In the Journals

International experts unveil new treatment for Barrett's esophagus

The international Benign Barrett’s and Cancer Taskforce, or BOB CAT, consensus group has developed evidence-based consensus recommendations for the clinical management of nondysplastic Barrett’s esophagus and low-grade dysplasia.

“We created a unique opportunity for doctors and scientists from around the world to work together,” Cathy Bennett, PhD, from Coventry University, United Kingdom, said in a press release. “We used a specially designed Web-based platform to interact, discuss and summarize the vast amount of medical evidence available for the management of this condition. As a result of our work, health care professionals from all parts of the world will be able to access these new key recommendations.”

Cathy Bennett

Janusz Jankowski

Although previous guidelines for the management of BE have been developed, their recommendations are variable between nations. The BOB CAT group, therefore, used an evidence-based Delphi process to review more than 20,000 papers and provide recommendations to inform clinical practice for a global audience. 

International definition of BE

According to the authors, the task force was able to establish an international agreement for the definition of BE for the first time, which until now differed between the U.S. definition (including patients with intestinal metaplasia [IM] only) and European and Japanese definitions (IM not required for diagnosis).

“First, we have refined the world definition of BE, so there is less heterogeneity of assessment and management of this condition,” Janusz Jankowski, MD, PhD, FRCP, AGAF, FACG, from the Warwick Medical School and University Hospitals Coventry & Warwickshire NHS Trust in the United Kingdom, told Healio Gastroenterology. “In this regard, BE is defined by the presence of columnar mucosa in the esophagus, and it should be stated whether IM is present above the gastroesophageal junction. ​This definition should avoid false over- or underdiagnoses due to hiatal hernias or inadequate biopsy sampling, respectively.”

Thus, BE diagnosis should result from a combination of endoscopic and pathological findings, the authors wrote.

Screening, surveillance and management

The task force recommends against screening the general population for BE with endoscopic or nonendoscopic methods, but suggests screening for certain high-risk populations.

“Men older than 60 years with GERD (even if controlled symptomatically with medication) for greater than 10 years should be screened for BE by endoscopy,” Jankowski said. “Moreover, BE surveillance should be targeted at high-risk groups, such as those aged at least 50 years, white race, male sex, central obesity, and symptoms. Once diagnosed with BE, persistence of low-grade dysplasia (LGD), multifocality of LGD, segment length and visible lesions in LGD are all signals that escalate risk, and in this case, patients should be managed with endoscopic resection and close surveillance.”

The authors also suggest against surveillance of nondysplastic BE in patients with a life expectancy of 5 years or less, as risk for malignant progression during a 5-year interval appears to be low.

The task force made a wide range of recommendations for management strategies based on disease progression, including a de-escalation strategy of surveillance for lower-risk patients and escalation to intervention with follow-up for high-risk patients.

“Consequently, we developed a checklist of recommendations and a pathway for clinicians to enable clinical decision making and illustrate the treatment journey with patients,” Jankowski said. 

Recommended further research

The authors also made strong recommendations for prioritization of future research. These include further research on the optimal pathways of BE management, including the optimal number of and optimal setting for surveillance; on appropriate surveillance intervals for LDG; and on the utility of molecular markers as adjuncts in histological assessment of dysplasia and methods of risk stratification. Finally, they recommend that more data are needed from the Aspirin Esomeprazole Chemoprevention Trial (AspECT) and chemopreventive trials of proton pump inhibitors in patients with BE.

“Of course, this isn’t the last word in Barrett’s,” Jankowski said. “A significant advance will be the results of a randomized controlled trial looking at scheduled surveillance vs. at need, being conducted in the United Kingdom, and genetic studies will identify those with early treatable dysplastic change and those at risk of progression to esophageal adenocarcinoma.” – by Adam Leitenberger

Disclosure: Bennett reports she was the coordinator of BOB CAT and received a consultancy fee; is a member of the data monitoring committee for the BOSS clinical trial; and is the proprietor of Systematic Research Ltd., a consultancy company, from which she derives an income. Jankowski reports he was a consultant to AstraZeneca, and chief investigator of the AspECT trial and the EAGLe genomics consortia. Please see the study for a full list of all other authors’ relevant financial disclosures.

The international Benign Barrett’s and Cancer Taskforce, or BOB CAT, consensus group has developed evidence-based consensus recommendations for the clinical management of nondysplastic Barrett’s esophagus and low-grade dysplasia.

“We created a unique opportunity for doctors and scientists from around the world to work together,” Cathy Bennett, PhD, from Coventry University, United Kingdom, said in a press release. “We used a specially designed Web-based platform to interact, discuss and summarize the vast amount of medical evidence available for the management of this condition. As a result of our work, health care professionals from all parts of the world will be able to access these new key recommendations.”

Cathy Bennett

Janusz Jankowski

Although previous guidelines for the management of BE have been developed, their recommendations are variable between nations. The BOB CAT group, therefore, used an evidence-based Delphi process to review more than 20,000 papers and provide recommendations to inform clinical practice for a global audience. 

International definition of BE

According to the authors, the task force was able to establish an international agreement for the definition of BE for the first time, which until now differed between the U.S. definition (including patients with intestinal metaplasia [IM] only) and European and Japanese definitions (IM not required for diagnosis).

“First, we have refined the world definition of BE, so there is less heterogeneity of assessment and management of this condition,” Janusz Jankowski, MD, PhD, FRCP, AGAF, FACG, from the Warwick Medical School and University Hospitals Coventry & Warwickshire NHS Trust in the United Kingdom, told Healio Gastroenterology. “In this regard, BE is defined by the presence of columnar mucosa in the esophagus, and it should be stated whether IM is present above the gastroesophageal junction. ​This definition should avoid false over- or underdiagnoses due to hiatal hernias or inadequate biopsy sampling, respectively.”

Thus, BE diagnosis should result from a combination of endoscopic and pathological findings, the authors wrote.

Screening, surveillance and management

The task force recommends against screening the general population for BE with endoscopic or nonendoscopic methods, but suggests screening for certain high-risk populations.

“Men older than 60 years with GERD (even if controlled symptomatically with medication) for greater than 10 years should be screened for BE by endoscopy,” Jankowski said. “Moreover, BE surveillance should be targeted at high-risk groups, such as those aged at least 50 years, white race, male sex, central obesity, and symptoms. Once diagnosed with BE, persistence of low-grade dysplasia (LGD), multifocality of LGD, segment length and visible lesions in LGD are all signals that escalate risk, and in this case, patients should be managed with endoscopic resection and close surveillance.”

The authors also suggest against surveillance of nondysplastic BE in patients with a life expectancy of 5 years or less, as risk for malignant progression during a 5-year interval appears to be low.

The task force made a wide range of recommendations for management strategies based on disease progression, including a de-escalation strategy of surveillance for lower-risk patients and escalation to intervention with follow-up for high-risk patients.

“Consequently, we developed a checklist of recommendations and a pathway for clinicians to enable clinical decision making and illustrate the treatment journey with patients,” Jankowski said. 

Recommended further research

The authors also made strong recommendations for prioritization of future research. These include further research on the optimal pathways of BE management, including the optimal number of and optimal setting for surveillance; on appropriate surveillance intervals for LDG; and on the utility of molecular markers as adjuncts in histological assessment of dysplasia and methods of risk stratification. Finally, they recommend that more data are needed from the Aspirin Esomeprazole Chemoprevention Trial (AspECT) and chemopreventive trials of proton pump inhibitors in patients with BE.

“Of course, this isn’t the last word in Barrett’s,” Jankowski said. “A significant advance will be the results of a randomized controlled trial looking at scheduled surveillance vs. at need, being conducted in the United Kingdom, and genetic studies will identify those with early treatable dysplastic change and those at risk of progression to esophageal adenocarcinoma.” – by Adam Leitenberger

Disclosure: Bennett reports she was the coordinator of BOB CAT and received a consultancy fee; is a member of the data monitoring committee for the BOSS clinical trial; and is the proprietor of Systematic Research Ltd., a consultancy company, from which she derives an income. Jankowski reports he was a consultant to AstraZeneca, and chief investigator of the AspECT trial and the EAGLe genomics consortia. Please see the study for a full list of all other authors’ relevant financial disclosures.