In the JournalsPerspective

ASGE releases updated screening, surveillance guidelines for BE

Sachin Wani

ASGE has released updated guidelines for the screening and surveillance of Barrett’s esophagus.

With the goal of improving morbidity and mortality related to esophageal adenocarcinoma (EAC), ASGE’s latest standards address clinical questions including the impact and role of screening and surveillance as well as the utility of sampling modalities and advanced imaging like volumetric laser endomicroscopy (VLE), chromoendoscopy, confocal laser endomicroscopy, wide-area transepithelial sampling and endoscopic ultrasound (EUS).

“The incidence of EAC continues to be among the fastest rising incidence cancers in the Western population and has been closely mirrored by a rise in EAC-related mortality,” Sachin Wani, MD, FASGE, chair of the ASGE Standards of Practice Committee, and colleagues wrote. “To ultimately impact the morbidity and mortality associated with EAC, several national and international medical societies recommend screening for BE in individuals with multiple risk factors and surveillance when the diagnosis of BE is established.”

Guidelines were established based on systematic reviews from available literature regarding five clinical questions related to BE, while recommendations for strength and quality of evidence were calculated using the GRADE methodology. Existing systematic reviews were used to draft initial guidelines for each question, and a new systematic review was conducted with the assistance of an expert librarian if no existing review could be found. GRADE methodologists assisted in the creation of evidence profiles, with recommendations drafted by a panel at a standards of practice meeting in March 2018.

Major recommendations from the report include:

  • Surveillance endoscopy is recommended for patients with nondysplastic BE.
  • If a screening endoscopy is performed for BE, a screening strategy that identifies an at-risk population should be used.
  • For patients with BE undergoing surveillance, chromoendoscopy, such as Seattle protocol biopsy sampling and virtual chromoendoscopy, are recommended over white-light endoscopy with Seattle protocol biopsy sampling.
  • ASGE recommends against routine use of confocal laser endomicroscopy as opposed to white-light endoscopy with Seattle protocol biopsy sampling.
  • ASGE recommends against routine use of EUS to differentiate submucosal and mucosal disease in patients with BE also with high-grade dysplasia, intramucosal carcinoma or nodules.
  • WATS-3D in addition to Seattle protocol biopsy sampling are recommended over white-light endoscopy with Seattle protocol biopsy sampling in patients with suspected or known BE.
  • Insufficient evidence is present to recommend for or against routine VLE in patients with BE undergoing surveillance.

“Future studies that refine and validate existing prediction tools for screening of BE and EAC are required,” the authors wrote. “Before we embrace the new generation of less-invasive and potentially less-expensive screening techniques and replace our current approach of using standard endoscopy for screening, these new techniques need to demonstrate high diagnostic performance characteristics, easy implementation at a primary care level, high uptake in the at-risk population and low cost.” – by Eamon Dreisbach

Disclosures: Qumseya reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Sachin Wani

ASGE has released updated guidelines for the screening and surveillance of Barrett’s esophagus.

With the goal of improving morbidity and mortality related to esophageal adenocarcinoma (EAC), ASGE’s latest standards address clinical questions including the impact and role of screening and surveillance as well as the utility of sampling modalities and advanced imaging like volumetric laser endomicroscopy (VLE), chromoendoscopy, confocal laser endomicroscopy, wide-area transepithelial sampling and endoscopic ultrasound (EUS).

“The incidence of EAC continues to be among the fastest rising incidence cancers in the Western population and has been closely mirrored by a rise in EAC-related mortality,” Sachin Wani, MD, FASGE, chair of the ASGE Standards of Practice Committee, and colleagues wrote. “To ultimately impact the morbidity and mortality associated with EAC, several national and international medical societies recommend screening for BE in individuals with multiple risk factors and surveillance when the diagnosis of BE is established.”

Guidelines were established based on systematic reviews from available literature regarding five clinical questions related to BE, while recommendations for strength and quality of evidence were calculated using the GRADE methodology. Existing systematic reviews were used to draft initial guidelines for each question, and a new systematic review was conducted with the assistance of an expert librarian if no existing review could be found. GRADE methodologists assisted in the creation of evidence profiles, with recommendations drafted by a panel at a standards of practice meeting in March 2018.

Major recommendations from the report include:

  • Surveillance endoscopy is recommended for patients with nondysplastic BE.
  • If a screening endoscopy is performed for BE, a screening strategy that identifies an at-risk population should be used.
  • For patients with BE undergoing surveillance, chromoendoscopy, such as Seattle protocol biopsy sampling and virtual chromoendoscopy, are recommended over white-light endoscopy with Seattle protocol biopsy sampling.
  • ASGE recommends against routine use of confocal laser endomicroscopy as opposed to white-light endoscopy with Seattle protocol biopsy sampling.
  • ASGE recommends against routine use of EUS to differentiate submucosal and mucosal disease in patients with BE also with high-grade dysplasia, intramucosal carcinoma or nodules.
  • WATS-3D in addition to Seattle protocol biopsy sampling are recommended over white-light endoscopy with Seattle protocol biopsy sampling in patients with suspected or known BE.
  • Insufficient evidence is present to recommend for or against routine VLE in patients with BE undergoing surveillance.

“Future studies that refine and validate existing prediction tools for screening of BE and EAC are required,” the authors wrote. “Before we embrace the new generation of less-invasive and potentially less-expensive screening techniques and replace our current approach of using standard endoscopy for screening, these new techniques need to demonstrate high diagnostic performance characteristics, easy implementation at a primary care level, high uptake in the at-risk population and low cost.” – by Eamon Dreisbach

Disclosures: Qumseya reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Dhyanesh A. Patel

    Dhyanesh A. Patel

    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.