Longer follow-up may not be advisable after complete remission of Barrett's esophagus

No evidence was seen of a clinically meaningful change in recurrence hazard rate of any Barrett's esophagus, dysplastic Barrett's esophagus, or high-grade dysplasia or cancer during follow-up of patients at five tertiary referral centers.

Recurrence rates for Barrett's esophagus remained constant over time after complete remission, a multicenter international cohort study found, suggesting that guidelines on postremission surveillance interval protocols may need to be re-evaluated.

Researchers obtained data on patients who had radiofrequency ablation for Barrett's esophagus from prospectively maintained databases of five tertiary referral centers, three in the U.S. and two in the U.K. Radiofrequency ablation was performed until complete remission of intestinal metaplasia was confirmed on two consecutive endoscopies. The goal of the study was to examine timeline, location, and patterns of recurrence after complete remission. Results were published by Gut on Jan. 11.

Five hundred ninety-four patients achieved complete remission of intestinal metaplasia, and of these, 151 developed recurrent Barrett's esophagus over a median follow-up of 2.8 years (interquartile range, 1.4 to 4.4 years). Cumulative recurrence risk of any Barrett's esophagus within two years was 19%, with an additional risk of 49% over the next 8.6 years. No evidence of a clinically meaningful change in the recurrence hazard rate of any Barrett's esophagus, dysplastic Barrett's esophagus, or high-grade dysplasia or cancer was seen during follow-up. When follow-up time was doubled, there was an estimated 2% (95% CI, −7% to 12%) change in recurrence rate of any Barrett's esophagus.

In the study, 74% of Barrett's esophagus recurrences developed at the gastroesophageal junction, and of these, 24.1% were dysplastic. The remainder, 26%, were in the tubular esophagus. In the absence of visible lesions, random biopsies from the tubular esophagus had a yield of 1% for Barrett's esophagus and 0.2% for dysplasia. Baseline high-grade dysplasia or cancer, but not low-grade dysplasia, predicted a higher risk of any recurrence (hazard ratio, 1.95; P=0.029) and dysplastic recurrence (hazard ratio, 4.81; P=0.026). The authors found weak evidence that the risk of dysplastic recurrence, but not overall recurrence, may be higher in patients who used other adjuvant ablation techniques.

The authors concluded that risk for recurrence after complete remission of intestinal metaplasia remained constant over time, so it may not be advisable to lengthen follow-up intervals in the first five years after complete remission. They also concluded that sampling the gastroesophageal junction is critical to detecting recurrence, since most recurrences developed in that location. Finally, the requirement for random biopsies of the neosquamous epithelium in the absence of visible lesions may need to be re-evaluated, they wrote. They called for their findings to be replicated in centers with less expertise to evaluate the cost-effectiveness of random biopsy sampling.