incidence of the tumor continues to rise, and <5% of patients with esophageal adenocarcinoma are known to have Barrett's esophagus before they develop cancer symptoms like dysphagia and weight loss.6

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  1. Division of Gastroenterology (111B1), Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA sjspechler@aol.com

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  1. SJ Spechler is Chief of the Division of Gastroenterology at the Dallas VA Medical Center, Professor of Medicine, and Holder of the Berta M and Cecil O Patterson Chair in Gastroenterology at The University of Texas Southwestern Medical Center, Dallas, TX, USA.,

    Stuart J Spechler

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The author has received grant/research support from the following companies: AstraZeneca, TAP Pharmaceutical Products, Barrx Medical.

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Spechler, S. Screening and surveillance for Barrett's esophagus—an unresolved dilemma. Nat Rev Gastroenterol Hepatol 4, 470–471 (2007). https://doi.org/10.1038/ncpgasthep0876

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