The authors did an excellent job of analyzing the literature and noting the limitations of the studies that are used to make the recommendations in the guidelines. It is important to recognize that most of these recommendations are made from cohort and observational studies. We do not have any high-quality randomized controlled trials that look at screening and surveillance for Barrett’s esophagus to see if it truly decreases mortality related to esophageal adenocarcinoma or incidence of adenocarcinoma. In fact, despite our screening and surveillance practice for Barrett’s esophagus over the last decade, most recent data from the U.S. National Cancer Institute surveillance still show increasing incidence of esophageal adenocarcinoma.
This is different from a screening colonoscopy, where after widespread adoption for colorectal screening, we certainly saw a decrease in the incidence of colorectal cancer and mortality associated with colorectal cancer. Unfortunately, we have not yet seen that with our screening and surveillance practice for Barrett’s esophagus. The ideal way to analyze the true impact would be to do a randomized controlled trial, but this is difficult given the low incidence of the outcome being measured. Thus, the quality of evidence for all the recommendations in the most recent ASGE guidelines are low to moderate.
The biggest change with these guidelines relates to a new recommendation, although conditional, with the addition of wide area transepithelial sampling with 3D tissue analysis (WATS3D, CDx Diagnostics) to the regular Seattle protocol biopsies for Barrett’s surveillance. The quality of evidence for this recommendation is very low as the definition of dysplasia varied across studies. Additionally, there is potential for bias given most of the studies were funded by the manufacturer. However, it can be a helpful tool because it allows us to sample a larger area of the esophagus. This seems to increase the detection of low-grade dysplasia by about 1.8% (absolute increase).
However, there are currently no cost-effectiveness studies evaluating this technology in routine surveillance of patients with Barrett’s esophagus. It should be emphasized that the recommendation is to do this in addition to regular Seattle protocol biopsies. This is important, because some providers due to time constraints, tend to use the WATS3D as the only means of surveillance, which is not recommended. Further, virtual chromoendoscopy is strongly recommended to enhance visibility of surface abnormalities in all patients.
Lastly, it is important for us to recognize that the decisions for not only screening, but surveillance for Barrett’s esophagus should be patient centered. We should discuss the risks and benefits along with quality of evidence for those recommendations. If doing screening or surveillance is unlikely to change their management because of significant comorbidities then they should not undergo endoscopy, because the risk for adenocarcinoma, even in patients with Barrett’s esophagus, is still very low.
Dhyanesh A. Patel, MD
Assistant Professor of Medicine
Center for Swallowing and Esophageal Disorders
Vanderbilt University Medical Center
Disclosures: Patel reports no relevant financial disclosures.