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Kodama S, Watanabe K, Shimodaira Y, Fukuda S, Yoshida T, Saruta Y, Okubo R, Matsuhashi T, Komatsu T, Iijima K. Development of a prediction score for Barrett's esophagus in Japanese health checkup settings. Esophagus 2024:10.1007/s10388-024-01079-3. [PMID: 39158677 DOI: 10.1007/s10388-024-01079-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 08/08/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND The incidence of esophageal adenocarcinoma has recently increased in Asia, including Japan. A system to identify individuals at high risk for Barrett's esophagus (BE), a pre-cancerous condition of esophageal adenocarcinoma, among the general population is needed to perform endoscopic surveillance appropriately. We therefore developed risk prediction scores for BE at health checkups in Japan. METHODS 4128 consecutive health checkup examinees were retrospectively enrolled from October 2021 to March 2022. A prediction score for BE was developed based on the linear transformation of β-regression coefficients in a multivariable regression model incorporating BE predictors. Internal validation was performed by evaluating discrimination and calibration of the prediction model. RESULTS Three prediction scores corresponding to BE based on its length were developed: all lengths, ≥ 1 cm, ≥ 2 cm. All scores were internally validated, and the model calibration was excellent. The performance of the prediction models was better for longer BE, with a c-statistic of 0.70 for BE ≥ 2 cm, than for shorter values. The prediction score for BE ≥ 2 cm yielded sensitivity and specificity of 52.9% and 78.6% in high-risk subjects and 91.2% and 29.3% in intermediate- or high-risk subjects, respectively. CONCLUSIONS This prediction score can potentially increase the endoscopic detection of BE by identifying potentially high-risk individuals from the general population. This is the first report on developing a prediction score for BE that may suit the Japanese population.
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Affiliation(s)
- So Kodama
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Kenta Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.
| | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tatsuki Yoshida
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yohei Saruta
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Ryo Okubo
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | | | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Iijima K. Etiologic factors for Barrett's esophagus: toward countermeasures in Asia. Expert Rev Gastroenterol Hepatol 2024:1-14. [PMID: 39072626 DOI: 10.1080/17474124.2024.2386367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/26/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Over the past several decades, Europe and the United States have experienced a rapid increase in esophageal adenocarcinoma. Research and countermeasures against Barrett's esophagus, its precancerous lesion, are progressing. Because esophageal adenocarcinoma has an extremely poor prognosis when diagnosed in an advanced stage, recommendations for early cancer detection have been made based on the various proven etiological factors of Barrett's esophagus and the actual cancer risk of Barrett's esophagus. In recent years, there have been indications of an increase in esophageal adenocarcinoma in Japan, and a similar trend of cancer will occur shortly in other Asian countries. Consequently, Asian countries must implement similar countermeasures against Barrett's esophagus and esophageal adenocarcinoma, referencing the knowledge gained thus far in Europe and the United States. AREAS COVERED This review summarizes the latest findings on the etiologic factors of Barrett's esophagus and discusses the differences between Westerners and Asians. The current status of Barrett's esophagus in Japan and other Asian countries is also summarized. EXPERT OPINION The etiological factors and cancer incidence of Barrett's esophagus in Asia diverge somewhat from those observed in Europe and America. Therefore, it is imperative to implement measures that are tailored to the actual circumstances of Asian people.
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Affiliation(s)
- Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
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Vantanasiri K, Kamboj AK, Kisiel JB, Iyer PG. Advances in Screening for Barrett Esophagus and Esophageal Adenocarcinoma. Mayo Clin Proc 2024; 99:459-473. [PMID: 38276943 PMCID: PMC10922282 DOI: 10.1016/j.mayocp.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 01/27/2024]
Abstract
Esophageal adenocarcinoma (EAC), the primary form of esophageal cancer in the United States, is a lethal cancer with exponentially increasing incidence. Screening for Barrett esophagus (BE), the only known precursor to EAC, followed by endoscopic surveillance to detect dysplasia and early-stage EAC and subsequent endoscopic treatment (to prevent progression of dysplasia to EAC and to treat early-stage EAC effectively) is recommended by several society guidelines. Sedated endoscopy (the primary current tool for BE screening) is both invasive and expensive, limiting its widespread use. In this review, we aim to provide a comprehensive review of recent innovations in the nonendoscopic detection of BE and EAC. These include swallowable cell sampling devices combined with protein and epigenetic biomarkers (which are now guideline endorsed as alternatives to sedated endoscopy), tethered capsule endomicroscopy, emerging peripheral blood-sampled molecular biomarkers, and exhaled volatile organic compounds. We also summarize progress and challenges in assessing BE and EAC risk, which is an important complementary component of the process for the clinical implementation of these innovative nonendoscopic tools, and propose a new paradigm for the strategy to reduce EAC incidence and mortality.
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Affiliation(s)
- Kornpong Vantanasiri
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Amrit K Kamboj
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John B Kisiel
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Sawas T, Zamani SA, Killcoyne S, Dullea A, Wang KK, Iyer PG, Fitzgerald RC, Katzka DA. Limitations of Heartburn and Other Societies' Criteria in Barrett's Screening for Detecting De Novo Esophageal Adenocarcinoma. Clin Gastroenterol Hepatol 2022; 20:1709-1718. [PMID: 34757196 DOI: 10.1016/j.cgh.2021.10.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/14/2021] [Accepted: 10/24/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Despite extensive Barrett's esophagus (BE) screening efforts, most patients with esophageal adenocarcinoma (EAC) present de novo. It is unclear how much of this problem is the result of insensitivity or poor applications of current screening guidelines. We aimed to evaluate the sensitivity of guidelines by determining the proportion of prevalent EAC cases that meet the American College of Gastroenterology (ACG) or the British Society of Gastroenterology (BSG) guidelines for BE screening and determine whether changes to criteria would enhance detection. METHODS A retrospective single-center cohort from the United States (n = 663) and a prospective multicenter cohort from the United Kingdom (n = 645) were collected and analyzed independently. Screening eligibility was determined as patients with chronic reflux and at least 2 or more risk factors as defined by the guidelines. We calculated the proportion of screening-eligible patients and then compared BE/EAC risk factors between screening-eligible and screening-ineligible patients using the chi-squared or Student t test as appropriate. RESULTS In the Mayo clinic cohort there were 54.9% EAC cases and in the UK cohort there were 38.9% EAC cases that were not identified by ACG or BSG screening criteria, respectively. Among patients who did not meet the screening criteria, lack of heartburn was observed in 86.5% in the Mayo clinic cohort and in 61.4% in the UK cohort. Other risk factors that were lacking included obesity (defined as a body mass index of ≥30 kg/m2) and family history of EAC. Eliminating chronic reflux from the ACG/BSG criteria improved eligibility for screening from 45.1% to 81.3% (P < .001) in the Mayo Clinic cohort and from 61.1% (n = 394) to 81.5% (n = 526; P < .001) in the UK cohort. However, reflux may be difficult to ascertain from the history, and by including proton pump inhibitor use status in addition to the BSG criteria, screening eligibility improved by 10.0% in the UK cohort (n = 459; P < .001). CONCLUSIONS ACG/BSG BE screening guidelines have limited our ability to detect prevalent EAC. An optimized approach to identifying the individuals most suitable for EAC screening needs to be implemented, particularly one that does not rely on chronic reflux symptoms.
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Affiliation(s)
- Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Shawn A Zamani
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Killcoyne
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom; European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, United Kingdom
| | - Andrew Dullea
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Chang K, Jackson CS, Vega KJ. Barrett's Esophagus: Diagnosis, Management, and Key Updates. Gastroenterol Clin North Am 2021; 50:751-768. [PMID: 34717869 DOI: 10.1016/j.gtc.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma (EAC) development. Unfortunately, BE screening/surveillance has not provided the anticipated EAC reduction benefit. Noninvasive techniques are increasingly available or undergoing testing to screen for BE among those with/without known risk factors, and the use of artificial intelligence platforms to aid endoscopic screening and surveillance will likely become routine, minimizing missed cases or lesions. Management of high-grade dysplasia and intramucosal EAC is clear with endoscopic eradication therapy preferred to surgery. BE with low-grade dysplasia can be managed with removal of visible lesions combined with endoscopic eradication therapy or endoscopic surveillance at present.
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Affiliation(s)
- Karen Chang
- Department of Internal Medicine, University of California, Riverside School of Medicine, 900 University Avenue, Riverside, CA 92521, USA
| | - Christian S Jackson
- Section of Gastroenterology, Loma Linda VA Healthcare System, 11201 Benton Street, 2A-38, Loma Linda, CA 92357, USA
| | - Kenneth J Vega
- Division of Gastroenterology & Hepatology, Augusta University-Medical College of Georgia, 1120 15th Street, AD-2226, Augusta, GA 30912, USA.
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Eusebi LH, Telese A, Cirota GG, Haidry R, Zagari RM, Bazzoli F, Ford AC. Systematic review with meta-analysis: risk factors for Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms. Aliment Pharmacol Ther 2021; 53:968-976. [PMID: 33705573 DOI: 10.1111/apt.16321] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux is considered the main risk factor for Barrett's oesophagus. The role of other potential risk factors for the development of Barrett's oesophagus in patients with gastro-oesophageal reflux symptoms is controversial. AIMS To perform a systematic review and meta-analysis examining risk factors in development of Barrett's oesophagus. METHODS Medline, Embase and Embase Classic were searched (until December 2020) to identify cross-sectional studies reporting prevalence of Barrett's oesophagus based on presence of one or more proposed risk factors in individuals with gastro-oesophageal reflux symptoms. Prevalence of Barrett's oesophagus was compared according to presence or absence of each risk factor in individuals with gastro-oesophageal reflux symptoms. RESULTS Of 7164 citations evaluated, 13 studies reported prevalence of Barrett's oesophagus in 11 856 subjects. Pooled prevalence of histologically confirmed Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms in all studies was 7.0% (95% CI 4.8% to 9.6%). Prevalence was higher in subjects with hiatal hernia (OR 2.74; 95% CI 1.58 to 4.75) and in those who drank alcohol (OR 1.51; 95% CI 1.17 to 1.95). Other features including non-steroidal anti-inflammatory drugs and/or aspirin use (OR 1.19; 95% CI 1.00 to 1.42), smoking (OR 1.14; 95% CI 0.96 to 1.35) or obesity (OR 1.10; 95% CI 0.92 to 1.33) were not significantly associated with Barrett's oesophagus. CONCLUSIONS The prevalence of Barrett's oesophagus in individuals with gastro-oesophageal reflux symptoms was higher in those who drank alcohol, although this association was modest. The strongest association found was between hiatal hernia and Barrett's oesophagus. Other potential risk factors assessed in this study did not appear to be associated with presence of Barrett's oesophagus among individuals with gastro-oesophageal symptoms.
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Affiliation(s)
- Leonardo H Eusebi
- Gastroenterology and Endoscopy Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Telese
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Giovanna G Cirota
- Gastroenterology and Endoscopy Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Rocco M Zagari
- Gastroenterology and Endoscopy Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Franco Bazzoli
- Gastroenterology and Endoscopy Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alexander C Ford
- Leeds Institute of Medical Research, St. James's University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Validation of Tools for Predicting Incident Adenocarcinoma of the Esophagus or Esophagogastric Junction. Am J Gastroenterol 2021; 116:949-957. [PMID: 33852454 DOI: 10.14309/ajg.0000000000001255] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Guidelines suggest screening of individuals who are at increased risk of esophageal adenocarcinoma (EAC). Tools for identifying patients at risk of Barrett's esophagus have been validated. Here, we aimed to compare and validate the tools for the primary outcomes of interest: EAC and esophagogastric junction adenocarcinoma (EGJAC). METHODS Retrospective longitudinal analysis of the Kaiser Permanente Northern California Multiphasic Health Checkup Cohort, a community-based cohort including 206,974 patients enrolled between 1964 and 1973 followed through 2016. Baseline questionnaires and anthropometrics classified predictor variables for each tool and were linked to cancer registry outcomes. Analyses used logistic regression, Cox proportional hazards regression, and Kaplan-Meier survival curves. RESULTS We identified 168 incident EAC cases and 151 EGJAC cases at a mean of 32 years after enrollment (mean follow-up among controls 26 years). Gastroesophageal reflux disease (GERD) symptoms predicted incident EAC (hazard ratio 2.66; 95% confidence interval 1.01, 7.00), but not EGJAC. The Nord-Trøndelag Health Study tool, Kunzmann tool, and Michigan Barrett's Esophagus pREdiction Tool were more accurate than GERD for predicting EAC, with individuals in the fourth quartile of Kunzmann having 17-fold the risk of those in the 1st quartile (hazard ratio = 16.7, 95% confidence interval = 4.72, 58.8). Each tool also predicted incident EGJAC with smaller magnitudes of effect. DISCUSSION The study independently validated 4 tools for predicting incident EAC and EGJAC in a large community-based population. The Kunzmann tool appears best calibrated; all appear preferable to using GERD alone for risk stratification. Future studies should determine how best to implement such tools into clinical practice.
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Eusebi LH, Cirota GG, Zagari RM, Ford AC. Global prevalence of Barrett's oesophagus and oesophageal cancer in individuals with gastro-oesophageal reflux: a systematic review and meta-analysis. Gut 2021; 70:456-463. [PMID: 32732370 DOI: 10.1136/gutjnl-2020-321365] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Chronic gastro-oesophageal reflux might lead to the development of Barrett's oesophagus (BO) or even oesophageal adenocarcinoma. There has been no definitive systematic review and meta-analysis of data to estimate global prevalence of BO or oesophageal adenocarcinoma in individuals with gastro-oesophageal reflux. DESIGN We searched MEDLINE, Embase and Embase Classic to identify cross-sectional surveys that reported prevalence of BO or oesophageal adenocarcinoma in adults with gastro-oesophageal reflux. We extracted prevalence for all studies, both for endoscopically suspected and histologically confirmed cases. We calculated pooled prevalence according to study location, symptom frequency and sex, as well as ORs with 95% CIs. RESULTS Of the 4963 citations evaluated, 44 reported prevalence of endoscopically suspected and/or histologically confirmed BO. Prevalence of BO among individuals with gastro-oesophageal reflux varied according to different geographical regions ranging from 3% to 14% for histologically confirmed BO with a pooled prevalence of 7.2% (95% CI 5.4% to 9.3%), whereas pooled prevalence for endoscopically suspected BO was 12.0% (95% CI 5.5% to 20.3%). There was heterogeneity in many of our analyses. Prevalence of BO was significantly higher in men, both for endoscopically suspected (OR=2.1; 95% CI 1.6 to 2.8) and histologically confirmed BO (OR=2.3; 95% CI 1.7 to 3.2). Dysplasia was present in 13.9% (95% CI 8.9% to 19.8%) of cases of histologically confirmed BO, 80.7% of which was low-grade. CONCLUSION The prevalence of Barrett's oesophagus among individuals with gastro-oesophageal reflux varied strikingly among countries, broadly resembling the geographical distribution of gastro-oesophageal reflux itself. Prevalence of BO was significantly higher in men.
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Affiliation(s)
| | | | | | - Alexander Charles Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, West Yorkshire, UK
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Cook MB, Thrift AP. Epidemiology of Barrett's Esophagus and Esophageal Adenocarcinoma: Implications for Screening and Surveillance. Gastrointest Endosc Clin N Am 2021; 31:1-26. [PMID: 33213789 PMCID: PMC7887893 DOI: 10.1016/j.giec.2020.08.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the United States, the incidence of esophageal adenocarcinoma increased markedly since the 1970s with a recent stabilization. Despite evolving screening and surveillance strategies to diagnose, risk triage, and intervene in Barrett's esophagus patients to prevent esophageal adenocarcinoma, most cases present with advanced disease and poor resultant survival. Epidemiologic studies have identified the main risk factors for these conditions, including increasing age, male sex, white race, gastroesophageal reflux disease, abdominal obesity, cigarette smoking, and lack of infection with Helicobacter pylori. This review summarizes the current epidemiologic evidence with implications for screening and surveillance in Barrett's esophagus and esophageal adenocarcinoma.
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Affiliation(s)
- Michael B Cook
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, 6E430, Rockville, MD 20850, USA.
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, and Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, One Baylor Plaza, MS: BCM307, Room 621D, Houston, TX 77030, USA
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10
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Progress in Screening for Barrett's Esophagus: Beyond Standard Upper Endoscopy. Gastrointest Endosc Clin N Am 2021; 31:43-58. [PMID: 33213799 DOI: 10.1016/j.giec.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The rapid increase in the incidence of esophageal adenocarcinoma in Western populations over the past 4 decades and its associated poor prognosis, unless detected early has generated great interest in screening for the precursor lesion Barrett's esophagus (BE). Recently, there have been significant developments in imaging-based modalities and esophageal cell-sampling devices coupled with biomarker assays. In this review, the authors discuss the rationale for screening for BE and the factors to consider for targeting the at-risk population. They also explore future avenues for research in this area.
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11
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Kamboj AK, Katzka DA, Iyer PG. Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges. Gastrointest Endosc Clin N Am 2021; 31:27-41. [PMID: 33213798 PMCID: PMC8127641 DOI: 10.1016/j.giec.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.
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12
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Risk Prediction Models for Barrett's Esophagus Discriminate Well and Are Generalizable in an External Validation Study. Dig Dis Sci 2020; 65:2992-2999. [PMID: 31897894 DOI: 10.1007/s10620-019-06018-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Barrett's esophagus is the precursor to the highly lethal esophageal adenocarcinoma. Risk prediction models have been developed to assist in its detection, potentially improving early identification and treatment of esophageal adenocarcinoma. Six models have been developed. AIMS To externally validate three models (Rubenstein, Thrift, and Baldwin-Hunter models) and compare them to a fourth risk prediction model (Ireland model) for Barrett's esophagus. METHODS Data from 120 Barrett's cases and 235 population controls were available to externally validate the three models. Discriminatory ability of these models was assessed by the area under the receiver operating characteristic curve. Calibration was assessed with the calibration slope, Hosmer-Lemeshow test, and Lowess smoother calibration plot. Following external validation, diagnostic accuracy of the three models was compared to that of the Ireland model. RESULTS On external validation, the Rubenstein model had an area under the receiver operating characteristic curve of 0.71 and was well calibrated (Hosmer-Lemeshow test, p = 0.67). Likewise, the Thrift and Baldwin-Hunter models had similar discrimination (0.71 and 0.70, respectively) and were also well calibrated (p = 0.69 and p = 0.28). Our previous external validation of the Ireland model provided an area under the receiver operating characteristic curve of 0.83 and was well calibrated (p = 0.14). The Ireland model demonstrated a statistically significantly greater area under the receiver operating characteristic curve than the Rubenstein (p = 0.02), Thrift (p = 0.001), and Baldwin-Hunter (p = 0.002) models. CONCLUSION We externally validated the Rubenstein, Thrift, and Baldwin-Hunter risk prediction models and compared them to the Ireland model. The Ireland model demonstrated improved accuracy, albeit with slightly poorer calibration.
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13
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Rubenstein JH, McConnell D, Waljee AK, Metko V, Nofz K, Khodadost M, Jiang L, Raghunathan T. Validation and Comparison of Tools for Selecting Individuals to Screen for Barrett's Esophagus and Early Neoplasia. Gastroenterology 2020; 158:2082-2092. [PMID: 32119928 PMCID: PMC7282990 DOI: 10.1053/j.gastro.2020.02.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines suggest endoscopic screening of individuals who are at increased risk for Barrett's esophagus (BE) and esophageal adenocarcinoma. Tools based on clinical factors are available for identifying patients at risk, but only some have been validated. We aimed to compare and validate available tools. METHODS We performed a prospective study of 1241 patients, ages 40 to 79 years, presenting either for their first esophagogastroduodenoscopy (EGD) or their first endoscopic therapy of early neoplastic BE, from April 2015 through June 2018. We calculated risk scores for 6 previously published tools (the Gerson, Locke, Thrift, Michigan BE pREdiction Tool [M-BERET], Nord-Trøndelag Health Study [HUNT], and Kunzmann tools). We also investigated the accuracy of frequency and duration of gastroesophageal reflux disease (GERD), using data from a randomly selected 50% of patients undergoing their first EGD. We compared the ability of all these tools to discriminate patients with BE and early neoplasia from patients without BE, using findings from endoscopy as the reference standard. RESULTS BE was detected in 81 of 1152 patients during their first EGD (7.0%). GERD symptoms alone identified patients with BE with an area under the receiver operating characteristic curve (AuROC) of 0.579. All of the tools were more accurate in identifying patients with BE than the frequency and duration of GERD (AuROC for GERD, 0.579 vs range for other tools, 0.660-0.695), and predicted risk correlated well with observed risk (calibration). The AUROCs of the HUNT tool (0.796), the M-BERET (0.773), and the Kunzmann tool (0.763) were comparable in discriminating between patients with early neoplasia (n = 94) vs no BE. Each tool was more accurate in discriminating BE with early neoplasia than GERD frequency and duration alone (AuROC, 0.667; P < .01). CONCLUSIONS The HUNT, M-BERET, and Kunzmann tools identify patients with BE with AuROC values ranging from 0.665 to 0.695, and discriminate patients with early neoplasia from patients without BE with AuROC values ranging from 0.763 to 0.796. These tools are more accurate than frequency and duration of GERD in identifying individuals at risk for neoplastic BE.
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Affiliation(s)
- Joel H. Rubenstein
- Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Daniel McConnell
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Akbar K. Waljee
- Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Valbona Metko
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kimberly Nofz
- Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
| | | | - Li Jiang
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Trivellore Raghunathan
- Institute for Social Research, University of Michigan, Ann Arbor, MI,Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
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14
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Rosenfeld A, Graham DG, Jevons S, Ariza J, Hagan D, Wilson A, Lovat SJ, Sami SS, Ahmad OF, Novelli M, Rodriguez Justo M, Winstanley A, Heifetz EM, Ben-Zecharia M, Noiman U, Fitzgerald RC, Sasieni P, Lovat LB. Development and validation of a risk prediction model to diagnose Barrett's oesophagus (MARK-BE): a case-control machine learning approach. Lancet Digit Health 2020; 2:E37-E48. [PMID: 32133440 PMCID: PMC7056359 DOI: 10.1016/s2589-7500(19)30216-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Screening for Barrett's Oesophagus (BE) relies on endoscopy which is invasive and has a low yield. This study aimed to develop and externally validate a simple symptom and risk-factor questionnaire to screen for patients with BE. Methods Questionnaires from 1299 patients in the BEST2 case-controlled study were analysed: 880 had BE including 40 with invasive oesophageal adenocarcinoma (OAC) and 419 were controls. This was randomly split into a training cohort of 776 patients and an internal validation cohort of 523 patients. External validation included 398 patients from the BOOST case-controlled study: 198 with BE (23 with OAC) and 200 controls. Identification of independently important diagnostic features was undertaken using machine learning techniques information gain (IG) and correlation based feature selection (CFS). Multiple classification tools were assessed to create a multi-variable risk prediction model. Internal validation was followed by external validation in the independent dataset. Findings The BEST2 study included 40 features. Of these, 24 added IG but following CFS, only 8 demonstrated independent diagnostic value including age, gender, smoking, waist circumference, frequency of stomach pain, duration of heartburn and acid taste and taking of acid suppression medicines. Logistic regression offered the highest prediction quality with AUC (area under the receiver operator curve) of 0.87. In the internal validation set, AUC was 0.86. In the BOOST external validation set, AUC was 0.81. Interpretation The diagnostic model offers valid predictions of diagnosis of BE in patients with symptomatic gastroesophageal reflux, assisting in identifying who should go forward to invasive testing. Overweight men who have been taking stomach medicines for a long time may merit particular consideration for further testing. The risk prediction tool is quick and simple to administer but will need further calibration and validation in a prospective study in primary care. Funding Charles Wolfson Trust and Guts UK.
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Affiliation(s)
- Avi Rosenfeld
- Department of Industrial Engineering Jerusalem College of Technology (JCT), Jerusalem, Israel
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
| | - David G Graham
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
- Gastrointestinal Services, University College London Hospital (UCLH), London, United Kingdom
| | - Sarah Jevons
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
| | - Jose Ariza
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
- Gastrointestinal Services, University College London Hospital (UCLH), London, United Kingdom
| | - Daryl Hagan
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
| | - Ash Wilson
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
| | - Samuel J Lovat
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
| | - Sarmed S Sami
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
- Gastrointestinal Services, University College London Hospital (UCLH), London, United Kingdom
| | - Omer F Ahmad
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
- Gastrointestinal Services, University College London Hospital (UCLH), London, United Kingdom
| | - Marco Novelli
- Dept of Pathology, University College London Hospital (UCLH), London, United Kingdom
| | | | - Alison Winstanley
- Dept of Pathology, University College London Hospital (UCLH), London, United Kingdom
| | - Eliyahu M Heifetz
- Department of Health Informatics, Jerusalem College of Technology (JCT), Jerusalem, Israel
| | - Mordehy Ben-Zecharia
- Department of Health Informatics, Jerusalem College of Technology (JCT), Jerusalem, Israel
| | - Uria Noiman
- Department of Health Informatics, Jerusalem College of Technology (JCT), Jerusalem, Israel
| | | | - Peter Sasieni
- Cancer Prevention Trials Unit, Queen Mary University of London, London, United Kingdom
- School of Cancer & Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Laurence B Lovat
- GENIE GastroENterological IntervEntion Group, Department for Targeted Intervention, University College London (UCL), London, United Kingdom
- Gastrointestinal Services, University College London Hospital (UCLH), London, United Kingdom
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15
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Use of the Electronic Health Record to Target Patients for Non-endoscopic Barrett's Esophagus Screening. Dig Dis Sci 2019; 64:3463-3470. [PMID: 31273597 PMCID: PMC7191846 DOI: 10.1007/s10620-019-05707-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/12/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clinical prediction models targeting patients for Barrett's esophagus (BE) screening include data obtained by interview, questionnaire, and body measurements. A tool based on electronic health records (EHR) data could reduce cost and enhance usability, particularly if combined with non-endoscopic BE screening methods. AIMS To determine whether EHR-based data can identify BE patients. METHODS We performed a retrospective review of patients ages 50-75 who underwent a first-time esophagogastroduodenoscopy. Data extracted from the EHR included demographics and BE risk factors. Endoscopy and pathology reports were reviewed for histologically confirmed BE. Screening criteria modified from clinical guidelines were assessed for association with BE. Subsequently, a score based on multivariate logistic regression was developed and assessed for its ability to identify BE subjects. RESULTS A total of 2931 patients were assessed, and BE was found in 1.9%. Subjects who met screening criteria were more likely to have BE (3.3% vs. 1.1%, p = 0.001), and the criteria predicted BE with an AUROC of 0.65 (95% CI 0.59-0.71). A score based on logistic regression modeling included gastroesophageal reflux disease, sex, body mass index, and ever-smoker status and identified BE subjects with an AUROC of 0.71 (95% CI 0.64-0.77). Both prediction tools produced higher AUROCs in women than in men. CONCLUSIONS EHR-based BE risk prediction tools identify BE patients with fair accuracy. While these tools may improve the efficiency of patient targeting for BE screening in the primary care setting, challenges remain to identify high-risk patients for non-invasive BE screening in clinical practice.
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16
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Ireland CJ, Gordon AL, Thompson SK, Watson DI, Whiteman DC, Reed RL, Esterman A. Validation of a risk prediction model for Barrett's esophagus in an Australian population. Clin Exp Gastroenterol 2018; 11:135-142. [PMID: 29628770 PMCID: PMC5878665 DOI: 10.2147/ceg.s158627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Esophageal adenocarcinoma is a disease that has a high mortality rate, the only known precursor being Barrett's esophagus (BE). While screening for BE is not cost-effective at the population level, targeted screening might be beneficial. We have developed a risk prediction model to identify people with BE, and here we present the external validation of this model. Materials and methods A cohort study was undertaken to validate a risk prediction model for BE. Individuals with endoscopy and histopathology proven BE completed a questionnaire containing variables previously identified as risk factors for this condition. Their responses were combined with data from a population sample for analysis. Risk scores were derived for each participant. Overall performance of the risk prediction model in terms of calibration and discrimination was assessed. Results Scores from 95 individuals with BE and 636 individuals from the general population were analyzed. The Brier score was 0.118, suggesting reasonable overall performance. The area under the receiver operating characteristic was 0.83 (95% CI 0.78-0.87). The Hosmer-Lemeshow statistic was p=0.14. Minimizing false positives and false negatives, the model achieved a sensitivity of 74% and a specificity of 73%. Conclusion This study has validated a risk prediction model for BE that has a higher sensitivity than previous models.
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Affiliation(s)
- Colin J Ireland
- School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Andrea L Gordon
- School of Pharmacy and Medical Science, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Sarah K Thompson
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - David I Watson
- Department of Surgery, Flinders University, Bedford Park, SA, Australia
| | - David C Whiteman
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Richard L Reed
- Discipline of General Practice, Flinders University, Bedford Park, SA, Australia
| | - Adrian Esterman
- School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
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17
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Gaddam S. Prediction of Barrett's esophagus: are we there yet? Dis Esophagus 2018; 31:4807356. [PMID: 29346553 DOI: 10.1093/dote/dox147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- S Gaddam
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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18
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: There is a pressing need for effective strategies to halt the increase in both the incidence and mortality of esophageal adenocarcinoma (EAC). Screening for Barrett's esophagus, which is the only known precursor of EAC, remains a ripe area for research, particularly with regard to identifying the target population, screening tools, and management of screen-detected populations. This review aims to explore in depth the rationale for screening for Barrett's esophagus, recent biotechnological advances which may have the potential of making screening feasible, and also highlight the challenges which will have to be overcome in order make screening for BE a realistic prospect. RECENT FINDINGS Imaging techniques such as portable transnasal endoscopy have the advantage of providing an immediate diagnosis of Barrett's esophagus as well as other significant pathologies such as reflux esophagitis and cancer; however, larger studies in non-enriched community screening populations are required to evaluate their feasibility. The capsule sponge is a cell-sampling device coupled with a biomarker, which has been most extensively evaluated with very promising results as regards feasibility, acceptability, accuracy, and cost-effectiveness. Its effectiveness in increasing the detection of Barrett's esophagus in primary care is currently being evaluated. Several Barrett's esophagus risk prediction scores have been developed with variable degrees of accuracy. Several minimally and non-invasive screening techniques have been studied including imaging and cell-sampling devices. Barrett's risk assessment models need to be further validated in independent, relevant screening populations with clear cut-offs for recommending screening to be defined.
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Affiliation(s)
- Sarmed S Sami
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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19
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Gastroesophageal Reflux Frequency, Severity, Age of Onset, Family History and Acid Suppressive Therapy Predict Barrett Esophagus in a Large Population. J Clin Gastroenterol 2018; 52:873-879. [PMID: 29356784 PMCID: PMC6053338 DOI: 10.1097/mcg.0000000000000983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS To identify risk factors associated with Barrett esophagus (BE) for potential improved surveillance and risk reduction. BACKGROUND Gastroesophageal reflux disease (GERD) is a known risk factor for esophageal adenocarcinoma, but the ability of GERD symptom frequency and severity to predict presence of its putative precursor lesion, BE, is less well-defined in large, community-based populations. STUDY We conducted a case-control study within the Kaiser Permanente Northern California population. Cases had new diagnoses of BE. To identify risk factors in the general population, we contrasted cases with population controls; to identify risk factors only among patients with GERD, we contrasted cases with GERD patients who lacked BE. RESULTS We interviewed 953 patients; 320 patients with BE, 316 patients with GERD who lacked BE and 317 population controls. Compared with population controls, BE risk was highest among patients with the most frequent and severe GERD symptoms [odds ratio (OR), 27.00; 95% confidence interval (CI), 14.52-50.21], nocturnal symptoms (OR, 5.40; 95% CI, 3.81-7.72), and family history of GERD (OR, 2.55; 95% CI, 1.80-3.62) or BE (OR, 10.08; 95% CI, 2.83-35.84). Although at least weekly proton pump inhibitor (PPI) use was a risk factor for BE (OR, 9.85; 95% CI, 6.54-14.84), among PPI users in the general population, GERD symptoms were not strongly associated with the risk of BE. Compared with GERD controls, cases were more likely to have onset of GERD symptoms before 30 years of age (OR, 1.93; 95% CI, 1.15-3.22) and a family history of BE (OR, 3.64; 95% CI, 1.50-8.83). CONCLUSIONS Severe and frequent GERD symptoms are strongly associated with increased risk of BE in the general population, especially in the absence of frequent PPI use. Among people with GERD, family history of BE and early age of symptom onset were stronger predictors of BE. These findings may improve identification of patients at highest risk for BE.
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20
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Ireland CJ, Fielder AL, Thompson SK, Laws TA, Watson DI, Esterman A. Development of a risk prediction model for Barrett's esophagus in an Australian population. Dis Esophagus 2017; 30:1-8. [PMID: 28881896 DOI: 10.1093/dote/dox033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 03/24/2017] [Indexed: 12/11/2022]
Abstract
Esophageal adenocarcinoma has poor 5-year survival rates. Increased survival might be achieved with earlier treatment, but requires earlier identification of the precursor, Barrett's esophagus. Population screening is not cost effective, this may be improved by targeted screening directed at individuals more likely to have Barrett's esophagus. To develop a risk prediction tool for Barrett's esophagus, this study compared individuals with Barrett's esophagus against population controls. Participants completed a questionnaire comprising 35 questions addressing medical history, symptom history, lifestyle factors, anthropomorphic measures, and demographic details. Statistical analysis addressed differences between cases and controls, and entailed initial variable selection, checking of model assumptions, and establishing calibration and discrimination. The area under the curve (AUC) was used to assess overall accuracy. One hundred and twenty individuals with Barrett's esophagus and 235 population controls completed the questionnaire. Significant differences were identified for age, gender, reflux history, family reflux history, history of hypertension, alcoholic drinks per week, and body mass index. These were used to develop a risk prediction model. The AUC was 0.82 (95% CI 0.78-0.87). Good calibration between predicted and observed risk was noted (Hosmer-Lemeshow test P = 0.67). At the point minimizing false positives and false negatives, the model achieved a sensitivity of 84.96% and a specificity of 66%. A well-calibrated risk prediction model with good discrimination has been developed to identify patients with Barrett's esophagus. The model needs to be externally validated before consideration for clinical practice.
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Affiliation(s)
| | - A L Fielder
- Schools of Nursing and Midwifery.,Pharmacy and Medical Science, University of South Australia
| | - S K Thompson
- Discipline of Surgery, University of Adelaide, Adelaide
| | - T A Laws
- Schools of Nursing and Midwifery.,School of Nursing and Midwifery, Keele University, Keele, UK
| | - D I Watson
- Department of Surgery, Flinders University, Bedford Park, South Australia
| | - A Esterman
- Schools of Nursing and Midwifery.,Centre for Chronic Disease Prevention, James Cook University, Cairns, Queensland
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21
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Amadi C, Gatenby P. Barrett’s oesophagus: Current controversies. World J Gastroenterol 2017; 23:5051-5067. [PMID: 28811703 PMCID: PMC5537175 DOI: 10.3748/wjg.v23.i28.5051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/03/2017] [Accepted: 07/04/2017] [Indexed: 02/06/2023] Open
Abstract
Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.
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22
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Blevins CH, Iyer PG. Who Deserves Endoscopic Screening for Esophageal Neoplasia? Gastrointest Endosc Clin N Am 2017; 27:365-378. [PMID: 28577762 DOI: 10.1016/j.giec.2017.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite the availability of safe and effective endoscopic treatment of Barrett's esophagus (BE)-related dysplasia and neoplasia, the incidence and mortality from esophageal adenocarcinoma (EAC) have continued to increase. This likely stems from the large population of patients that develop EAC outside of a BE screening and surveillance program. Identification of BE with screening followed by enrollment in an appropriate surveillance/risk stratification program could be a strategy to address both the incidence of and mortality from EAC. This article summarizes the rationale and challenges for BE screening, the risk factors for BE, and the currently described BE risk assessment tools.
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Affiliation(s)
- Christopher H Blevins
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, 200 First Street Southwest, Rochester, MN 55905, USA.
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23
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Alkaddour A, Palacio C, Vega KJ. Risk of histologic Barrett's esophagus between African Americans and non-Hispanic whites: A meta-analysis. United European Gastroenterol J 2017; 6:22-28. [PMID: 29435310 DOI: 10.1177/2050640617707862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/29/2017] [Indexed: 12/16/2022] Open
Abstract
Background Barrett's esophagus (BE) is rare in African Americans (AA). However, the risk difference magnitude in histologic BE prevalence between AA and non-Hispanic whites (nHw) has not been quantified to date. Objective The objective of this article is to determine the degree of histologic BE risk difference between AA and nHw. Methods PubMed, Web of Science and EMBASE were searched for studies reporting histologic BE in AA/nHw for inclusion. Pooled odds ratios (ORs) with risk estimates of histologic BE occurrence between AA/nHw were calculated along with 95% confidence intervals (CIs). Forest plots were used to quantify heterogeneity. Funnel plots and the Cochrane Collaboration Risk of Bias tool were used to assess bias risk. Results Eight studies reported BE histologic confirmation in AA/nHw. Analysis demonstrated a nearly 400% increased histologic BE risk in nHw patients compared to AA (OR 3.949, 95% CI 3.069-5.082). In the model without the case-control study, histologic BE risk remained elevated at approximately 360% in nHw compared to AA (OR 3.618, 95% CI 2.769-4.726). Heterogeneity was not present in either model. Risk of bias was significant. Conclusions Histologic BE risk is elevated in nHw by 3.6-4 times compared to AA. Investigation into understanding any clinical, molecular or genetic mechanisms underlying this risk disparity is warranted.
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Affiliation(s)
- Ahmad Alkaddour
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Carlos Palacio
- Department of Medicine, University of Florida/Jacksonville, Jacksonville, FL, USA
| | - Kenneth J Vega
- Division of Gastroenterology, National Jewish Health, Denver, CO, USA
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24
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Nakayama Y, Ida S. Endoscopic findings of esophagogastric junction in children. Dig Endosc 2017; 29 Suppl 2:11-17. [PMID: 28425652 DOI: 10.1111/den.12793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 12/21/2016] [Indexed: 12/13/2022]
Abstract
Esophagogastric landmarks are recognizable in the same way both in children and in adults, and palisade-shaped vessels can be observed at the distal position of esophageal mucosa, even in infants. Few studies have been done in respect to Barrett's esophagus (BE) in children. Incidence of endoscopically suspected BE among all children undergoing esophagogastroduodenoscopy (EGD) is approximately 0.25-1.4%, but can be up to 9.7% in patients with gastroesophageal reflux disease (GERD). Some data suggest that BE is an acquired disorder and point to the possibility of a congenital component in combination with severe mucosal injury. Recent reports noted that multilayered epithelium (ME), which shows morphological and immunocytochemical characteristics of both squamous and columnar epithelium, is associated with goblet cell metaplasia in adult patients with columnar-lined esophagus. The role of ME in the development of intestinal metaplasia in children is uncertain. Furthermore, detailed mechanisms about how short-segment BE (SSBE) changes to long-segment BE (LSBE) are not yet well understood. Further studies are required to understand the pathological esophagogastric junction (EGJ) and BE in children based on reliable epidemiological data and analysis especially in children who have reflux symptoms. Better understanding of the pediatric EGJ and BE may allow improved diagnosis, monitoring, therapy and, therefore, prognosis of GERD-related disorders in adulthood.
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Affiliation(s)
- Yoshiko Nakayama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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25
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Palles C, Findlay JM, Tomlinson I. Common Variants Confer Susceptibility to Barrett's Esophagus: Insights from the First Genome-Wide Association Studies. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 908:265-90. [PMID: 27573776 DOI: 10.1007/978-3-319-41388-4_13] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Eight loci have been identified by the two genome-wide association studies of Barrett's esophagus that have been conducted to date. Esophageal adenocarcinoma cases were included in the second study following evidence that predisposing genetic variants for this cancer overlap with those for Barrett's esophagus. Genes with roles in embryonic development of the foregut are adjacent to 6 of the loci identified (FOXF1, BARX1, FOXP1, GDF7, TBX5, and ALDH1A2). An additional locus maps to a gene with known oncogenic potential (CREB-regulated transcription coactivator 1), but expression quantitative trait data implicates yet another gene involved in esophageal development (PBX4). These results strongly support a model whereby dysregulation of genes involved in esophageal and thoracic development increases susceptibility to Barrett's esophagus and esophageal adenocarcinoma, probably by reducing anatomical antireflux mechanisms. An additional signal at 6p21 in the major histocompatibility complex also reinforces evidence that immune and inflammatory response to reflux is involved in the development of both diseases. All of the variants identified are intronic or intergenic rather than coding and are presumed to be or to mark regulatory variants. As with genome-wide association studies of other diseases, the functional variants at each locus are yet to be identified and the genes affected need confirming. In this chapter as well as discussing the biology behind each genome-wide association signal, we review the requirements for successfully conducting genome-wide association studies and discuss how progress in understanding the genetic variants that contribute to Barrett's esophagus/esophageal adenocarcinoma susceptibility compares to other cancers.
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Affiliation(s)
- Claire Palles
- Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, OX3 7BN, UK.
| | - John M Findlay
- Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, OX3 7BN, UK
- NIHR Oxford Biomedical Research Centre, Churchill Hospital, Old Road, Oxford, OX3 7LE, UK
- Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Oxford, OX3 7LE, UK
| | - Ian Tomlinson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, OX3 7BN, UK
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26
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Nathanson BH, Navab F. An analysis of sleep position during young adulthood in men who develop Barrett’s Esophagus. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1233684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
| | - Farhad Navab
- Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
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27
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Brandtner AK, Quante M. Risk prediction in Barrett's esophagus - aspects of a combination of molecular and epidemiologic biomarkers reflecting alterations of the microenvironment. Scand J Clin Lab Invest 2016; 245:S63-S69. [PMID: 27467504 DOI: 10.1080/00365513.2016.1210327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Barrett's esophagus (BE) is a chronic, metaplastic lesion of the esophagus and the only known precursor of esophageal adenocarcinoma. The identification of risk factors to assess the risk for BE and their correspondence with hallmarks of malignant progression for early stratification purposes is critically needed. Data legitimate the assumption that aside of reflux symptoms and related conditions, also demographic and environmental factors are thought to be associated with the risk for BE and its progression to esophageal adenocarcinoma. Molecular biomarkers and inflammatory mechanisms are subjects of intensive research and dispone of promising features regarding risk assessment especially for progressive BE. The amount of investigated epidemiologic factors, as well as discovered biomarkers gets confusingly large. Despite the recognized potential relevance of environmental and molecular factors, the efforts to date have resulted in moderately applicable risk estimates. More prospective data is needed to allow an imputation of the mostly retrospectively assessed factors to reappraise their meaningfulness in risk prediction approaches.
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Affiliation(s)
- Anna K Brandtner
- a II. Medizinische Klinik, Klinikum Rechts der Isar , Technische Universität München , Munich , Germany
- b Inflammation Research Unit, Department of Internal Medicine I , Medical University of Innsbruck , Innsbruck , Austria
| | - Michael Quante
- a II. Medizinische Klinik, Klinikum Rechts der Isar , Technische Universität München , Munich , Germany
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28
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Dutta SK, Agrawal K, Girotra M, Fleisher AS, Motevalli M, Mah'moud MA, Nair PP. Barrett's esophagus and β-carotene therapy: symptomatic improvement in GERD and enhanced HSP70 expression in esophageal mucosa. Asian Pac J Cancer Prev 2016; 13:6011-6. [PMID: 23464395 DOI: 10.7314/apjcp.2012.13.12.6011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Epidemiological studies suggest a protective role for β-carotene with several malignancies. Esophageal adenocarcinoma frequently arises from Barrett's esophagus (BE). We postulated that β-carotene therapy maybe protective in BE. MATERIALS AND METHOD We conducted a prospective study in which 25 mg of β-carotene was administered daily for six-months to six patients. Each patient underwent upper endoscopy before and after therapy and multiple mucosal biopsies were obtained. Additionally, patients completed a gastroesophageal reflux disease (GERD) symptoms questionnaire before and after therapy and severity score was calculated. To study the effect of β-carotene at molecular level, tissue extracts of the esophageal mucosal biopsy were subjected to assessment of heat-shock protein 70 (HSP70). RESULTS A significant (p<0.05) reduction in mean GERD symptoms severity score from 7.0±2.4 to 2.7±1.7 following β-carotene therapy was noted. Measurement of Barrett's segment also revealed a significant reduction in mean length after therapy. In fact, two patients had complete disappearance of intestinal metaplasia. Furthermore, marked enhancement of HSP70 expression was demonstrated in biopsy specimens from Barrett's epithelium in four cases that were tested. CONCLUSIONS Long- term β-carotene therapy realizes amelioration of GERD symptoms along with restitution of the histological and molecular changes in esophageal mucosa of patients with BE, associated with concurrent increase in mucosal HSP70 expression.
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Affiliation(s)
- Sudhir K Dutta
- Department of Medicine, University of Maryland School of Medicine and Division Director of Gastroenterology, USA.
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Sharma N, Ho KY. Risk Factors for Barrett's Oesophagus. Gastrointest Tumors 2016; 3:103-108. [PMID: 27904862 DOI: 10.1159/000445349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Barrett's oesophagus (BO) is a premalignant condition associated with the development of oesophageal adenocarcinoma (OAC). Globally, the incidence of OAC is rising. Furthermore, the prognosis regarding the morbidity and mortality of OAC is bleak, with an estimated 5-year survival of 10-15%. Hence, detection of the premalignant phase is paramount. Endoscopy and biopsy sampling is the mainstay of diagnosis. Patients may present with symptoms of gastro-oesophageal reflux disease (GORD) or be completely asymptomatic. Therefore, symptomatology alone is a poor indicator of this condition. SUMMARY This review highlights the current risk factors associated with the development of BO. KEY MESSAGE Primary risk factors for BO include male gender, increased age, a family history of the disease, long-standing GORD, smoking, obesity (specifically determined by the waist-to-hip ratio as opposed to BMI), and Caucasian race. Alcohol consumption and Helicobacter pylori are not associated with the condition. PRACTICAL IMPLICATIONS By ensuring an appropriate understanding of the risk factors, clinicians can discern at-risk patients for endoscopic diagnosis and surveillance.
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Affiliation(s)
- Neel Sharma
- Asia Pacific Barrett's Consortium, National University Hospital Singapore, Singapore
| | - Khek Yu Ho
- Asia Pacific Barrett's Consortium, National University Hospital Singapore, Singapore
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Ireland CJ, Thompson SK, Laws TA, Esterman A. Risk factors for Barrett’s esophagus: a scoping review. Cancer Causes Control 2016; 27:301-23. [DOI: 10.1007/s10552-015-0710-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/22/2015] [Indexed: 02/08/2023]
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Findlay JM, Middleton MR, Tomlinson I. Genetic Biomarkers of Barrett's Esophagus Susceptibility and Progression to Dysplasia and Cancer: A Systematic Review and Meta-Analysis. Dig Dis Sci 2016; 61:25-38. [PMID: 26445852 PMCID: PMC4700058 DOI: 10.1007/s10620-015-3884-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/11/2015] [Indexed: 01/01/2023]
Abstract
Barrett's esophagus (BE) is a common and important precursor lesion of esophageal adenocarcinoma (EAC). A third of patients with BE are asymptomatic, and our ability to predict the risk of progression of metaplasia to dysplasia and EAC (and therefore guide management) is limited. There is an urgent need for clinically useful biomarkers of susceptibility to both BE and risk of subsequent progression. This study aims to systematically identify, review, and meta-analyze genetic biomarkers reported to predict both. A systematic review of the PubMed and EMBASE databases was performed in May 2014. Study and evidence quality were appraised using the revised American Society of Clinical Oncology guidelines, and modified Recommendations for Tumor Marker Scores. Meta-analysis was performed for all markers assessed by more than one study. A total of 251 full-text articles were reviewed; 52 were included. A total of 33 germline markers of susceptibility were identified (level of evidence II-III); 17 were included. Five somatic markers of progression were identified; meta-analysis demonstrated significant associations for chromosomal instability (level of evidence II). One somatic marker of progression/relapse following photodynamic therapy was identified. However, a number of failings of methodology and reporting were identified. This is the first systematic review and meta-analysis to evaluate genetic biomarkers of BE susceptibility and risk of progression. While a number of limitations of study quality temper the utility of those markers identified, some-in particular, those identified by genome-wide association studies, and chromosomal instability for progression-appear plausible, although robust validation is required.
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Affiliation(s)
- John M Findlay
- Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, OX3 7BN, UK.
- Oxford OesophagoGastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation trust, Oxford, OX3 7LJ, UK.
- NIHR Oxford Biomedical Research Centre, The Joint Research Office, Churchill Hospital, Oxford, OX3 7LE, UK.
| | - Mark R Middleton
- NIHR Oxford Biomedical Research Centre, The Joint Research Office, Churchill Hospital, Oxford, OX3 7LE, UK
- Department of Oncology, Old Road Campus Research Building, University of Oxford, Roosevelt Drive, Oxford, OX3 7DQ, UK
| | - Ian Tomlinson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Roosevelt Drive, Oxford, OX3 7BN, UK
- NIHR Oxford Biomedical Research Centre, The Joint Research Office, Churchill Hospital, Oxford, OX3 7LE, UK
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Yu M, O'Leary RM, Kaz AM, Morris SM, Carter KT, Chak A, Chandar A, Willis JE, Moinova HR, Markowitz SD, Brenner DE, Anandabapasathy S, Westerhoff M, Wong CJ, Shaheen NJ, Chen Y, Barnholtz-Sloan JS, Grady WM. Methylated B3GAT2 and ZNF793 Are Potential Detection Biomarkers for Barrett's Esophagus. Cancer Epidemiol Biomarkers Prev 2015; 24:1890-7. [PMID: 26545406 DOI: 10.1158/1055-9965.epi-15-0370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Barrett's esophagus (BE) is a preneoplastic condition in which normal esophageal squamous epithelium (SQ) is replaced by specialized intestinal metaplasia. It is the presumed precursor for esophageal adenocarcinoma (EAC) as well as the strongest risk factor for this cancer. Unfortunately, many patients with BE go undiagnosed under the current BE screening guidelines. The development of noninvasive and accurate BE detection assays could potentially identify many of these undiagnosed BE patients. METHODS DNA methylation is a common epigenetic alteration in BE. Therefore, we conducted a genome-wide methylation screen to identify potential BE biomarkers. Samples from SQ (N = 12), stomach (N = 28), and BE (N = 29) were analyzed and methylation levels at over 485,000 CpG sites were compared. Pyrosequencing assays were used to validate the results and MethyLight assays were developed to detect the methylated alleles in endoscopic brushings. RESULTS We discovered two genes, B3GAT2 and ZNF793, that are aberrantly methylated in BE. Clinical validation studies confirmed B3GAT2 and ZNF793 methylation levels were significantly higher in BE samples (median = 32.5% and 33.1%, respectively) than in control tissues (median = 2.29% and 2.52%, respectively; P < 0.0001 for both genes). Furthermore, gene-specific MethyLight assays could accurately detect BE (P < 0.0001 for both) in endoscopic brushing samples. CONCLUSION B3GAT2 and ZNF793 are hypermethylated in BE, and the methylation status of these genes can be used to detect BE in tissue samples. IMPACT These findings support the development of methylated B3GAT2 and ZNF793 as biomarkers for noninvasive assays for the detection of BE.
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Affiliation(s)
- Ming Yu
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rachele M O'Leary
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrew M Kaz
- Research and Development Service, VA Puget Sound Health Care System, Seattle, Washington. Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Shelli M Morris
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kelly T Carter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio. Division of Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Apoorva Chandar
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio. Division of Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Joseph E Willis
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Helen R Moinova
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sanford D Markowitz
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio. Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Dean E Brenner
- University of Michigan Medical Center, Ann Arbor, Michigan
| | | | - Maria Westerhoff
- Department of Anatomic Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Chao-Jen Wong
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nicholas J Shaheen
- Division of Gastroenterology & Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Yanwen Chen
- Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - William M Grady
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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Prevalence of Barrett's Esophagus in Asian Countries: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2015; 13:1907-18. [PMID: 26260107 PMCID: PMC4615528 DOI: 10.1016/j.cgh.2015.07.050] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The prevalence and risk factors of Barrett's esophagus (BE) in Asian countries are unclear. Studies report a wide range of BE prevalence in Asian countries. We conducted a systematic review and meta-analysis to examine the prevalence of BE and its temporal changes and risk factors in Asian countries. METHODS Two investigators performed independent literature searches by using PubMed and EMBASE databases, and subsequent data abstraction for studies had to meet several set inclusion and exclusion criteria. Pooled BE prevalence was calculated by using a random-effect model. Estimates of relative risk for possible risk or protective factors were also calculated. RESULTS A total of 51 studies (N = 453,147), mainly from Eastern Asia, were included. The pooled prevalence of endoscopic BE was 7.8% (95% confidence interval, 5.0-12.1; 23 studies) and of histologically confirmed BE was 1.3% (95% confidence interval, 0.7-2.2; 28 studies). Most of histologic BE (82.1%) was short-segment BE (<3 cm). There was a trend toward an increase in prevalence of BE over time from 1991 to 2014, especially in Eastern Asian countries. Within BE cohorts, pooled prevalence of low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma was 6.9%, 3.0%, and 2.0%, respectively. Reflux symptoms, male sex, hiatus hernia, and smoking were associated with a significantly increased risk of histologic BE in patients with BE compared with patients without BE. However, half of the patients with histologic BE did not have reflux symptoms. CONCLUSIONS BE is not uncommon in Asian countries and seems to share similar risk factors and potential for neoplastic progression to those seen in Western countries.
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Abstract
There is substantial interest in identifying patients with premalignant conditions such as Barrett's esophagus (BE), to improve outcomes of subjects with esophageal adenocarcinoma. However, there is limited consensus on the rationale for screening, the appropriate target population, and optimal screening modality. Recent progress in the development and validation of minimally invasive tools for BE screening has reinvigorated interest in BE screening. BE risk scores combining clinical, anthropometric, and laboratory variables are being developed that may allow more precise targeting of screening to high-risk individuals. This article reviews and summarizes data on recent progress and challenges in screening for BE.
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Affiliation(s)
- Milli Gupta
- Division of Gastroenterology and Hepatology, University of Calgary, 2500 University Dr NW, Calgary, Alberta T2N 1N4, Canada
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Sami SS, Ragunath K, Iyer PG. Screening for Barrett's esophagus and esophageal adenocarcinoma: rationale, recent progress, challenges, and future directions. Clin Gastroenterol Hepatol 2015; 13:623-34. [PMID: 24887058 PMCID: PMC4254386 DOI: 10.1016/j.cgh.2014.03.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/26/2014] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
As the incidence and mortality of esophageal adenocarcinoma continue to increase, strategies to counter this need to be explored. Screening for Barrett's esophagus, which is the known precursor of a large majority of adenocarcinomas, has been debated without a firm consensus. Given evidence for and against perceived benefits of screening, the multitude of challenges in the implementation of such a strategy and in the downstream management of subjects with Barrett's esophagus who could be diagnosed by screening, support for screening has been modest. Recent advances in the form of development and initial accuracy of noninvasive tools for screening, risk assessment tools, and biomarker panels to risk stratify subjects with BE, have spurred renewed interest in the early detection of Barrett's esophagus and related neoplasia, particularly with the advent of effective endoscopic therapy. In this review, we explore in depth the potential rationale for screening for Barrett's esophagus, recent advances that have the potential of making screening feasible, and also highlight some of the challenges that will have to be overcome to develop an effective approach to improve the outcomes of subjects with esophageal adenocarcinoma.
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Affiliation(s)
- Sarmed S. Sami
- University of Nottingham, Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham, United Kingdom
| | - Krish Ragunath
- University of Nottingham, Digestive Diseases Centre and NIHR Biomedical Research Unit, Nottingham, United Kingdom
| | - Prasad G. Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester
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Risk factors and populations at risk: selection of patients for screening for Barrett's oesophagus. Best Pract Res Clin Gastroenterol 2015; 29:41-50. [PMID: 25743455 DOI: 10.1016/j.bpg.2014.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 11/24/2014] [Indexed: 01/31/2023]
Abstract
Screening for Barrett's oesophagus is an attractive notion due to the rising incidence of oesophageal adenocarcinoma, the relative ease of acquiring tissue from the oesophagus, and the availability of endoscopic therapy for early neoplastic lesions. If screening is recommended, the question remains: which patients should be screened? Endoscopy is frequently performed in patients with symptoms of gastro-oesophageal reflux disease, but the vast majority of patients diagnosed with oesophageal adenocarcinoma have never undergone a prior endoscopy. The efficiency of screening needs to be improved. A number of tools for predicting the presence of Barrett's oesophagus or future risk of developing oesophageal adenocarcinoma are available. More research is needed to validate these tools and to identify the thresholds at which screening should be offered.
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Utility of endoscopy for diagnosis of barrett in a non-Western society: endoscopic and histopathologic correlation. Int Surg 2015; 100:720-5. [PMID: 25588717 DOI: 10.9738/intsurg-d-14-00167.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Barrett esophagus is metaplastic transformation of esophageal squamous epithelium to columnar cells. A total of 1370 patients who had undergone upper endoscopy because of dyspeptic complaints were enrolled in the study. Age, sex, alcohol and smoking habits, body mass index, type and duration of symptoms (heartburn, epigastric pain, nausea, vomiting), and use of proton pump inhibitors were evaluated in all patients and recorded on standardized forms. Patients were grouped as normal esophagogastric junction, long-segment Barrett esophagus, and short-segment Barrett. Biopsies were taken from at least 6 points and examined histopathologically. Of the 1370 patients involved in the study, 748 (54.6%) were female and 622 (45.4%) were male. Mean age was 47.2 ± 15.30 years. Short-segment Barrett esophagus was detected in 16 patients, and long-segment Barrett was detected in 11 patients. Although Barrett esophagus was detected in 11 cases that were suspected to have Barrett during endoscopy, histopathology was negative in all cases that were not suspected to have Barrett. Barrett esophagus prevalence was significantly higher in people who used alcohol and tobacco and who had hiatal hernia. Although Barrett esophagus was detected in 40% of cases that were suspected to have Barrett during endoscopy, histopathology was negative in all cases that were not suspected to have Barrett. Barrett was detected in 40.7% of cases that were suspected to have Barrett during endoscopy; histopathology was negative in all cases that were not suspected to have Barrett. Senstivity of endoscopy is questionable in detection of short-segment Barrett.
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Desilets DJ, Nathanson BH, Navab F. Barrett's Esophagus in Practice: Gender and Screening Issues. JOURNAL OF MENS HEALTH 2014. [DOI: 10.1089/jomh.2014.0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Thrift AP, Cook MB, Vaughan TL, Anderson LA, Murray LJ, Whiteman DC, Shaheen NJ, Corley DA. Alcohol and the risk of Barrett's esophagus: a pooled analysis from the International BEACON Consortium. Am J Gastroenterol 2014; 109:1586-94. [PMID: 25047401 PMCID: PMC4189971 DOI: 10.1038/ajg.2014.206] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/08/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Results from studies examining the association between alcohol consumption and the risk of Barrett's esophagus have been inconsistent. We assessed the risk of Barrett's esophagus associated with total and beverage-specific alcohol consumption by pooling individual participant data from five case-control studies participating in the international Barrett's and Esophageal Adenocarcinoma Consortium. METHODS For analysis, there were 1,282 population-based controls, 1,418 controls with gastroesophageal reflux disease (GERD), and 1,169 patients with Barrett's esophagus (cases). We estimated study-specific odds ratios (ORs) and 95% confidence intervals (95% CI) using multivariable logistic regression models adjusted for age, sex, body mass index (BMI), education, smoking status, and GERD symptoms. Summary risk estimates were obtained by random-effects models. We also examined potential effect modification by sex, BMI, GERD symptoms, and cigarette smoking. RESULTS For comparisons with population-based controls, although there was a borderline statistically significant inverse association between any alcohol consumption and the risk of Barrett's esophagus (any vs. none, summary OR=0.77, 95% CI=0.60-1.00), risk did not decrease in a dose-response manner (Ptrend=0.72). Among alcohol types, wine was associated with a moderately reduced risk of Barrett's esophagus (any vs. none, OR=0.71, 95% CI=0.52-0.98); however, there was no consistent dose-response relationship (Ptrend=0.21). We found no association with alcohol consumption when cases were compared with GERD controls. Similar associations were observed across all strata of BMI, GERD symptoms, and cigarette smoking. CONCLUSIONS Consistent with findings for esophageal adenocarcinoma, we found no evidence that alcohol consumption increases the risk of Barrett's esophagus.
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Affiliation(s)
- Aaron P. Thrift
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA,Cancer Control Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Michael B. Cook
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Thomas L. Vaughan
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lesley A. Anderson
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - Liam J. Murray
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - David C. Whiteman
- Cancer Control Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Douglas A. Corley
- Division of Research and Oakland Medical Center, Kaiser Permanente, Oakland, CA, USA
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Almond LM, Old O, Barr H. Strategies for the prevention of oesophageal adenocarcinoma. Int J Surg 2014; 12:931-5. [PMID: 25091397 DOI: 10.1016/j.ijsu.2014.07.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/29/2014] [Indexed: 01/30/2023]
Abstract
The incidence of oesophageal adenocarcinoma has increased by 500% over the past 30 years [1]. Improved understanding of the mechanisms of neoplastic progression provides an opportunity to reverse this trend. A thorough review of emerging strategies aiming to prevent the formation of oesophageal malignancy is presented. These include dietary modification, chemoprevention, early endoscopic identification and treatment of premalignant disease, and the potential for a non-endoscopic screening test. Oesophageal adenocarcinoma has become a major public health problem in the West and it is essential that clinicians are fully informed of risk reduction strategies so that they can be actively promoted in the community.
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Affiliation(s)
| | - Oliver Old
- Biophotonics Research Unit, Gloucester, UK
| | - Hugh Barr
- Department of Oesophagogastric Surgery, Gloucestershire Hospitals NHS Trust, UK
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Thrift AP, Garcia JM, El-Serag HB. A multibiomarker risk score helps predict risk for Barrett's esophagus. Clin Gastroenterol Hepatol 2014; 12:1267-71. [PMID: 24362047 PMCID: PMC4063886 DOI: 10.1016/j.cgh.2013.12.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/12/2013] [Accepted: 12/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Risk prediction models for Barrett's esophagus (BE) have been developed using multiple demographic and clinical variables, but their predictive performance has been modest. Adding a multibiomarker risk score may improve discriminatory ability. METHODS We used data from 141 patients with definitive BE and 138 controls participating in a case-control study at the Michael E. DeBakey Veterans Affairs Medical Center (Houston, TX) (97% men, 65% of controls were white, and 89% of cases were white). We derived and compared 3 prediction models. Model 1 included only gastroesophageal reflux disease (GERD) frequency and duration; model 2 included GERD frequency and duration, age, sex, race, waist-to-hip ratio, and Helicobacter pylori status; and model 3 included the variables in model 2 as well as a multibiomarker risk score based on serum levels of interleukin (IL)12p70, IL6, IL8, IL10, and leptin. We assessed their predictive accuracy in terms of discrimination using the area under the receiver operating characteristic curve and calibration analyses. RESULTS The multibiomarker risk score was associated significantly with risk for BE. Compared with persons with a score of 0, persons with a score of 3 or higher had a greater than 10-fold increased risk for BE (biomarker risk score, ≥3; odds ratio, 11.9; 95% confidence interval, 4.06-34.9; P trend < .001). Risk prediction using the multibiomarker score in conjunction with demographic and clinical features improved discrimination compared with using only GERD frequency and duration (area under the receiver operating characteristic curve, 0.85 vs 0.74; P = .01). CONCLUSIONS Based on data from a case-control study of predominantly white male veterans, a risk prediction model including a multibiomarker score, derived from serum levels of cytokines and leptin, as well as GERD frequency and duration, age, sex, race, waist-to-hip ratio, and H pylori infection, can identify persons in this population with BE more accurately than previous methods.
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Affiliation(s)
- Aaron P Thrift
- Cancer Control Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia; Program in Epidemiology, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Jose M Garcia
- Section of Endocrinology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Huffington Center on Aging, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Houston VA Veteran Affairs Health Services Research & Development Center of Excellence, Houston, Texas; Sections of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Liu X, Wong A, Kadri SR, Corovic A, O’Donovan M, Lao-Sirieix P, Lovat LB, Burnham RW, Fitzgerald RC. Gastro-esophageal reflux disease symptoms and demographic factors as a pre-screening tool for Barrett's esophagus. PLoS One 2014; 9:e94163. [PMID: 24736597 PMCID: PMC3988048 DOI: 10.1371/journal.pone.0094163] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/11/2014] [Indexed: 02/07/2023] Open
Abstract
Background Barrett’s esophagus (BE) occurs as consequence of reflux and is a risk factor for esophageal adenocarcinoma. The current “gold-standard” for diagnosing BE is endoscopy which remains prohibitively expensive and impractical as a population screening tool. We aimed to develop a pre-screening tool to aid decision making for diagnostic referrals. Methodology/Principal Findings A prospective (training) cohort of 1603 patients attending for endoscopy was used for identification of risk factors to develop a risk prediction model. Factors associated with BE in the univariate analysis were selected to develop prediction models that were validated in an independent, external cohort of 477 non-BE patients referred for endoscopy with symptoms of reflux or dyspepsia. Two prediction models were developed separately for columnar lined epithelium (CLE) of any length and using a stricter definition of intestinal metaplasia (IM) with segments ≥2 cm with areas under the ROC curves (AUC) of 0.72 (95%CI: 0.67–0.77) and 0.81 (95%CI: 0.76–0.86), respectively. The two prediction models included demographics (age, sex), symptoms (heartburn, acid reflux, chest pain, abdominal pain) and medication for “stomach” symptoms. These two models were validated in the independent cohort with AUCs of 0.61 (95%CI: 0.54–0.68) and 0.64 (95%CI: 0.52–0.77) for CLE and IM≥2 cm, respectively. Conclusions We have identified and validated two prediction models for CLE and IM≥2 cm. Both models have fair prediction accuracies and can select out around 20% of individuals unlikely to benefit from investigation for Barrett’s esophagus. Such prediction models have the potential to generate useful cost-savings for BE screening among the symptomatic population.
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Affiliation(s)
- Xinxue Liu
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - Angela Wong
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | | | - Andrej Corovic
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - Maria O’Donovan
- Department of Histopathology, Addenbrooke’s Hospital, Cambridge, United Kingdom
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Abstract
The management of Barrett's oesophagus and associated neoplasia has evolved considerably in recent years. Modern endoscopic strategies including endoscopic resection and mucosal ablation can eradicate dysplastic Barrett's and prevent progression to invasive oesophageal cancer. However, several aspects of Barrett's management remain controversial including the stage in the disease process at which to intervene, and the choice of endoscopic or surgical therapy. A review of articles pertaining to the management of Barrett's oesophagus with or without associated neoplasia, was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Embase and Cochrane databases were searched to identify literature relevant to eight pre-defined areas of clinical controversy. The following search terms were used: Barrett's oesophagus; dysplasia; intramucosal carcinoma; endotherapy; endoscopic resection; ablation; oesophagectomy. A significant body of evidence exists to support early endoscopic therapy for high-grade dysplasia (HGD). Although not supported by randomised controlled trial evidence, endoscopic therapy is now favoured ahead of oesophagectomy for most patients with HGD. Focal intramucosal (T1a) carcinomas can be managed effectively using endoscopic and surgical therapy, however surgery should be considered the first line therapy where there is submucosal invasion (T1b). Treatment of low grade dysplasia is not supported at present due to widespread over-reporting of the disease. The role of surveillance endoscopy in non-dysplastic Barrett's remains controversial.
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Huang RJ, Chun CL, Friday K, Triadafilopoulos G. Manometric abnormalities in the postural orthostatic tachycardia syndrome: a case series. Dig Dis Sci 2013; 58:3207-11. [PMID: 24068608 DOI: 10.1007/s10620-013-2865-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 08/23/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) is a rare disease that is believed to be mediated by dysautonomia. Gastrointestinal complaints in POTS patients are common and disturbing but not well characterized. AIMS We hypothesized that gastrointestinal dysmotility may be contributory to these symptoms. METHODS We studied 12 POTS patients who presented with gastrointestinal symptoms to a tertiary referral center. Gastrointestinal symptoms were quantified using a previously validated symptom questionnaire. All patients underwent gastroduodenal manometry (GDM); select patients also underwent further testing including esophageal manometry (EM), anorectal manometry (ARM), plain abdominal radiography (AXR), abdominal computed tomography (CT), gastric emptying studies (GES), and colonic transit time (CTT) studies. RESULTS The four most common symptoms were bloating, constipation, abdominal pain, and nausea/vomiting, all experienced by greater than 70 % of patients. On GDM testing, 93 % of patients demonstrated signs of neuropathy, and the most common abnormalities observed included bursts of uncoordinated phasic activity in both fasting (59 %) and post-prandial (42 %) states, low contractility in the post-prandial state (67 %), and lack of post-prandial pattern (42 %). A total of 67 % of patients undergoing EM and 86 % of those undergoing ARM demonstrated abnormalities consistent with dysmotility. On AXR or CT, 58 % demonstrated either dilated intestinal loops or air-fluid levels. On CTT 80 % demonstrated delayed colonic transit, while on GES 60 % demonstrated delayed gastric emptying. CONCLUSIONS In this cohort of POTS patients with gastrointestinal symptoms, there is a high prevalence of abnormal manometric and radiographic findings suggestive of dysmotility.
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Affiliation(s)
- Robert J Huang
- Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
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Cook MB. Optimization and expansion of predictive models for Barrett's esophagus and esophageal adenocarcinoma: could a life-course exposure history be beneficial? Am J Gastroenterol 2013; 108:923-5. [PMID: 23735915 DOI: 10.1038/ajg.2013.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Thrift et al. provide preliminary evidence that younger age of symptomatic gastroesophageal reflux disease exposure is associated with increased risk of Barrett's esophagus. If these findings are confirmed in other studies, the next logical steps are to test whether this, and other age-specific exposures, can help optimize predictive models of Barrett's esophagus and progression to esophageal adenocarcinoma. Expansion of these models to the general population and the greater Barrett's esophagus population, respectively, will be required for a screening and surveillance approach to be clinically successful and cost-effective.
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Cummings LC, Shah N, Maimone S, Salah W, Khiani V, Chak A. Barrett's esophagus and the risk of obstructive sleep apnea: a case-control study. BMC Gastroenterol 2013; 13:82. [PMID: 23663216 PMCID: PMC3668164 DOI: 10.1186/1471-230x-13-82] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 05/03/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Prior studies suggest that obstructive sleep apnea may be associated with gastroesophageal reflux disease, a strong risk factor for Barrett's esophagus. The goals of this pilot case-control study were to determine whether Barrett's esophagus patients have an increased likelihood of obstructive sleep apnea and to determine whether nocturnal gastroesophageal reflux symptoms affect the relationship between Barrett's esophagus and obstructive sleep apnea risk. METHODS Patients with Barrett's esophagus completed the Berlin Questionnaire, a validated survey instrument identifying subjects at high risk for obstructive sleep apnea. Two outpatient control groups were recruited: 1) EGD Group, subjects matched to Barrett's esophagus cases by age, race, and gender with esophagogastroduodenoscopy negative for Barrett's esophagus; and 2) Colonoscopy Group, patients getting colonoscopy. Rates of scoring at high risk for obstructive sleep apnea were compared. Respondents were also questioned regarding severity of their typical gastroesophageal reflux symptoms and presence of nocturnal gastroesophageal reflux symptoms. RESULTS The study included 287 patients (54 Barrett's esophagus, 62 EGD, and 171 colonoscopy subjects). Barrett's esophagus patients were slightly older than colonoscopy patients and more obese. 56% (n = 30) of Barrett's esophagus subjects scored at high risk for obstructive sleep apnea, compared with 42% (n = 26) of EGD subjects (OR 1.73, 95% CI [0.83, 3.62]) and 37% (n = 64) of colonoscopy patients (OR 2.08, 95% CI [1.12, 3.88]). The association between Barrett's esophagus and scoring at high risk for obstructive sleep apnea compared with colonoscopy patients disappeared after adjusting for age. Barrett's esophagus patients reported more severe typical heartburn and regurgitation symptoms than either control group. Among all subjects, patients with nocturnal reflux symptoms were more likely to score at high risk for obstructive sleep apnea than patients without nocturnal reflux. CONCLUSIONS In this pilot study, a high proportion of Barrett's esophagus subjects scored at high risk for obstructive sleep apnea. Having Barrett's esophagus was associated with more severe gastroesophageal reflux symptoms, and nocturnal reflux symptoms were associated with scoring at high risk for obstructive sleep apnea. The need for obstructive sleep apnea screening in Barrett's esophagus patients with nocturnal gastroesophageal reflux symptoms should be further evaluated.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, 1100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA
| | - Ninad Shah
- Gastroenterology Associates, 1400 N Ritter Avenue Suite 370, Indianapolis, IN, 46219, USA
| | - Santo Maimone
- Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Wajeeh Salah
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, 1100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA
| | - Vijay Khiani
- University of Illinois at Chicago, Section of Digestive Diseases and Nutrition, 840 South Wood Street (MC716), Chicago, IL, 60612, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, 1100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA
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Shah AK, Saunders NA, Barbour AP, Hill MM. Early diagnostic biomarkers for esophageal adenocarcinoma--the current state of play. Cancer Epidemiol Biomarkers Prev 2013; 22:1185-209. [PMID: 23576690 DOI: 10.1158/1055-9965.epi-12-1415] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Esophageal adenocarcinoma (EAC) is one of the two most common types of esophageal cancer with alarming increase in incidence and very poor prognosis. Aiming to detect EAC early, currently high-risk patients are monitored using an endoscopic-biopsy approach. However, this approach is prone to sampling error and interobserver variability. Diagnostic tissue biomarkers related to genomic and cell-cycle abnormalities have shown promising results, although with current technology these tests are difficult to implement in the screening of high-risk patients for early neoplastic changes. Differential miRNA profiles and aberrant protein glycosylation in tissue samples have been reported to improve performance of existing tissue-based diagnostic biomarkers. In contrast to tissue biomarkers, circulating biomarkers are more amenable to population-screening strategies, due to the ease and low cost of testing. Studies have already shown altered circulating glycans and DNA methylation in BE/EAC, whereas disease-associated changes in circulating miRNA remain to be determined. Future research should focus on identification and validation of these circulating biomarkers in large-scale trials to develop in vitro diagnostic tools to screen population at risk for EAC development.
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Affiliation(s)
- Alok Kishorkumar Shah
- The University of Queensland Diamantina Institute; and School of Medicine, The University of Queensland, Woolloongabba, Queensland, Australia
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Waist-to-hip ratio, but not body mass index, is associated with an increased risk of Barrett's esophagus in white men. Clin Gastroenterol Hepatol 2013; 11:373-381.e1. [PMID: 23220167 PMCID: PMC3606681 DOI: 10.1016/j.cgh.2012.11.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/25/2012] [Accepted: 11/19/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Abdominal obesity increases the risk of gastroesophageal reflux disease (GERD) and also might contribute to the development of Barrett's esophagus (BE), although results are inconsistent. We examined the effects of waist-to-hip ratio (WHR) and body mass index (BMI) on the risk of BE and investigated whether race, GERD symptoms, or hiatus hernia were involved. METHODS We conducted a case-control study using data from eligible patients who underwent elective esophagogastroduodenoscopy; 237 patients had BE and the other 1021 patients served as endoscopy controls. We also analyzed data and tissue samples from enrolled patients who were eligible for screening colonoscopies at a primary care clinic (colonoscopy controls, n = 479). All patients underwent esophagogastroduodenoscopy, completed a survey, and had anthropometric measurements taken. WHR was categorized as high if it was 0.9 or greater for men or 0.85 or greater for women. Data were analyzed with logistic regression. RESULTS There was no association between BMI and BE. However, more patients with BE had a high WHR (92.4%) than endoscopy controls (79.5%) or colonoscopy controls (84.6%) (P < .001 and P = .008, respectively). In adjusted analysis, patients with BE were 2-fold more likely to have a high WHR than endoscopy controls (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.1-3.5), this association was stronger for patients with long-segment BE (OR, 2.81; 95% CI, 1.0-7.9). A high WHR was associated significantly with BE only in whites (OR, 2.5; 95% CI, 1.2-5.4), but not in blacks or Hispanics. GERD symptoms, hiatus hernia, or gastroesophageal valve flap grade could not account for the association. CONCLUSIONS High WHR, but not BMI, is associated with a significant increase in the risk of BE, especially long-segment BE and in whites. The association is not caused by GERD symptoms or hiatus hernia.
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Abstract
Symptoms of gastroesophageal reflux are the only commonly used criterion for endoscopic screening for esophageal adenocarcinoma (EAC). Recent research has elucidated multiple other risk factors for both EAC and Barrett's esophagus (BE). Utilization of these risk factors may allow for the selection of a screening population with a much higher pre-test probability of disease. A recently developed risk-prediction model for BE is a significant step in the right direction; however, further refinements in this model will likely be necessary to optimize utility. Our inability to prognosticate cancer risk in BE does temper enthusiasm for increasing the pool of patients under endoscopic surveillance for BE, and again highlights the need for better, cheaper, and more accurate means of stratifying cancer risk in BE.
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50
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Rubenstein JH, Morgenstern H, Appelman H, Scheiman J, Schoenfeld P, McMahon LF, Metko V, Near E, Kellenberg J, Kalish T, Inadomi JM. Prediction of Barrett's esophagus among men. Am J Gastroenterol 2013; 108:353-62. [PMID: 23318485 PMCID: PMC3903120 DOI: 10.1038/ajg.2012.446] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Risk factors for Barrett's esophagus include gastroesophageal reflux disease (GERD) symptoms, age, abdominal obesity, and tobacco use. We aimed to develop a tool using these factors to predict the presence of Barrett's esophagus. METHODS Male colorectal cancer (CRC) screenees were recruited to undergo upper endoscopy, identifying newly diagnosed cases of Barrett's esophagus. Logistic regression models predicting Barrett's esophagus using GERD symptoms alone and together with abdominal obesity, tobacco use, and age were compared. RESULTS Barrett's esophagus was found in 70 (8.5%) of 822 CRC screenees. Mutually adjusting for other covariates, Barrett's esophagus was associated with weekly GERD (odds ratio (OR)=2.33, 95% confidence interval (CI)=1.34, 4.05), age (OR per 10 years=1.53, 95% CI=1.05, 2.25), waist-to-hip ratio (OR per 0.10=1.44, 95% CI=0.898, 2.32) and pack-years of cigarette use (OR per 10 pack-years=1.09, 95% CI=1.04, 1.14). A model including those four factors had a greater area under the receiver operating characteristics curve than did a model based on GERD frequency and duration alone (0.72 vs. 0.61, P<0.001), and it had a net reclassification improvement index of 19-25%. CONCLUSIONS The prevalence of Barrett's esophagus was substantial in our population of older overweight men. A model based on GERD, age, abdominal obesity, and cigarette use more accurately classified the presence of Barrett's esophagus than did a model based on GERD alone. Following validation of the tool in another population, its use in clinical practice might improve the efficiency of screening for Barrett's esophagus.
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Affiliation(s)
- Joel H. Rubenstein
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA,Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Hal Morgenstern
- Departments of Epidemiology and Environmental Health Sciences, School of Public Health, and Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Henry Appelman
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James Scheiman
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Philip Schoenfeld
- Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA,Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Laurence F. McMahon
- Department of Internal Medicine, Division of General Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Valbona Metko
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ellen Near
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Joan Kellenberg
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tal Kalish
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - John M. Inadomi
- Department of Internal Medicine, Division of Gastroenterology, University of Washington Medical School, Seattle, Washington, USA
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