Spotlight on screening for Barrett's esophagus

Recent studies looked at a nonendoscopic test for Barrett's esophagus in primary care, as well as screening for the condition before and after gastric bypass procedures.

Several studies this month discussed the possibility of screening for Barrett's esophagus, in primary care and before and after gastric bypass procedures.

The first study, a randomized controlled trial in England, looked at whether a nonendoscopic test for Barrett's esophagus would increase detection versus usual management among patients taking medication for gastroesophageal reflux disease (GERD). The nonendoscopic test, called the Cytosponge-TFF3 procedure, involves a cell collection device and an in vitro test for trefoil factor 3 (TFF3), the specific biomarker that identifies intestinal metaplasia. Patients were eligible for the trial if they were ages 50 years and older, had been taking acid-suppressing medications for GERD for more than six months, and had not had an endoscopic procedure in the past five years.

In the usual care group, participants received standard management and endoscopy only if required by their general practitioner. In the intervention group, participants received usual care plus an offer of a nonendoscopic procedure and subsequent endoscopy if the procedure identified suspicious cells. The trial's primary outcome was a Barrett's esophagus diagnosis 12 months after study enrollment in all participants in the intervention group versus all participants in the usual care group. The study was funded in part by the manufacturer of the nonendoscopic test, and two of the authors hold related patents. Results were published Aug. 1 by The Lancet.

Overall, 13,514 patients at 109 general practice clinics were randomly assigned per practice or at the individual-patient level to usual care (n=6,531) or to the intervention (n=6,983). After randomization, 149 patients (2%) in the intervention group and 143 (2%) in the usual care group withdrew or were found to be ineligible. In the intervention group, the nonendoscopic test was performed successfully in 1,654 patients, 221 of whom (13%) had a positive result and were referred for endoscopy. Over 12 months of follow-up, 140 patients in the intervention group and 13 patients in the usual care group were diagnosed with Barrett's esophagus (2% vs. <1%; absolute difference, 18.3 per 1,000 person-years [95% CI, 14.8 to 21.8 per 1,000 person-years]; rate ratio adjusted for cluster randomization, 10.6 [95% CI, 6.0 to 18.8]; P<0.0001). Four patients in the intervention group received a diagnosis of dysplastic Barrett's esophagus, and five received a diagnosis of stage I esophagogastric cancer. In the intervention group, 131 of 221 patients (59%) who had endoscopy after the nonendoscopic test were diagnosed with Barrett's esophagus or cancer. Sore throat was the most common side effect of nonendoscopic testing, reported in 63 of 1,654 patients (4%).

The authors noted that patients who opted for the nonendoscopic procedure might have differed from those who declined and that endoscopies varied in quality across the study facilities, among other limitations. They concluded that in patients with GERD who have required acid-suppressing medications for at least six months, nonendoscopic testing in primary care is a safe, effective way to improve detection of Barrett's esophagus. Additional studies examining cost-effectiveness are needed, they added, since more endoscopies will be performed with this approach.

An accompanying editorial called the results “encouraging” and said that the Cytosponge-TFF3 procedure is a promising nonendoscopic screening tool that can likely play a role in screening for Barrett's esophagus and esophagogastric cancer. “As with colorectal cancer, this procedure is unlikely to be the sole screening tool, as multiple tests will be needed to enhance participation in a screening programme,” the editorialists wrote. They noted that the test may need to be restricted to high-risk patients going forward in order to increase its cost-effectiveness.

Regarding gastric bypass, a systematic review and meta-analysis published Aug. 14 by Gastrointestinal Endoscopy looked at the prevalence of Barrett's esophagus in patients who had had sleeve gastrectomy, since this procedure is a major risk factor for the condition. The authors included 10 studies involving 680 patients who had had esophagogastroduodenoscopy (EGD) six months to 10 years after sleeve gastrectomy. The pooled prevalence of Barrett's esophagus was 11.6% (95% CI, 8.1% to 16.4%; P<0.001). No association was found in logistic meta-regression analysis between Barrett's esophagus and postoperative GERD, but a linear relationship was seen between time of postoperative EGD and rate of esophagitis, with risk increasing 13% each year after sleeve gastrectomy.

The researchers concluded that patients who undergo EGD after sleeve gastrectomy seem to have a high prevalence of Barrett's esophagus and that there is no correlation with GERD symptoms. Most cases were seen after three years of follow-up, the authors noted. They concluded that patients who have had sleeve gastrectomy should be considered for Barrett's esophagus screening even if they have no postoperative symptoms of GERD.

Finally, a review published Aug. 13 by Annals of the New York Academy of Sciences looked at perioperative screening, management, and surveillance of Barrett's esophagus in patients having bariatric surgery. The authors aimed to evaluate the available evidence on screening for Barrett's esophagus before bariatric surgery, the effects of bariatric surgery on Barrett's esophagus, and surveillance of patients who have or develop Barrett's esophagus after bariatric surgery. Studies published through January 2020 that reported any experiences or outcomes of Barrett's esophagus and bariatric surgery were included.

The review found that current screening practices before surgery vary widely and that recommendations from bariatric societies conflict. If Barrett's esophagus is detected before bariatric surgery, it might affect the type of procedure done, and while selective screening prevents unnecessary endoscopies, not all patients with Barrett's esophagus exhibit symptoms, the review found. Regarding type of procedure, sleeve gastrectomy has been associated with increased risk for Barrett's esophagus while Roux-en-Y gastric bypass has been associated with decreased symptoms of reflux and may improve or resolve Barrett's esophagus. The researchers found no guidelines that specifically addressed de novo surveillance for Barrett's esophagus after bariatric surgery, noting that most recommendations focus on patients with known risk factors for the disease, such as chronic GERD, older age, and male sex.

“Screening before bariatric surgery may be valuable as, theoretically, it helps guide procedure selection and may inform future BE [Barrett's esophagus] surveillance,” the authors concluded. “Strong consideration should be given to endoscopic surveillance after [sleeve gastrectomy], given the reported rates of development of BE at 5-10 years.” They called for further prospective studies to strengthen their conclusions and facilitate development of evidence-based guidelines for perioperative management of Barrett's esophagus in bariatric surgery patients.