Barrett's Esophagus and Cancer: Not A Clear Link
Barrett's Esophagus and Cancer: Not A Clear Link
Hvid-Jensen F, Pedersen L, Ph.D., Drewes AM, et al
N Engl J Med. 2011;365:1375-1383
Barrett's esophagus (intestinal metaplasia in the distal esophagus) is considered an important risk factor for esophageal adenocarcinoma, and current estimates of risk of adenocarcinoma in patients with Barrett's suggest an annual risk of 0.5%. This paper details a large, contemporary, Danish epidemiology study of 11,028 patients with Barrett's esophagus followed for a median of 5.2 years using a cancer registry and a national cohort pathology registry. Within the first year after diagnosis of Barrett's, 131 new cases of adenocarcinoma were diagnosed. During subsequent years, 66 new cases were detected (incidence rate for adenocarcinoma of 1.2 cases per 1000 person-years; (95% confidence interval [CI], 0.9-1.5). As compared with the risk in the general population, the relative risk of adenocarcinoma among patients with Barrett's esophagus was 11.3 (95% CI, 8.8-14.4). The annual risk of esophageal adenocarcinoma was 0.12% (95% CI, 0.09-0.15). For low-grade dysplasia, the incidence rate for adenocarcinoma was 5.1 cases per 1000 person-years and for no dysplasia, it was 1.0 case per 1000 person-years.
Esophageal adenocarcinoma is widely thought to result from transformation of Barrett's esophagus, which in turn is caused by reflux disease. The risk for esophageal adenocarcinoma is rapidly increasing in the past 2 decades, and increased reflux disease is thought to be a potential causative factor. This has led to calls for increasing surveillance for esophageal adenocarcinoma in patients with Barrett's esophagus. In this study, however, the authors report a far lower estimate of the risk of malignancy than expected (0.12% annual risk vs 0.5% estimated) -- a finding that calls into question the value of surveillance endoscopy in this population, particularly for those without dysplasia. This also lays open the question of etiology of esophageal adenocarcinoma, given the low rate of malignancy as well as the fact that up to 40% of patients with adenocarcinoma report no history of heartburn. A search for other causes of the increase in incidence is warranted.
Abstract
Incidence of Adenocarcinoma Among Patients With Barrett's Esophagus
Hvid-Jensen F, Pedersen L, Ph.D., Drewes AM, et al
N Engl J Med. 2011;365:1375-1383
Study Summary
Barrett's esophagus (intestinal metaplasia in the distal esophagus) is considered an important risk factor for esophageal adenocarcinoma, and current estimates of risk of adenocarcinoma in patients with Barrett's suggest an annual risk of 0.5%. This paper details a large, contemporary, Danish epidemiology study of 11,028 patients with Barrett's esophagus followed for a median of 5.2 years using a cancer registry and a national cohort pathology registry. Within the first year after diagnosis of Barrett's, 131 new cases of adenocarcinoma were diagnosed. During subsequent years, 66 new cases were detected (incidence rate for adenocarcinoma of 1.2 cases per 1000 person-years; (95% confidence interval [CI], 0.9-1.5). As compared with the risk in the general population, the relative risk of adenocarcinoma among patients with Barrett's esophagus was 11.3 (95% CI, 8.8-14.4). The annual risk of esophageal adenocarcinoma was 0.12% (95% CI, 0.09-0.15). For low-grade dysplasia, the incidence rate for adenocarcinoma was 5.1 cases per 1000 person-years and for no dysplasia, it was 1.0 case per 1000 person-years.
Viewpoint
Esophageal adenocarcinoma is widely thought to result from transformation of Barrett's esophagus, which in turn is caused by reflux disease. The risk for esophageal adenocarcinoma is rapidly increasing in the past 2 decades, and increased reflux disease is thought to be a potential causative factor. This has led to calls for increasing surveillance for esophageal adenocarcinoma in patients with Barrett's esophagus. In this study, however, the authors report a far lower estimate of the risk of malignancy than expected (0.12% annual risk vs 0.5% estimated) -- a finding that calls into question the value of surveillance endoscopy in this population, particularly for those without dysplasia. This also lays open the question of etiology of esophageal adenocarcinoma, given the low rate of malignancy as well as the fact that up to 40% of patients with adenocarcinoma report no history of heartburn. A search for other causes of the increase in incidence is warranted.
Abstract
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