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Hicheri C, Azimuddin AM, Kortum A, Bailey J, Tang Y, Schwarz RA, Rosen D, Jain S, Mansour NM, Groth S, Vasavada S, Rao A, Maliga A, Gallego L, Carns J, Anandasabapathy S, Richards-Kortum R. Design and Evaluation of ScanCap: A Low-Cost, Reusable Tethered Capsule Endoscope with Blue-Green Illumination Imaging for Unsedated Screening and Early Detection of Barrett's Esophagus. Bioengineering (Basel) 2024; 11:557. [PMID: 38927792 PMCID: PMC11200367 DOI: 10.3390/bioengineering11060557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 06/28/2024] Open
Abstract
Esophageal carcinoma is the sixth-leading cause of cancer death worldwide. A precursor to esophageal adenocarcinoma (EAC) is Barrett's Esophagus (BE). Early-stage diagnosis and treatment of esophageal neoplasia (Barrett's with high-grade dysplasia/intramucosal cancer) increase the five-year survival rate from 10% to 98%. BE is a global challenge; however, current endoscopes for early BE detection are costly and require extensive infrastructure for patient examination and sedation. We describe the design and evaluation of the first prototype of ScanCap, a high-resolution optical endoscopy system with a reusable, low-cost tethered capsule, designed to provide high-definition, blue-green illumination imaging for the early detection of BE in unsedated patients. The tethered capsule (12.8 mm diameter, 35.5 mm length) contains a color camera and rotating mirror and is designed to be swallowed; images are collected as the capsule is retracted manually via the tether. The tether provides electrical power and illumination at wavelengths of 415 nm and 565 nm and transmits data from the camera to a tablet. The ScanCap prototype capsule was used to image the oral mucosa in normal volunteers and ex vivo esophageal resections; images were compared to those obtained using an Olympus CV-180 endoscope. Images of superficial capillaries in intact oral mucosa were clearly visible in ScanCap images. Diagnostically relevant features of BE, including irregular Z-lines, distorted mucosa, and dilated vasculature, were clearly visible in ScanCap images of ex vivo esophageal specimens.
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Affiliation(s)
- Cheima Hicheri
- Department of Bioengineering, Rice University, Houston, TX 77030, USA; (C.H.); (R.A.S.)
| | - Ahad M. Azimuddin
- Houston Methodist Hospital, Houston, TX 77030, USA;
- Texas A&M School of Medicine, Houston, TX 77030, USA
| | - Alex Kortum
- Department of Bioengineering, Rice University, Houston, TX 77030, USA; (C.H.); (R.A.S.)
| | - Joseph Bailey
- Rice360 Institute for Global Health Technologies, Rice University, Houston, TX 77030, USA
| | - Yubo Tang
- Department of Bioengineering, Rice University, Houston, TX 77030, USA; (C.H.); (R.A.S.)
| | - Richard A. Schwarz
- Department of Bioengineering, Rice University, Houston, TX 77030, USA; (C.H.); (R.A.S.)
| | - Daniel Rosen
- Baylor College of Medicine, Houston, TX 77030, USA (L.G.)
| | - Shilpa Jain
- Baylor College of Medicine, Houston, TX 77030, USA (L.G.)
| | | | - Shawn Groth
- Baylor College of Medicine, Houston, TX 77030, USA (L.G.)
| | | | - Ashwin Rao
- Baylor College of Medicine, Houston, TX 77030, USA (L.G.)
| | | | - Leslie Gallego
- Baylor College of Medicine, Houston, TX 77030, USA (L.G.)
| | - Jennifer Carns
- Department of Bioengineering, Rice University, Houston, TX 77030, USA; (C.H.); (R.A.S.)
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Jalali P, Yaghoobi A, Rezaee M, Zabihi MR, Piroozkhah M, Aliyari S, Salehi Z. Decoding common genetic alterations between Barrett's esophagus and esophageal adenocarcinoma: A bioinformatics analysis. Heliyon 2024; 10:e31194. [PMID: 38803922 PMCID: PMC11128929 DOI: 10.1016/j.heliyon.2024.e31194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
Background Esophageal adenocarcinoma (EAC) is a common cancer with a poor prognosis in advanced stages. Therefore, early EAC diagnosis and treatment have gained attention in recent decades. It has been found that various pathological changes, particularly Barrett's Esophagus (BE), can occur in the esophageal tissue before the development of EAC. In this study, we aimed to identify the molecular contributor in BE to EAC progression by detecting the essential regulatory genes that are differentially expressed in both BE and EAC. Materials and methods We conducted a comprehensive bioinformatics analysis to detect BE and EAC-associated genes. The common differentially expressed genes (DEGs) and common single nucleotide polymorphisms (SNPs) were detected using the GEO and DisGeNET databases, respectively. Then, hub genes and the top modules within the protein-protein interaction network were identified. Moreover, the co-expression network of the top module by the HIPPIE database was constructed. Additionally, the gene regulatory network was constructed based on miRNAs and circRNAs. Lastly, we inspected the DGIdb database for possible interacted drugs. Results Our microarray dataset analysis identified 92 common DEGs between BE and EAC with significant enrichment in skin and epidermis development genes. The study also identified 22 common SNPs between BE and EAC. The top module of PPI network analysis included SCEL, KRT6A, SPRR1A, SPRR1B, SPRR3, PPL, SPRR2B, EVPL, and CSTA. We constructed a ceRNA network involving three specific mRNAs, 23 miRNAs, and 101 selected circRNAs. According to the results from the DGIdb database, TD101 was found to interact with the KRT6A gene. Conclusion The present study provides novel potential candidate genes that may be involved in the molecular association between Esophageal adenocarcinoma and Barrett's Esophagus, resulting in developing the diagnostic tools and therapeutic targets to prevent progression of BE to EAC.
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Affiliation(s)
- Pooya Jalali
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Yaghoobi
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Malihe Rezaee
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zabihi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Piroozkhah
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Aliyari
- Division of Applied Bioinformatics, German Cancer Research Center DKFZ Heidelberg, Iran
| | - Zahra Salehi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
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Zhao YX, Zhao HP, Zhao MY, Yu Y, Qi X, Wang JH, Lv J. Latest insights into the global epidemiological features, screening, early diagnosis and prognosis prediction of esophageal squamous cell carcinoma. World J Gastroenterol 2024; 30:2638-2656. [PMID: 38855150 PMCID: PMC11154680 DOI: 10.3748/wjg.v30.i20.2638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/26/2024] [Accepted: 05/13/2024] [Indexed: 05/27/2024] Open
Abstract
As a highly invasive carcinoma, esophageal cancer (EC) was the eighth most prevalent malignancy and the sixth leading cause of cancer-related death worldwide in 2020. Esophageal squamous cell carcinoma (ESCC) is the major histological subtype of EC, and its incidence and mortality rates are decreasing globally. Due to the lack of specific early symptoms, ESCC patients are usually diagnosed with advanced-stage disease with a poor prognosis, and the incidence and mortality rates are still high in many countries, especially in China. Therefore, enormous challenges still exist in the management of ESCC, and novel strategies are urgently needed to further decrease the incidence and mortality rates of ESCC. Although the key molecular mechanisms underlying ESCC pathogenesis have not been fully elucidated, certain promising biomarkers are being investigated to facilitate clinical decision-making. With the advent and advancement of high-throughput technologies, such as genomics, proteomics and metabolomics, valuable biomarkers with high sensitivity, specificity and stability could be identified for ESCC. Herein, we aimed to determine the epidemiological features of ESCC in different regions of the world, especially in China, and focused on novel molecular biomarkers associated with ESCC screening, early diagnosis and prognosis prediction.
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Affiliation(s)
- Yi-Xin Zhao
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
| | - He-Ping Zhao
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
| | - Meng-Yao Zhao
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
| | - Yan Yu
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
| | - Xi Qi
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
| | - Ji-Han Wang
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, Shaanxi Province, China
| | - Jing Lv
- Department of Clinical Laboratory, Honghui Hospital, Xi’an Jiaotong University, Xi’an 710054, Shaanxi Province, China
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di Pietro M, Trudgill NJ, Vasileiou M, Longcroft-Wheaton G, Phillips AW, Gossage J, Kaye PV, Foley KG, Crosby T, Nelson S, Griffiths H, Rahman M, Ritchie G, Crisp A, Deed S, Primrose JN. National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma. Gut 2024; 73:897-909. [PMID: 38553042 PMCID: PMC11103346 DOI: 10.1136/gutjnl-2023-331557] [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: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 05/12/2024]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.
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Affiliation(s)
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Gaius Longcroft-Wheaton
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
- Department of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Alexander W Phillips
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Gossage
- Department of Gastrointestinal Surgery, St Thomas' Hospital, London, UK
| | - Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kieran G Foley
- Division of Cancer and Genetics, Cardiff University, Cardiff, Cardiff, UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Sophie Nelson
- Kenmore Medical Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Muksitur Rahman
- National Institute for Health and Care Excellence, London, UK
| | - Gill Ritchie
- National Institute for Health and Care Excellence, London, UK
| | - Amy Crisp
- National Institute for Health and Care Excellence, London, UK
| | - Stephen Deed
- National Institute for Health and Care Excellence, London, UK
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
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Chien S, Glen P, Penman I, Cruickshank N, Bryce G, Crumley A, Phull P, Miller M, Fletcher J, Gunjaca I, Apollos J, Robertson K, Fullarton G. Oesophageal cell collection device and biomarker testing to identify high-risk Barrett's patients requiring endoscopic investigation. Br J Surg 2024; 111:znae117. [PMID: 38736137 PMCID: PMC11089076 DOI: 10.1093/bjs/znae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/25/2024] [Accepted: 04/11/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Barrett's oesophagus surveillance places significant burden on endoscopy services yet is vital to detect early cancerous change. Oesophageal cell collection device (OCCD) testing was introduced across Scotland for Barrett's surveillance in response to the COVID-19 pandemic. This national pragmatic retrospective study presents the CytoSCOT programme results and evaluates whether OCCD testing is successfully identifying high-risk Barrett's patients requiring urgent endoscopy. METHODS All patients undergoing OCCD testing for Barrett's surveillance across 11 Scottish health boards over a 32-month period were identified. Patients who underwent endoscopy within 12 months of OCCD test were included. Individual patient records were interrogated to record clinical information and OCCD test result to categorize patients into risk groups. Endoscopic histopathology results were analysed according to risk group and segment length. Patients were deemed high risk if the OCCD test demonstrated atypia and/or p53 positivity. RESULTS 4204 OCCD tests were performed in 3745 patients: 608 patients underwent endoscopy within 12 months and were included in this analysis. Patients with longer Barrett's segments were significantly more likely to have an abnormal OCCD test. 50/608 patients (8.2%) had high-grade dysplasia or cancer on endoscopic biopsies: this equates to 1.3% of the total group (50/3745). 46/50 patients (92.0%) were deemed high risk, triggering urgent endoscopy: this rose to 100% with insufficient tests removed. There were no cancers diagnosed within 12 months post-OCCD in the low-risk group. CONCLUSION OCCD testing is an effective triage tool to identify high-risk patients with Barrett's oesophagus requiring further investigation with endoscopy within the real-world setting.
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Affiliation(s)
- Siobhan Chien
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
- Centre for Sustainable Delivery, Golden Jubilee National Hospital, Glasgow, UK
| | - Paul Glen
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ian Penman
- Centre for Liver & Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Gavin Bryce
- Department of General Surgery, University Hospital Wishaw, Wishaw, UK
| | - Andrew Crumley
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, UK
| | - Perminder Phull
- Department of Gastroenterology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Miller
- Department of Gastroenterology, Ninewells Hospital, Dundee, UK
| | - Jonathan Fletcher
- Department of Gastroenterology, Borders General Hospital, Melrose, UK
| | - Ivan Gunjaca
- Department of Gastroenterology, Raigmore Hospital, Inverness, UK
| | - Jeyakumar Apollos
- Department of General Surgery, Dumfries & Galloway Royal Infirmary, Dumfries, UK
| | - Kevin Robertson
- Department of General Surgery, University Hospital Crosshouse, Kilmarnock, UK
| | - Grant Fullarton
- Centre for Sustainable Delivery, Golden Jubilee National Hospital, Glasgow, UK
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Chien S, Glen P, Penman I, Bryce G, Cruickshank N, Miller M, Crumley A, Fletcher J, Phull P, Gunjaca I, Robertson K, Apollos J, Fullarton G. National adoption of an esophageal cell collection device for Barrett's esophagus surveillance: impact on delay to investigation and pathological findings. Dis Esophagus 2024; 37:doae002. [PMID: 38267082 DOI: 10.1093/dote/doae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/30/2023] [Accepted: 01/04/2024] [Indexed: 01/26/2024]
Abstract
High quality Barrett's esophagus surveillance is crucial to detect early neoplastic changes. An esophageal cell collection device (OCCD) was introduced as a triage tool for Barrett's surveillance. This study aims to evaluate whether the Scottish OCCD program (CytoSCOT) has reduced delays to Barrett's surveillance, and whether delayed surveillance negatively impacts endoscopic pathology. All patients undergoing OCCD testing for Barrett's surveillance across 11 Scottish health boards between 14/9/2020 and 13/9/2022 were identified. Patients were dichotomised into two groups (Year 1 vs. Year 2), with individual records interrogated to record demographics, recommended surveillance interval, time from last endoscopy to OCCD test, and OCCD result. Patients were deemed high-risk if the OCCD demonstrated atypia and/or p53 positivity. Further analysis was performed on patients who underwent endoscopy within 12 months of OCCD testing. A total of 3223 OCCD tests were included in the analysis (1478 in Year 1; 1745 in Year 2). In Year 1 versus Year 2, there was a longer median delay to surveillance (9 vs. 5 months; P < 0.001), increased proportion of patients with delayed surveillance (72.6% vs. 57.0%; P < 0.001), and more high-risk patients (12.0% vs. 5.3%; P < 0.001). 425/3223 patients (13.2%) were further investigated with upper gastrointestinal endoscopy, 57.9% of which were high-risk. As surveillance delay increased beyond 24 months, high-risk patients were significantly more likely to develop dysplasia or malignancy (P = 0.004). Delayed Barrett's esophagus surveillance beyond 24 months is associated with increased risk of pre-cancerous pathology. The CytoSCOT program has reduced delays in surveillance, promoting earlier detection of dysplasia and reducing burden on endoscopy services.
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Affiliation(s)
- Siobhan Chien
- Centre for Sustainable Delivery, Golden Jubilee National Hospital, Clydebank, Glasgow G81 4DN, UK
- School of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1QH, UK
| | - Paul Glen
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Ian Penman
- Centre for Liver & Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Gavin Bryce
- Department of General Surgery, University Hospital Wishaw, Wishaw ML2 0DP, UK
| | - Neil Cruickshank
- Department of General Surgery, Victoria Hospital, Kirkcaldy KY2 5AH, UK
| | - Michael Miller
- Department of Gastroenterology, Ninewells Hospital, Dundee DD2 1SG, UK
| | - Andrew Crumley
- Department of General Surgery, Forth Valley Royal Hospital, Larbert FK5 4WR, UK
| | - Jonathan Fletcher
- Department of Gastroenterology, Borders General Hospital, Melrose TD6 9BS, UK
| | - Perminder Phull
- Department of Gastroenterology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
| | - Ivan Gunjaca
- Department of Gastroenterology, Raigmore Hospital, Inverness IV2 3UJ, UK
| | - Kevin Robertson
- Department of General Surgery, University Hospital Crosshouse, Kilmarnock KA2 0BE, UK
| | - Jeyakumar Apollos
- Department of General Surgery, Dumfries & Galloway Royal Infirmary, Dumfries DG2 8RX, UK
| | - Grant Fullarton
- Centre for Sustainable Delivery, Golden Jubilee National Hospital, Clydebank, Glasgow G81 4DN, UK
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Huang Q, Lew E, Cheng Y, Shinagare S, Deshpande V, Gold JS, Wiener D, Weber HC. Esophageal adenocarcinoma heterogeneity in clinicopathology and prognosis: A single center longitudinal study of 146 cases over a 20-year period. Ann Diagn Pathol 2024; 70:152285. [PMID: 38518703 DOI: 10.1016/j.anndiagpath.2024.152285] [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: 12/26/2023] [Revised: 02/23/2024] [Accepted: 02/25/2024] [Indexed: 03/24/2024]
Abstract
Recent genomic studies suggest that esophageal adenocarcinoma (EAC) is not homogeneous and can be divided into true (tEAC) and probable (pEAC) groups. We compared clinicopathologic and prognostic features between the two groups of EAC. Based on endoscopic, radiologic, surgical, and pathologic reports, tumors with epicenters beyond 2 cm of the gastroesophageal junction (GEJ) were assigned to the tEAC group (N = 63), while epicenters within 2 cm of, but not crossing the GEJ, were allocated to the pEAC group (N = 83). All 146 consecutive patients were male (age: median 70 years, range: 51-88) and White-predominant (98.6 %). There was no significant difference in gastroesophageal reflux disease, obesity, comorbidity, and the prevalence of Barrett's esophagus, and cases diagnosed during endoscopic surveillance. However, compared to the pEAC group, the tEAC group had significantly more cases with hiatal hernia (P = 0.003); their tumors were significantly smaller in size (P = 0.007), more frequently with tubular/papillary adenocarcinoma (P = 0.001), had fewer cases with poorly cohesive carcinoma (P = 0.018), and demonstrated better prognosis in stage I disease (P = 0.012); 5-year overall survival (34.9 months) was significantly longer (versus 16.8 months in pEACs) (P = 0.043). Compared to the patients without resection, the patients treated with endoscopic or surgical resection showed significantly better outcomes, irrespective of stages. We concluded that EACs were heterogeneous with two distinct tEAC and pEAC groups in clinicopathology and prognosis; resection remained the better option for improved outcomes. CONDENSED ABSTRACT: Esophageal adenocarcinoma can be divided into true or probable groups with distinct clinicopathology and better prognosis in the former than in the latter. we showed that resection remained the better option for improved outcomes.
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Affiliation(s)
- Qin Huang
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Edward Lew
- Department of Gastroenterology, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - Yuqing Cheng
- Department of Pathology, Changzhou Second People's Hospital and Nanjing Medical University, Changzhou, China
| | - Shweta Shinagare
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jason S Gold
- Department of Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - Daniel Wiener
- Department of Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
| | - H Christian Weber
- Department of Gastroenterology, Veterans Affairs Boston Healthcare System and Boston University Medical School, West Roxbury, MA, USA
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Giacometti C, Gusella A, Cassaro M. Gastro-Esophageal Junction Precancerosis: Histological Diagnostic Approach and Pathogenetic Insights. Cancers (Basel) 2023; 15:5725. [PMID: 38136271 PMCID: PMC10741421 DOI: 10.3390/cancers15245725] [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: 10/21/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Barrett's esophagus (BE) was initially defined in the 1950s as the visualization of gastric-like mucosa in the esophagus. Over time, the definition has evolved to include the identification of goblet cells, which confirm the presence of intestinal metaplasia within the esophagus. Chronic gastro-esophageal reflux disease (GERD) is a significant risk factor for adenocarcinoma of the esophagus, as intestinal metaplasia can develop due to GERD. The development of adenocarcinomas related to BE progresses in sequence from inflammation to metaplasia, dysplasia, and ultimately carcinoma. In the presence of GERD, the squamous epithelium changes to columnar epithelium, which initially lacks goblet cells, but later develops goblet cell metaplasia and eventually dysplasia. The accumulation of multiple genetic and epigenetic alterations leads to the development and progression of dysplasia. The diagnosis of BE requires the identification of intestinal metaplasia on histologic examination, which has thus become an essential tool both in the diagnosis and in the assessment of dysplasia's presence and degree. The histologic diagnosis of BE dysplasia can be challenging due to sampling error, pathologists' experience, interobserver variation, and difficulty in histologic interpretation: all these problems complicate patient management. The development and progression of Barrett's esophagus (BE) depend on various molecular events that involve changes in cell-cycle regulatory genes, apoptosis, cell signaling, and adhesion pathways. In advanced stages, there are widespread genomic abnormalities with losses and gains in chromosome function, and DNA instability. This review aims to provide an updated and comprehensible diagnostic approach to BE based on the most recent guidelines available in the literature, and an overview of the pathogenetic and molecular mechanisms of its development.
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Affiliation(s)
- Cinzia Giacometti
- Pathology Unit, Department of Diagnostic Services, ULSS 6 Euganea, 35131 Padova, Italy; (A.G.); (M.C.)
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Landy R, Killcoyne S, Tang C, Juniat S, O’Donovan M, Goel N, Gehrung M, Fitzgerald RC. Real-world implementation of non-endoscopic triage testing for Barrett's oesophagus during COVID-19. QJM 2023; 116:659-666. [PMID: 37220898 PMCID: PMC10497181 DOI: 10.1093/qjmed/hcad093] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/27/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND The Coronavirus pandemic (COVID-19) curtailed endoscopy services, adding to diagnostic backlogs. Building on trial evidence for a non-endoscopic oesophageal cell collection device coupled with biomarkers (Cytosponge), an implementation pilot was launched for patients on waiting lists for reflux and Barrett's oesophagus surveillance. AIMS (i) To review reflux referral patterns and Barrett's surveillance practices. (ii) To evaluate the range of Cytosponge findings and impact on endoscopy services. DESIGN AND METHODS Cytosponge data from centralized laboratory processing (trefoil factor 3 (TFF3) for intestinal metaplasia (IM), haematoxylin & eosin for cellular atypia and p53 for dysplasia) over a 2-year period were included. RESULTS A total of 10 577 procedures were performed in 61 hospitals in England and Scotland, of which 92.5% (N = 9784/10 577) were sufficient for analysis. In the reflux cohort (N = 4074 with gastro-oesophageal junction sampling), 14.7% had one or more positive biomarkers (TFF3: 13.6% (N = 550/4056), p53: 0.5% (21/3974), atypia: 1.5% (N = 63/4071)), requiring endoscopy. Among samples from individuals undergoing Barrett's surveillance (N = 5710 with sufficient gland groups), TFF3-positivity increased with segment length (odds ratio = 1.37 per cm (95% confidence interval: 1.33-1.41, P < 0.001)). Some surveillance referrals (21.5%, N = 1175/5471) had ≤1 cm segment length, of which 65.9% (707/1073) were TFF3 negative. Of all surveillance procedures, 8.3% had dysplastic biomarkers (4.0% (N = 225/5630) for p53 and 7.6% (N = 430/5694) for atypia), increasing to 11.8% (N = 420/3552) in TFF3+ cases with confirmed IM and 19.7% (N = 58/294) in ultra-long segments. CONCLUSIONS Cytosponge-biomarker tests enabled targeting of endoscopy services to higher-risk individuals, whereas those with TFF3 negative ultra-short segments could be reconsidered regarding their Barrett's oesophagus status and surveillance requirements. Long-term follow-up will be important in these cohorts.
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Affiliation(s)
- R Landy
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - S Killcoyne
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
| | - C Tang
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
| | - S Juniat
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
| | - M O’Donovan
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N Goel
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
| | - M Gehrung
- Cyted Ltd, 22 Station Road, Cambridge CB1 2JD, UK
| | - R C Fitzgerald
- Department of Oncology, Early Cancer Institute, University of Cambridge, Cambridge CB2 0XZ, UK
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10
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Wenker TN, Rubenstein JH, Thrift AP, Singh H, El-Serag HB. Development and Validation of the Houston-BEST, a Barrett's Esophagus Risk Prediction Model Adaptable to Electronic Health Records. Clin Gastroenterol Hepatol 2023; 21:2424-2426.e0. [PMID: 35985640 PMCID: PMC9935746 DOI: 10.1016/j.cgh.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/22/2022] [Accepted: 08/05/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Theresa Nguyen Wenker
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Joel H Rubenstein
- LTC Charles S Kettles Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
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11
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Vithayathil M, Modolell I, Ortiz-Fernandez-Sordo J, Pappas A, Januszewicz W, O’Donovan M, Bianchi M, White JR, Kaye P, Ragunath K, di Pietro M. The effect of procedural time on dysplasia detection rate during endoscopic surveillance of Barrett's esophagus. Endoscopy 2023; 55:491-498. [PMID: 36657467 PMCID: PMC10212647 DOI: 10.1055/a-2015-8883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/23/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND : Endoscopic surveillance of Barrett's esophagus (BE) with Seattle protocol biopsies is time-consuming and inadequately performed in routine practice. There is no recommended procedural time for BE surveillance. We investigated the duration of surveillance procedures with adequate tissue sampling and effect on dysplasia detection rate (DDR). METHODS : We performed post hoc analysis from the standard arm of a crossover randomized controlled trial recruiting patients with BE (≥C2 and/or ≥M3) and no clearly visible dysplastic lesions. After inspection with white-light imaging, targeted biopsies of subtle lesions and Seattle protocol biopsies were performed. Procedure duration and biopsy number were stratified by BE length. The effect of endoscopy-related variables on DDR was assessed by multivariable logistic regression. RESULTS : Of 142 patients recruited, 15 (10.6 %) had high grade dysplasia/intramucosal cancer and 15 (10.6 %) had low grade dysplasia. The median procedural time was 16.5 minutes (interquartile range 14.0-19.0). Endoscopy duration increased by 0.9 minutes for each additional 1 cm of BE length. Seattle protocol biopsies had higher sensitivity for dysplasia than targeted biopsies (86.7 % vs. 60.0 %; P = 0.045). Longer procedural time was associated with increased likelihood of dysplasia detection on quadrantic biopsies (odds ratio [OR] 1.10, 95 %CI 1.00-1.20, P = 0.04), and for patients with BE > 6 cm also on targeted biopsies (OR 1.21, 95 %CI 1.04-1.40; P = 0.01). CONCLUSIONS : In BE patients with no clearly visible dysplastic lesions, longer procedural time was associated with increased likelihood of dysplasia detection. Adequate time slots are required to perform good-quality surveillance and maximize dysplasia detection.
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Affiliation(s)
- Mathew Vithayathil
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ines Modolell
- Department of Gastroenterology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Jacobo Ortiz-Fernandez-Sordo
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Apostolos Pappas
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Wladyslaw Januszewicz
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Maria O’Donovan
- Department of Histopathology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Michele Bianchi
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan R. White
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Philip Kaye
- Department of Histopathology, Nottingham University Hospital NHS Foundation Trust, Nottingham, United Kingdom
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Massimiliano di Pietro
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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12
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Nguyen Wenker T, Natarajan Y, Caskey K, Novoa F, Mansour N, Pham HA, Hou JK, El-Serag HB, Thrift AP. Using Natural Language Processing to Automatically Identify Dysplasia in Pathology Reports for Patients With Barrett's Esophagus. Clin Gastroenterol Hepatol 2023; 21:1198-1204. [PMID: 36115659 PMCID: PMC10014472 DOI: 10.1016/j.cgh.2022.09.005] [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: 06/17/2022] [Revised: 08/30/2022] [Accepted: 09/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Identifying dysplasia of Barrett's esophagus (BE) in the electronic medical record (EMR) requires manual abstraction of unstructured data. Natural language processing (NLP) creates structure to unstructured free text. We aimed to develop and validate an NLP algorithm to identify dysplasia in BE patients on histopathology reports with varying report formats in a large integrated EMR system. METHODS We randomly selected 600 pathology reports for NLP development and 400 reports for validation from patients with suspected BE in the national Veterans Affairs databases. BE and dysplasia were verified by manual review of the pathology reports. We used NLP software (Clinical Language Annotation, Modeling, and Processing Toolkit; Melax Tech, Houston, TX) to develop an algorithm to identify dysplasia using findings. The algorithm performance characteristics were calculated as recall, precision, accuracy, and F-measure. RESULTS In the development set of 600 patients, 457 patients had confirmed BE (60 with dysplasia). The NLP identified dysplasia with 98.0% accuracy, 91.7% recall, and 93.2% precision, with an F-measure of 92.4%. All 7 patients with confirmed high-grade dysplasia were classified by the algorithm as having dysplasia. Among the 400 patients in the validation cohort, 230 had confirmed BE (39 with dysplasia). Compared with manual review, the NLP algorithm identified dysplasia with 98.7% accuracy, 92.3% recall, and 100.0% precision, with an F-measure of 96.0%. CONCLUSIONS NLP yielded a high degree of sensitivity and accuracy for identifying dysplasia from diverse types of pathology reports for patients with BE. The application of this algorithm would facilitate research and clinical care in an EMR system with text reports in large data repositories.
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Affiliation(s)
- Theresa Nguyen Wenker
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Yamini Natarajan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Kadon Caskey
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Francisco Novoa
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Nabil Mansour
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Jason K Hou
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
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13
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Shah MA, Altorki N, Patel P, Harrison S, Bass A, Abrams JA. Improving outcomes in patients with oesophageal cancer. Nat Rev Clin Oncol 2023; 20:390-407. [PMID: 37085570 DOI: 10.1038/s41571-023-00757-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/23/2023]
Abstract
The care of patients with oesophageal cancer or of individuals who have an elevated risk of oesophageal cancer has changed dramatically. The epidemiology of squamous cell and adenocarcinoma of the oesophagus has diverged over the past several decades, with a marked increase in incidence only for oesophageal adenocarcinoma. Only in the past decade, however, have molecular features that distinguish these two forms of the disease been identified. This advance has the potential to improve screening for oesophageal cancers through the development of novel minimally invasive diagnostic technologies predicated on cancer-specific genomic or epigenetic alterations. Surgical techniques have also evolved towards less invasive approaches associated with less morbidity, without compromising oncological outcomes. With improvements in multidisciplinary care, advances in radiotherapy and new tools to detect minimal residual disease, certain patients may no longer even require surgical tumour resection. However, perhaps the most anticipated advance in the treatment of patients with oesophageal cancer is the advent of immune-checkpoint inhibitors, which harness and enhance the host immune response against cancer. In this Review, we discuss all these advances in the management of oesophageal cancer, representing only the beginning of a transformation in our quest to improve patient outcomes.
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Affiliation(s)
- Manish A Shah
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Nasser Altorki
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Pretish Patel
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sebron Harrison
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Adam Bass
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Julian A Abrams
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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14
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Sharma P, Falk GW, Bhor M, Ozbay AB, Latremouille-Viau D, Guérin A, Shi S, Elvekrog MM, Limburg P. Real-world upper endoscopy utilization patterns among patients with gastroesophageal reflux disease, Barrett esophagus, and Barrett esophagus-related esophageal neoplasia in the United States. Medicine (Baltimore) 2023; 102:e33072. [PMID: 36961193 PMCID: PMC10036066 DOI: 10.1097/md.0000000000033072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 03/25/2023] Open
Abstract
This study fills a gap in literature by providing contemporary real-world evidence on the prevalence of patients with gastroesophageal reflux disease (GERD), Barrett esophagus (BE), and Barrett esophagus-related neoplasia (BERN) and their upper endoscopy utilization patterns in the United States. A retrospective cohort study design was used: adults with GERD, nondysplastic Barrett esophagus (NDBE), and BERN (indefinite for dysplasia [IND], low-grade dysplasia [LGD], high-grade dysplasia [HGD], or esophageal adenocarcinoma [EAC]) were identified from the MarketScan databases (January 01, 2015-December 31, 2019). For each disease stage, prevalence of adults in commercial claims by calendar year, annual number of upper endoscopies per patient and time between upper endoscopies were reported. In 2019, in commercial claims (N = 12,363,227), the annual prevalence rate of GERD was 13.7% and 0.70% for BE/BERN, among which, 87.1% had NDBE, 6.8% had IND, 2.3% had LGD, 1.0% had HGD, and 2.8% had EAC. From 2015-2019, the study included 3,310,385 patients with GERD, 172,481 with NDBE, 11,516 with IND, 4332 with LGD, 1549 with HGD, and 11,676 with EAC. Annual mean number of upper endoscopies was 0.20 per patient for GERD, 0.37 per patient for NDBE, 0.43 for IND, 0.58 for LGD, and 0.87 for HGD. Median time (months) to second upper endoscopy was 38.10 for NDBE, 36.63 for IND, 22.63 for LGD, and 11.90 for HGD. Upper endoscopy utilization increased from GERD to BE to BERN, and time between upper endoscopies decreased as the disease stage progressed from BE to BERN, with less frequent utilization in BERN than what would be expected from guideline recommendations for surveillance.
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Affiliation(s)
- Prateek Sharma
- Department of Gastroenterology, University of Kansas School of Medicine and VA Medical Center, Kansas City, MO
| | - Gary W. Falk
- Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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15
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van der Laan JJH, van der Putten JA, Zhao X, Karrenbeld A, Peters FTM, Westerhof J, de With PHN, van der Sommen F, Nagengast WB. Optical Biopsy of Dysplasia in Barrett's Oesophagus Assisted by Artificial Intelligence. Cancers (Basel) 2023; 15:cancers15071950. [PMID: 37046611 PMCID: PMC10093622 DOI: 10.3390/cancers15071950] [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: 02/03/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Optical biopsy in Barrett's oesophagus (BE) using endocytoscopy (EC) could optimize endoscopic screening. However, the identification of dysplasia is challenging due to the complex interpretation of the highly detailed images. Therefore, we assessed whether using artificial intelligence (AI) as second assessor could help gastroenterologists in interpreting endocytoscopic BE images. First, we prospectively videotaped 52 BE patients with EC. Then we trained and tested the AI pm distinct datasets drawn from 83,277 frames, developed an endocytoscopic BE classification system, and designed online training and testing modules. We invited two successive cohorts for these online modules: 10 endoscopists to validate the classification system and 12 gastroenterologists to evaluate AI as second assessor by providing six of them with the option to request AI assistance. Training the endoscopists in the classification system established an improved sensitivity of 90.0% (+32.67%, p < 0.001) and an accuracy of 77.67% (+13.0%, p = 0.020) compared with the baseline. However, these values deteriorated at follow-up (-16.67%, p < 0.001 and -8.0%, p = 0.009). Contrastingly, AI-assisted gastroenterologists maintained high sensitivity and accuracy at follow-up, subsequently outperforming the unassisted gastroenterologists (+20.0%, p = 0.025 and +12.22%, p = 0.05). Thus, best diagnostic scores for the identification of dysplasia emerged through human-machine collaboration between trained gastroenterologists with AI as the second assessor. Therefore, AI could support clinical implementation of optical biopsies through EC.
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Affiliation(s)
- Jouke J H van der Laan
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Joost A van der Putten
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Xiaojuan Zhao
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Arend Karrenbeld
- Department of Pathology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
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16
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Why Has Screening and Surveillance for Barrett's Esophagus Fallen Short in Stemming the Rising Incidence of Esophageal Adenocarcinoma? Am J Gastroenterol 2023; 118:590-592. [PMID: 36728873 DOI: 10.14309/ajg.0000000000002159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/20/2022] [Indexed: 02/03/2023]
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17
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Identification of potential biomarkers in Barrett's esophagus derived esophageal adenocarcinoma. Sci Rep 2023; 13:2345. [PMID: 36759514 PMCID: PMC9910260 DOI: 10.1038/s41598-022-17107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/20/2022] [Indexed: 02/11/2023] Open
Abstract
Almost 50% of esophageal adenocarcinoma (EAC) patients progressed from Barrett's esophagus (BE). EAC is often diagnosed at late stages and is related to dismal prognosis. However, there are still no effective methods for stratification and therapy in BE and EAC. Two public datasets (GSE26886 and GSE37200) were analyzed to identify differentially expressed genes (DEGs) between BE and EAC. Then, a series of bioinformatics analyses were performed to explore potential biomarkers associated with BE-EAC. 27 up- and 104 down-regulated genes were observed between GSE26886 and GSE37200. The GO and KEGG enrichment analysis indicated that the DEGs were highly involved in tumorigenesis. Subsequently, Weighted Gene Co-Expression Network Analysis (WGCNA) were performed to explore the potential genes related to BE-EAC, which were validated in The Cancer Genome Atlas (TCGA) database, and 5 up-regulated genes (MYO1A, ACE2, COL1A1, LGALS4, and ADRA2A) and 3 down-regulated genes (AADAC, RAB27A, and P2RY14) were found in EAC. Meanwhile, ADRA2A and AADAC could contribute to EAC pathogenesis and progression. MYO1A, ACE2, COL1A1, LGALS4, ADRA2A, AADAC, RAB27A, and P2RY14 could be potential novel diagnostic and prognostic biomarkers in BE-EAC.
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18
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High rate of missed Barrett's esophagus when screening with forceps biopsies. Esophagus 2023; 20:143-149. [PMID: 35864425 PMCID: PMC9813185 DOI: 10.1007/s10388-022-00943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Screening for Barrett's esophagus (BE) with endoscopy plus forceps biopsy (FB) has poor compliance with the recommended Seattle protocol and fails to sample large areas of mucosa. This statistical modeling study estimates, for the first time, the actual frequency of missed BE cases by FB. METHODS Published, calibrated models in the literature were combined to calculate the age-specific prevalence of BE in white males with gastroesophageal reflux disease (GERD). We started with estimates of the prevalence of BE and GERD, and applied the relative risk for BE in patients with GERD based on the literature. This created estimates of the true prevalence of BE in white males with GERD by decade of life. The proportion of BE missed was calculated as the difference between the prevalence and the proportion with a positive screen. RESULTS The prevalence of BE in white males with GERD was 8.9%, 12.1%, 15.3%, 18.7% and 22.0% for the third through eighth decades of life. Even after assuming no false positives, missed cases of BE were about 50% when estimated for patients of ages 50 or 60 years, and over 60% for ages of 30, 40 or 70 years. Sensitivity analysis was done for all variables in the model calculations. For ages 50 and 60 years, this resulted in values from 30.3 to 57.3% and 36.4 to 60.9%. CONCLUSION Screening for BE with endoscopy and FB misses approximately 50% of BE cases. More sensitive methods of BE detection or better adherence to the Seattle protocol are needed.
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19
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Cruz JDC, Paculdo D, Ganesan D, Baker M, Critchley-Thorne RJ, Shaheen NJ, Wani S, Peabody JW. Clinical variation in surveillance and management of Barrett's esophagus: A cross-sectional study of gastroenterologists and gastrointestinal surgeons. Medicine (Baltimore) 2022; 101:e32187. [PMID: 36595793 PMCID: PMC9794215 DOI: 10.1097/md.0000000000032187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Appropriate surveillance and treatment of Barrett's esophagus (BE) is vital to prevent disease progression and decrease esophageal adenocarcinoma (EAC)-related mortality. We sought to determine the variation in BE care and identify improvement opportunities. 275 physicians (113 general gastroenterologists, 128 interventional gastroenterologists, 34 gastrointestinal surgeons) cared for 3 simulated patients, one each from 3 BE clinical scenarios: non-dysplastic BE (NDBE), BE indefinite for dysplasia (IND), and BE with low grade dysplasia (LGD), and care scores were measured against societal guidelines. Overall quality-of-care scores ranged from 17% to 85% with mean of 47.9% ± 11.8% for NDBE, 50.8% ± 11.7% for IND, and 52.7% ± 12.2% for LGD. Participants appropriately determined risk of progression 20.3% of the time: 14.4% for NDBE cases, 19.9% for LGD cases, and 26.8% for IND cases (P = .001). Treatment and follow-up care scores averaged 12.9% ± 17.5% overall. For the LGD cases, guideline-recommended twice-daily PPI treatment was ordered only 24.7% of the time. Guideline-based follow-up endoscopic surveillance was done in only 27.7% of NDBE cases and 32.7% of IND cases. For the LGD cases, 45.4% ordered endoscopic eradication therapy while 25.1% chose annual endoscopic surveillance. Finally, participants provided counseling on lifestyle modifications in just 20% of cases. Overall care of patients diagnosed with BE varied widely and showed room for improvement. Specific opportunities for improvement were adherence to guideline recommended surveillance intervals, patient counseling, and treatment selection for LGD. Physicians would potentially benefit from additional BE education, endoscopic advances, and better methods for risk stratification.
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Affiliation(s)
| | | | | | | | | | | | - Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, CO
| | - John W Peabody
- QURE Healthcare, San Francisco, CA
- University of California, San Francisco, CA
- University of California, Los Angeles, CA
- *Correspondence: John W Peabody QURE Healthcare, 450 Pacific Avenue, Suite 200, San Francisco, CA 94133 (e-mail: )
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20
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Wenker TN, Thrift AP, El-Serag HB. Limits of the AGA Practice Update for Barrett's Esophagus Screening: A Proposal for Electronic Health Record-Adaptable Risk Models. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00833-3. [PMID: 36087710 DOI: 10.1016/j.cgh.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Theresa Nguyen Wenker
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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21
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Abstract
Oesophageal adenocarcinoma (OAC) develops from columnar metaplasia of the distal oesophagus, Barrett's oesophagus (BO), secondary to chronic gastro-oesophageal reflux disease (GORD). In the present review, the stepwise development of GORD, BO and OAC is presented and the evidence of OAC prevention, including treatment with proton pump inhibitors (PPIs). PPIs are the main treatment of GORD and BO, with some evidence of prevention of OAC in these patients. However, as about 40% of OAC patient do not report a history of GORD and fewer than 15% of OAC cases are detected in individuals during BO surveillance, prevention of OAC is limited by PPI use in GORD and BO patients.
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Affiliation(s)
- Eivind Ness-Jensen
- HUNT Research Centre, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway.,Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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22
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Arnold M, Morgan E, Bardot A, Rutherford MJ, Ferlay J, Little A, Møller B, Bucher O, De P, Woods RR, Saint-Jacques N, Gavin AT, Engholm G, Achiam MP, Porter G, Walsh PM, Vernon S, Kozie S, Ramanakumar AV, Lynch C, Harrison S, Merrett N, O'Connell DL, Mala T, Elwood M, Zalcberg J, Huws DW, Ransom D, Bray F, Soerjomataram I. International variation in oesophageal and gastric cancer survival 2012-2014: differences by histological subtype and stage at diagnosis (an ICBP SURVMARK-2 population-based study). Gut 2022; 71:1532-1543. [PMID: 34824149 DOI: 10.1136/gutjnl-2021-325266] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/04/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To provide the first international comparison of oesophageal and gastric cancer survival by stage at diagnosis and histological subtype across high-income countries with similar access to healthcare. METHODS As part of the ICBP SURVMARK-2 project, data from 28 923 patients with oesophageal cancer and 25 946 patients with gastric cancer diagnosed during 2012-2014 from 14 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were included. 1-year and 3-year age-standardised net survival were estimated by stage at diagnosis, histological subtype (oesophageal adenocarcinoma (OAC) and oesophageal squamous cell carcinoma (OSCC)) and country. RESULTS Oesophageal cancer survival was highest in Ireland and lowest in Canada at 1 (50.3% vs 41.3%, respectively) and 3 years (27.0% vs 19.2%) postdiagnosis. Survival from gastric cancer was highest in Australia and lowest in the UK, for both 1-year (55.2% vs 44.8%, respectively) and 3-year survival (33.7% vs 22.3%). Most patients with oesophageal and gastric cancer had regional or distant disease, with proportions ranging between 56% and 90% across countries. Stage-specific analyses showed that variation between countries was greatest for localised disease, where survival ranged between 66.6% in Australia and 83.2% in the UK for oesophageal cancer and between 75.5% in Australia and 94.3% in New Zealand for gastric cancer at 1-year postdiagnosis. While survival for OAC was generally higher than that for OSCC, disparities across countries were similar for both histological subtypes. CONCLUSION Survival from oesophageal and gastric cancer varies across high-income countries including within stage groups, particularly for localised disease. Disparities can partly be explained by earlier diagnosis resulting in more favourable stage distributions, and distributions of histological subtypes of oesophageal cancer across countries. Yet, differences in treatment, and also in cancer registration practice and the use of different staging methods and systems, across countries may have impacted the comparisons. While primary prevention remains key, advancements in early detection research are promising and will likely allow for additional risk stratification and survival improvements in the future.
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Affiliation(s)
- Melina Arnold
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Eileen Morgan
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Aude Bardot
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Mark J Rutherford
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jacques Ferlay
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Alana Little
- Cancer Institute New South Wales, Alexandria, New South Wales, Australia
| | | | | | - Prithwish De
- Surveillance and Cancer Registry, Cancer Care Ontario, Toronto, Ontario, Canada
| | | | - Nathalie Saint-Jacques
- Registry & Analytics, Nova Scotia Health Authority Cancer Care Program, Halifax, Nova Scotia, Canada
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Gerda Engholm
- Cancer Prevention & Documentation, Danish Cancer Society, Copenhagen, Denmark
| | - Michael P Achiam
- Danish EsophagoGastric Cancer group, Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Geoff Porter
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | | | | | - Serena Kozie
- Saskatchewan Cancer Agency, Regina, Saskatchewan, Canada
| | | | - Charlotte Lynch
- International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London, UK
| | - Samantha Harrison
- International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London, UK
| | - Neil Merrett
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital and School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Dianne L O'Connell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Tom Mala
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Mark Elwood
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - John Zalcberg
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dyfed W Huws
- Swansea University, Swansea, Wales, UK
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales, Cardiff, Wales, UK
| | - David Ransom
- WA Cancer and Palliative Care Network Policy Unit, Health Networks Branch, Department of Health, Perth, WA, Australia
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
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Prognostic, Diagnostic and Predictive Biomarkers in the Barrett’s Oesophagus-Adenocarcinoma Disease Sequence. Cancers (Basel) 2022; 14:cancers14143427. [PMID: 35884487 PMCID: PMC9315596 DOI: 10.3390/cancers14143427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/16/2022] [Accepted: 07/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Oesophageal adenocarcinoma (OAC) is a type of cancer of the oesophagus (food pipe) which is associated with poor patient outcomes. Barrett’s oesophagus (BO) is a precancerous condition of the oesophagus associated with chronic heartburn. Currently, surveillance programs exist which monitor patients with BO to prevent it from developing into OAC. However, these surveillance programs are expensive and unpleasant for patients. Prognostic biomarkers are signs which could be measured to determine the chance of someone with BO developing OAC, allowing more targeted surveillance. Similarly, diagnostic biomarkers are indicators which could be measured to see if someone has OAC. Developing new diagnostic biomarkers could allow wider population testing. Only a small proportion of patients with OAC respond to treatment before surgery. Predictive biomarkers could be measured to predict whether someone would respond to the treatments, allowing more individualized therapy. This review focuses on potential biomarkers which could improve patient outcomes in BO/OAC. Abstract Oesophageal adenocarcinoma (OAC) incidence has increased dramatically in the developed world, yet outcomes remain poor. Extensive endoscopic surveillance programs among patients with Barrett’s oesophagus (BO), the precursor lesion to OAC, have aimed to both prevent the development of OAC via radiofrequency ablation (RFA) and allow earlier detection of disease. However, given the low annual progression rate and the costs of endoscopy/RFA, improvement is needed. Prognostic biomarkers to stratify BO patients based on their likelihood to progress would enable a more targeted approach to surveillance and RFA of high-risk precursor lesions, improving the cost–risk–benefit ratio. Similarly, diagnostic biomarkers for OAC could enable earlier diagnosis of disease by allowing broader population screening. Current standard treatment for locally advanced OAC includes neoadjuvant chemotherapy (+/− radiotherapy) despite only a minority of patients benefiting from neoadjuvant treatment. Accordingly, biomarkers predictive of response to neoadjuvant therapy could improve patient outcomes by reducing time to surgery and unnecessary toxicity for the patients who would have received no benefit from the therapy. In this mini-review, we will discuss the emerging biomarkers which promise to dramatically improve patient outcomes along the BO-OAC disease sequence.
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Nguyen TH, Thrift AP, Ketwaroo GA, Du XL, Novelo LL, George R, Rosen DG, El-Serag HB. External validation of a model determining risk of neoplastic progression of Barrett's esophagus in a cohort of U.S. veterans. Gastrointest Endosc 2022; 95:1113-1122. [PMID: 34998796 PMCID: PMC9119926 DOI: 10.1016/j.gie.2021.12.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Risk of esophageal adenocarcinoma (EAC) in those with Barrett's esophagus (BE) is 11-fold greater than the general population. It remains unclear which BE patients are at highest risk of progression to EAC. We aimed to validate a predictive model risk-stratifying BE patients. METHODS We conducted a retrospective cohort study at the Houston Veteran Affairs Medical Center of consecutive patients with a new diagnosis of BE from November 1990 to January 2019. Study follow-up was through February 2020. Patients were excluded if they had no follow-up EGD with esophageal biopsy sampling after the initial BE-diagnosing EGD or evidence of high-grade dysplasia (HGD) or EAC on initial EGD. We performed an external validation study of a risk model containing sex, smoking, BE length, and low-grade dysplasia (LGD) status and assessed discriminatory ability using the area under the receiver operating characteristic curve (AUROC). RESULTS Among 608 BE patients, 24 progressed to HGD/EAC. The points-based model discriminated well with an AUROC of .72 (95% confidence interval [CI], .63-.82). When categorized into low-, intermediate-, and high-risk groups according to published cutoffs, the AUROC was poor at .57. Restructured into low-risk versus high-risk groups, the AUROC was .72 (95% CI, .64-.80). Excluding baseline LGD did not reduce discriminatory ability (AUROC, .73; 95% CI, .64-.82). CONCLUSIONS This external validation provides further evidence that the model including sex, LGD status, smoking status, and BE length may help to risk stratify BE patients. A simplified version excluding LGD status and/or reducing the number of risk groups has increased utility in clinical practice without loss of discriminatory ability.
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Affiliation(s)
- Theresa H. Nguyen
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Aaron P. Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Gyanprakash A. Ketwaroo
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Xianglin L. Du
- Department of Epidemiology, The University of Texas School of Public Health, Houston, Texas, USA
| | - Luis Leon Novelo
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston - School of Public Health, Houston, Texas, USA
| | - Rollin George
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel G. Rosen
- Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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25
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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26
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Cummings LC, Kou TD, Chak A, Schluchter MD, Margevicius S, Cooper GS. Receipt of Serial Endoscopy Procedures Prior to Esophageal Adenocarcinoma Diagnosis Is Associated with Better Survival. Dig Dis Sci 2022; 67:1036-1044. [PMID: 33881677 PMCID: PMC8528889 DOI: 10.1007/s10620-021-06927-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The poor prognosis of esophageal adenocarcinoma (EAC) has focused efforts on early detection by serial endoscopic surveillance of Barrett's esophagus (BE). Previously, we reported that receipt of endoscopy before EAC diagnosis was associated with improved survival. AIM We aimed to refine our previous analysis, assessing surveillance as measured by performance of serial endoscopy before EAC diagnosis and evaluating its association with stage and survival. METHODS A retrospective cohort study was performed using the Surveillance, Epidemiology and End Results-Medicare database. Patients aged ≥ 70 years with EAC diagnosed during 1998-2009 were identified. Diagnosis with BE and receipt of ≥ 2 upper endoscopic procedures within 5 years before cancer diagnosis were identified. We compared a reference group not receiving serial endoscopy to 3 patterns based on ≥ 2 endoscopy dates relative to a timepoint 2 years before cancer diagnosis: "remote," "recent," and "sustained." RESULTS Among 5532 patients, 28% (n = 1,575) had localized stage. Thirteen percent (n = 703) received ≥ 2 endoscopic procedures before cancer diagnosis: 224, 298, and 181 in the "recent," "remote," and "sustained" groups. Serial endoscopy and prior BE were associated with localized stage ("sustained" group OR 2.95, 95% confidence interval [CI] 2.07, 4.19; prior BE OR 2.68, 95% CI 2.03, 3.56). Serial endoscopy was associated with improved survival even with adjustment for lead time bias ("sustained" group HR 0.45, 95% CI 0.37, 0.55) and length time bias. CONCLUSIONS Sustained endoscopy was associated with earlier stage and improved survival. These results support the role of sustained surveillance in early detection of EAC.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA.
- Case Comprehensive Cancer Center, 10900 Euclid Avenue, Cleveland, OH, 44106-7285, USA.
- Department of Medicine, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Tzuyung Doug Kou
- Department of Quantitative and Population Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA
- Case Comprehensive Cancer Center, 10900 Euclid Avenue, Cleveland, OH, 44106-7285, USA
- Department of Medicine, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Mark D Schluchter
- Case Comprehensive Cancer Center, 10900 Euclid Avenue, Cleveland, OH, 44106-7285, USA
- Department of Quantitative and Population Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Seunghee Margevicius
- Case Comprehensive Cancer Center, 10900 Euclid Avenue, Cleveland, OH, 44106-7285, USA
- Department of Quantitative and Population Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Gregory S Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue Mailstop 5066, Cleveland, OH, 44106-5066, USA
- Case Comprehensive Cancer Center, 10900 Euclid Avenue, Cleveland, OH, 44106-7285, USA
- Department of Medicine, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
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27
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Offman J, Pesola F, Fitzgerald RC, Hamilton W, Sasieni P. Impact of Barrett oesophagus diagnoses and endoscopies on oesophageal cancer survival in the UK: A cohort study. Cancer Med 2022; 11:1160-1171. [PMID: 34913599 PMCID: PMC8855914 DOI: 10.1002/cam4.4484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/16/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Current guidelines recommend endoscopic surveillance for Barrett oesophagus (BE), but the value of surveillance is still debated. Using a combination of primary care, secondary care and cancer registry datasets, we examined the impact of a prior BE diagnosis, clinical and risk factors on survival from oesophageal cancer and adenocarcinoma. METHODS Retrospective cohort study of patients aged 50 and above diagnosed with malignant oesophageal cancer between 1993 and 2014 using Clinical Practice Research Datalink (CPRD). All prior BE diagnoses and endoscopies were identified from CPRD and Hospital Episode Statistics. Histology information was obtained from linked cancer registry data. We used flexible parametric models to estimate excess hazard ratios (EHRs) for relative survival. We simulated the potential impact of lead-time by adding random lead-times from a variety of distributions to all those with prior BE. RESULTS Among our oesophageal cancer (n = 7503) and adenocarcinoma (n = 1476) cohorts only small percentages, 3.4% and 5.3%, respectively, had a prior BE diagnosis. Two-year relative survival was better among patients with BE: 48.0% (95% CI 41.9-54.9) compared to 25.2% (24.3-26.2) without. Patients with BE had a better prognosis (EHR = 0.53, 0.41-0.68). Survival was higher even if patients with BE had fewer than two endoscopies (50.0%; 43.6-57.3). A survival benefit was still observed after lead-time adjustment, with a 20% absolute difference in 2-year survival using a 5 year mean sojourn time. CONCLUSIONS Patients with a prior BE diagnosis had a survival advantage. This was not fully explained by surveillance endoscopies.
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Affiliation(s)
- Judith Offman
- Comprehensive Cancer CentreSchool of Cancer and Pharmaceutical SciencesFaculty of Life Sciences & MedicineKing’s College LondonLondonUK
| | - Francesca Pesola
- Comprehensive Cancer CentreSchool of Cancer and Pharmaceutical SciencesFaculty of Life Sciences & MedicineKing’s College LondonLondonUK
- Current affiliation: Health and Lifestyle Research UnitWolfson Institute of Preventive MedicineQueen Mary University of LondonLondonUK
| | | | | | - Peter Sasieni
- Comprehensive Cancer CentreSchool of Cancer and Pharmaceutical SciencesFaculty of Life Sciences & MedicineKing’s College LondonLondonUK
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28
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Holmberg D, Santoni G, von Euler-Chelpin MC, Färkkilä M, Kauppila JH, Maret-Ouda J, Ness-Jensen E, Lagergren J. Incidence and Mortality in Upper Gastrointestinal Cancer After Negative Endoscopy for Gastroesophageal Reflux Disease. Gastroenterology 2022; 162:431-438.e4. [PMID: 34627859 DOI: 10.1053/j.gastro.2021.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/06/2021] [Accepted: 10/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Gastroesophageal reflux disease (GERD) is associated with an increased risk of cancer of the upper gastrointestinal tract. This study aimed to assess whether and to what extent a negative upper endoscopy in patients with GERD is associated with decreased incidence and mortality in upper gastrointestinal cancer (ie, esophageal, gastric, or duodenal cancer). METHODS We conducted a population-based cohort study of all patients with newly diagnosed GERD between July 1, 1979 and December 31, 2018 in Denmark, Finland, Norway, and Sweden. The exposure, negative upper endoscopy, was examined as a time-varying exposure, where participants contributed unexposed person-time from GERD diagnosis until screened and exposed person-time from the negative upper endoscopy. The incidence and mortality in upper gastrointestinal cancer were assessed using parametric flexible models, providing adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS Among 1,062,740 patients with GERD (median age 58 years; 52% were women) followed for a mean of 7.0 person-years, 5324 (0.5%) developed upper gastrointestinal cancer and 4465 (0.4%) died from such cancer. Patients who had a negative upper endoscopy had a 55% decreased risk of upper gastrointestinal cancer compared with those who did not undergo endoscopy (HR, 0.45; 95% CI, 0.43-0.48), a decrease that was more pronounced during more recent years (HR, 0.34; 95% CI, 0.30-0.38 from 2008 onward), and was otherwise stable across sex and age groups. The corresponding reduction in upper gastrointestinal mortality among patients with upper endoscopy was 61% (adjusted HR, 0.39; 95% CI, 0.37-0.42). The risk reduction after a negative upper endoscopy in incidence and mortality lasted for 5 and at least 10 years, respectively. CONCLUSIONS Negative upper endoscopy is associated with strong and long-lasting decreases in incidence and mortality in upper gastrointestinal cancer in patients with GERD.
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Affiliation(s)
- Dag Holmberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Giola Santoni
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | - Martti Färkkilä
- Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joonas H Kauppila
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - John Maret-Ouda
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Eivind Ness-Jensen
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim/Levanger, Norway; Medical Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; School of Cancer and Pharmacological Sciences, King's College London, London, UK.
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29
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Jung HK, Tae CH, Song KH, Kang SJ, Park JK, Gong EJ, Shin JE, Lim HC, Lee SK, Jung DH, Choi YJ, Seo SI, Kim JS, Lee JM, Kim BJ, Kang SH, Park CH, Choi SC, Kwon JG, Park KS, Park MI, Lee TH, Kim SY, Cho YS, Lee HH, Jung KW, Kim DH, Moon HS, Miwa H, Chen CL, Gonlachanvit S, Ghoshal UC, Wu JCY, Siah KTH, Hou X, Oshima T, Choi MY, Lee KJ. 2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:453-481. [PMID: 34642267 PMCID: PMC8521465 DOI: 10.5056/jnm21077] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Ho Song
- Division of Gastroenterology, Department of Internal Medicine, CHA Ilsan Medical Center, CHA University School of Medicine, Ilsan, Jeollabuk-do, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Choi
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung In Seo
- Division of Gastroenterology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jung Min Lee
- Digestive Disease Center, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Jeollabuk-do, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Seung Young Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan, Hospital, Cheonan, Chungcheongnamdo, Korea
| | - Han Hong Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hirota Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Chien-Lin Chen
- Institute of Medical Sciences, Tzu Chi University, and Department of Public Health, College of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Uday C Ghoshal
- Departments of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Justin C Y Wu
- Institute of Digestive Disease, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China
| | - Kewin T H Siah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore
| | - Xiaohua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mi-Young Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
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Medina AL, Troendle DM, Park JY, Thaker A, Dunbar KB, Cheng E. Eosinophilic esophagitis, Barrett's esophagus and esophageal neoplasms in the pediatric patient: a narrative review. Transl Gastroenterol Hepatol 2021; 6:32. [PMID: 34423153 DOI: 10.21037/tgh-20-223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/31/2020] [Indexed: 01/07/2023] Open
Abstract
There are several esophageal disorders that can occur in the pediatric population. Eosinophilic esophagitis (EoE) is an eosinophil predominant inflammatory disease of the esophagus that was first characterized in the early 1900's. EoE is the most common pediatric esophageal inflammatory condition after gastroesophageal reflux disease (GERD). Longstanding GERD is a known risk factor for the development of Barrett's esophagus (BE) in both children and adults. BE is associated with the development of dysplasia and, if left undiagnosed, may progress to the development of esophageal adenocarcinoma (EAC). EAC and esophageal squamous cell carcinoma (ESCC) comprise the majority of childhood esophageal malignant neoplasms. The prevalence of EoE continues to rise within the pediatric population. On the other hand, both BE and esophageal neoplasms remain extremely rare in children. The relationship between a chronic inflammatory condition like EoE to BE and/or esophageal neoplasms remains unclear. The current research of these disease entities is prioritized to further understanding the disease pathogenesis and disease progression, exploring new diagnostic modalities, and developing novel treatments or less invasive therapeutic options. The focus of the following narrative review is to provide a summary of the current clinical practices, future research and their implications on these various esophageal disorders.
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Affiliation(s)
- Annette L Medina
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Health Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David M Troendle
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Health Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jason Y Park
- Department of Pathology, Children's Health Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ameet Thaker
- Department of Pathology, Children's Health Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kerry B Dunbar
- Division of Gastroenterology and Hepatology, Department of Medicine, Esophageal Diseases Center, Dallas VA Medical Center, VA North Texas Healthcare System, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edaire Cheng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Health Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Swart N, Maroni R, Muldrew B, Sasieni P, Fitzgerald RC, Morris S. Economic evaluation of Cytosponge®-trefoil factor 3 for Barrett esophagus: A cost-utility analysis of randomised controlled trial data. EClinicalMedicine 2021; 37:100969. [PMID: 34195582 PMCID: PMC8225801 DOI: 10.1016/j.eclinm.2021.100969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Esophageal adenocarcinoma has a very poor prognosis unless detected early. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett esophagus, a precursor of esophageal adenocarcinoma. Randomised controlled trial data from the BEST3 trial has shown that an offer of Cytosponge-TFF3 in the primary care setting in England to individuals on medication for acid reflux increases detection of Barrett esophagus 10-fold over a year compared with standard care. This is an economic evaluation of Cytosponge-TFF3 screening versus usual care using data from the BEST3 trial which took place between 20th March 2017 and 21st March 2019. METHODS A Markov model with a one-year cycle-length and a lifetime time horizon was created, adapting previous modeling work on Cytosponge screening. The impact of one round of Cytosponge screening was modelled in patients with a median age of 69 years (based on BEST3 trial population). Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were conducted on model parameters. FINDINGS Per person, one round of Cytosponge-TFF3 screening, including confirmatory endoscopy and treatment, in the intervention arm costed £82 more than usual care and generated an additional 0.015 quality-adjusted life-years (QALYs) at an ICER of £5,500 per QALY gained. Probabilistic sensitivity analysis gave an ICER of £5,405 (95% CI -£6,791 to £17,600). The average QALY gain per person is small because the majority of patients in the model will not develop BE and therefore will have no resulting change in their utility, however the small proportion of patients who are identified with BE dysplasia or cancer derive large benefit. At a willingness-to-pay threshold of £20,000 per QALY, the probability that Cytosponge-TFF3 was cost-effective was over 90%. INTERPRETATION Using data from a pragmatic randomised trial, one-off Cytosponge-TFF3 screen is cost-effective relative to usual care for patients with gastro-esophageal reflux disease, despite relatively low uptake and an older population in this trial setting than previously modelled. Improving Cytosponge-TFF3 uptake and targeting younger patients is likely to further improve cost-effectiveness.
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Affiliation(s)
- Nicholas Swart
- Department of Applied Health Research, University College London, UK
| | - Roberta Maroni
- School of Cancer and Pharmaceutical Sciences, Cancer Research UK & King's College London Cancer Prevention Trials Unit, Cancer Prevention Group, King's College London, UK
| | - Beth Muldrew
- School of Cancer and Pharmaceutical Sciences, Cancer Research UK & King's College London Cancer Prevention Trials Unit, Cancer Prevention Group, King's College London, UK
| | - Peter Sasieni
- School of Cancer and Pharmaceutical Sciences, Cancer Research UK & King's College London Cancer Prevention Trials Unit, Cancer Prevention Group, King's College London, UK
| | - Rebecca C. Fitzgerald
- Cambridge University Hospitals NHS Foundation Trust, UK
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - BEST3 Consortium
- BEST3 Trial team NIHR, Clinical Research Networks, UK. Full list of members given in Appendix, UK
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Global burden and epidemiology of Barrett oesophagus and oesophageal cancer. Nat Rev Gastroenterol Hepatol 2021; 18:432-443. [PMID: 33603224 DOI: 10.1038/s41575-021-00419-3] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 02/07/2023]
Abstract
Oesophageal cancer is a global health problem; in 2018 there were more than 572,000 people newly diagnosed with oesophageal cancer worldwide. There are two main histological subtypes of oesophageal cancer, oesophageal adenocarcinoma (EAC) and oesophageal squamous cell carcinoma (ESCC), and there has been a dramatic shift in its epidemiology. While the incidence of EAC and its precursor lesion, Barrett oesophagus, has increased in Western populations over the past four decades, the incidence of ESCC has declined in most parts of the world over the same period. ESCC still accounts for the vast majority of all oesophageal cancer cases diagnosed worldwide each year. Prognosis for patients with oesophageal cancer is strongly related to stage at diagnosis. As most patients are diagnosed with late-stage disease, overall 5-year survival for oesophageal cancer remains <20%. Knowledge of epidemiology and risk factors for oesophageal cancer is essential for public health and clinical decisions about risk stratification, screening and prevention. The goal of this Review is to establish the current epidemiology of oesophageal cancer, with a particular focus on the Western world and the increasing incidence of EAC and Barrett oesophagus.
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Song JH, Tieu AH, Cheng Y, Ma K, Akshintala VS, Simsek C, Prasath V, Shin EJ, Ngamruengphong S, Khashab MA, Abraham JM, Meltzer SJ. Novel Long Noncoding RNA miR205HG Functions as an Esophageal Tumor-Suppressive Hedgehog Inhibitor. Cancers (Basel) 2021; 13:cancers13071707. [PMID: 33916875 PMCID: PMC8038513 DOI: 10.3390/cancers13071707] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Barrett’s esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Long noncoding RNAs (lncRNAs) have been identified as key regulators of biological pathways and we identified lncRNA, miR205HG, as a tumor suppressor in the development of Barrett’s esophagus and esophageal adenocarcinoma, in part through its effect on the Hedgehog signaling pathway. The aims of the current study were: (1) to study involvement of miR205HG in the development of BE and EAC (2) to clarify the role of miR205HG in in vitro and in vivo experiments; and (3) to investigate the mechanism of miR205HG involving the Hedgehog (Hh) signaling pathway Abstract Barrett’s esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Recently, long noncoding RNAs (lncRNAs) have been identified as key regulators of biological pathways. However, involvement of lncRNAs in the development of BE and EAC has not been well-studied. The aims of the current study were: (1) to study involvement of the lncRNA, miR205HG, in the development of BE and EAC; (2) to clarify the role of miR205HG in in vitro and in vivo experiments; and (3) to investigate the mechanism of miR205HG involving the Hedgehog (Hh) signaling pathway. These experiments revealed that miR205HG was downregulated in EAC vs. normal esophageal epithelia (NE) as well as in EAC cell lines, and its forced overexpression inhibited EAC cell proliferation and cell cycle progression in vitro. Similarly, overexpression of miR205HG inhibited xenograft tumor growth in mice In vivo. Finally, we show that one mechanism of action of miR205HG involves the Hh signaling pathway: miR205HG and Hh expression levels were inversely correlated in both EAC (r = −0.73) and BE (r = −0.83) tissues, and in vitro studies revealed details of Hh signaling inhibition induced by miR205HG. In conclusion, these findings establish that lncRNA miR205HG functions as a tumor suppressor in the development of BE and EAC, at least in part through its effect on the Hh signaling pathway.
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Affiliation(s)
- Jee Hoon Song
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21287, USA
| | - Alan H. Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
- Division of Gastroenterology and Hepatology, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA 23456, USA
| | - Yulan Cheng
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Ke Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Venkata S. Akshintala
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Cem Simsek
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Vishnu Prasath
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - John M. Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
| | - Stephen J. Meltzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (J.H.S.); (A.H.T.); (Y.C.); (K.M.); (V.S.A.); (C.S.); (V.P.); (E.J.S.); (S.N.); (M.A.K.); (J.M.A.)
- Correspondence: ; Tel.: +410-502-6071
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Morgan E, Soerjomataram I, Gavin AT, Rutherford MJ, Gatenby P, Bardot A, Ferlay J, Bucher O, De P, Engholm G, Jackson C, Kozie S, Little A, Møller B, Shack L, Tervonen H, Thursfield V, Vernon S, Walsh PM, Woods RR, Finley C, Merrett N, O'Connell DL, Reynolds JV, Bray F, Arnold M. International trends in oesophageal cancer survival by histological subtype between 1995 and 2014. Gut 2021; 70:234-242. [PMID: 32554620 DOI: 10.1136/gutjnl-2020-321089] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/24/2020] [Accepted: 05/12/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Survival from oesophageal cancer remains poor, even across high-income countries. Ongoing changes in the epidemiology of the disease highlight the need for survival assessments by its two main histological subtypes, adenocarcinoma (AC) and squamous cell carcinoma (SCC). METHODS The ICBP SURVMARK-2 project, a platform for international comparisons of cancer survival, collected cases of oesophageal cancer diagnosed 1995 to 2014, followed until 31st December 2015, from cancer registries covering seven participating countries with similar access to healthcare (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK). 1-year and 3-year age-standardised net survival alongside incidence rates were calculated by country, subtype, sex, age group and period of diagnosis. RESULTS 111 894 cases of AC and 73 408 cases of SCC were included in the analysis. Marked improvements in survival were observed over the 20-year period in each country, particularly for AC, younger age groups and 1 year after diagnosis. Survival was consistently higher for both subtypes in Australia and Ireland followed by Norway, Denmark, New Zealand, the UK and Canada. During 2010 to 2014, survival was higher for AC compared with SCC, with 1-year survival ranging from 46.9% (Canada) to 54.4% (Ireland) for AC and 39.6% (Denmark) to 53.1% (Australia) for SCC. CONCLUSION Marked improvements in both oesophageal AC and SCC survival suggest advances in treatment. Less marked improvements 3 years after diagnosis, among older age groups and patients with SCC, highlight the need for further advances in early detection and treatment of oesophageal cancer alongside primary prevention to reduce the overall burden from the disease.
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Affiliation(s)
- Eileen Morgan
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Isabelle Soerjomataram
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Mark J Rutherford
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Piers Gatenby
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
| | - Aude Bardot
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Jacques Ferlay
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Oliver Bucher
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Prithwish De
- Surveillance and Cancer Registry, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Gerda Engholm
- Cancer Surveillance and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Christopher Jackson
- Cancer Society of New Zealand, Wellington, New Zealand
- Department of Medicine, Otago Medical School, Dunedin, New Zealand
| | - Serena Kozie
- Saskatchewan Cancer Agency, Regina, Saskatchewan, Canada
| | - Alana Little
- Cancer Information and Analysis, Cancer Institute NSW, Alexandria, New South Wales, Australia
| | - Bjorn Møller
- Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Lorraine Shack
- Cancer Control Alberta, Alberta Health Services, Edmonton, Alberta, Canada
| | - Hanna Tervonen
- Cancer Information and Analysis, Cancer Institute NSW, Alexandria, New South Wales, Australia
| | - Vicky Thursfield
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Sally Vernon
- National Cancer Registration and Analysis Service, Public Health England, Cambridge, UK
| | | | - Ryan R Woods
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Christian Finley
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Neil Merrett
- School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Dianne L O'Connell
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - John V Reynolds
- National Centre for Oesophageal Cancer, St James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Melina Arnold
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
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Abstract
Barrett's esophagus is the precursor lesion for esophageal adenocarcinoma. The goals of endoscopic surveillance are to detect dysplasia and early esophageal adenocarcinoma in order to improve patient outcomes. Despite the ongoing debate regarding the efficacy of surveillance, all current gastrointestinal societies recommend surveillance at this time. Optimal surveillance technique includes adequate inspection time, evaluation using high-definition white light and chromoendoscopy, appropriate documentation of the metaplastic segment using the Prague C & M criteria as well as the Paris classification should lesions be found, utilization of the Seattle biopsy protocol, and endoscopic resection of visible lesions.
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Affiliation(s)
- Joseph R. Triggs
- Clinical Instructor, Division of Gastroenterology. Hospital of the University of Pennsylvania. University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gary W. Falk
- Professor of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania. University of Pennsylvania Perelman School of Medicine Pennsylvania, Philadelphia, PA, USA
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Singer ME, Smith MS. Wide Area Transepithelial Sampling with Computer-Assisted Analysis (WATS 3D) Is Cost-Effective in Barrett's Esophagus Screening. Dig Dis Sci 2021; 66:1572-1579. [PMID: 32578042 PMCID: PMC8053177 DOI: 10.1007/s10620-020-06412-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 06/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Wide area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is an adjunct to the standard random 4-quadrant forceps biopsies (FB, "Seattle protocol") that significantly increases the detection of Barrett's esophagus (BE) and associated neoplasia in patients undergoing screening or surveillance. AIMS To examine the cost-effectiveness of adding WATS3D to the Seattle protocol in screening patients for BE. METHODS A decision analytic model was used to compare the effectiveness and cost-effectiveness of two alternative BE screening strategies in chronic gastroesophageal reflux disease patients: FB with and without WATS3D. The reference case was a 60-year-old white male with gastroesophageal reflux disease (GERD). Effectiveness was measured by the number needed to screen to avert one cancer and one cancer-related death, and quality-adjusted life years (QALYs). Cost was measured in 2019 US$, and the incremental cost-effectiveness ratio (ICER) was measured in $/QALY using thresholds for cost-effectiveness of $100,000/QALY and $150,000/QALY. Cost was measured in 2019 US$. Cost and QALYs were discounted at 3% per year. RESULTS Between 320 and 337 people would need to be screened with WATS3D in addition to FB to avert one additional cancer, and 328-367 people to avert one cancer-related death. Screening with WATS3D costs an additional $1219 and produced an additional 0.017 QALYs, for an ICER of $71,395/QALY. All one-way sensitivity analyses resulted in ICERs under $84,000/QALY. CONCLUSIONS Screening for BE in 60-year-old white male GERD patients is more cost-effective when WATS3D is used adjunctively to the Seattle protocol than with the Seattle protocol alone.
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Affiliation(s)
- Mendel E. Singer
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH USA
| | - Michael S. Smith
- Division of Gastroenterology and Hepatology, Mount Sinai West and Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, Ambulatory Care Center, 13th Floor, 440 W 114th St., New York, NY 10025 USA
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Endoscopic Eradication Therapy for Barrett's Neoplasia: Where Do We Stand a Decade Later? Curr Gastroenterol Rep 2020; 22:61. [PMID: 33277663 DOI: 10.1007/s11894-020-00799-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer associated with increasing incidence and poor survival. Early identification and effective treatment of BE-related neoplasia prior to the development of invasive adenocarcinoma are essential to limiting the morbidity and mortality associated with this cancer. In this review, we summarized the recent evidence guiding endoscopic eradication therapies (EET) for neoplastic BE. RECENT FINDINGS New sampling technologies and the application of artificial intelligence (AI) systems have potential to revolutionize early neoplasia detection in BE. EET for BE are safe and effective in achieving complete eradication of intestinal metaplasia (CE-IM) and reducing the progression to EAC, a practice endorsed by all GI society guidelines. EET should be considered in patients with high-grade dysplasia (HGD), intramucosal carcinoma (IMC), and select cases with low-grade dysplasia (LGD). The increasing use of endoscopic submucosal dissection (ESD) in the West may allow EET of select cases with submucosal EAC. Post-EET surveillance strategies will continue to evolve as knowledge of specific risk factors and long-term neoplasia recurrence rates improve. In the last decade, major advancements in EET for neoplastic BE have been achieved. These now represent the standard of care in the management of BE-related dysplasia and intramucosal cancer.
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O'Byrne LM, Witherspoon J, Verhage RJJ, O'Brien M, Muldoon C, Ryan C, Buckley M, Murphy T, Reynolds R, Patchett S, Kay E, Azam H, Robb W, Arumugasamy M, Mathuna PM, Leyden J, Gargan S, Doherty G, Sheahan K, Collins C, Nath A, O'Sullivan J, Donohoe CL, Ravi N, O'Toole D, Reynolds JV. Barrett's Registry Collaboration of academic centers in Ireland reveals high progression rate of low-grade dysplasia and low risk from nondysplastic Barrett's esophagus: report of the RIBBON network. Dis Esophagus 2020; 33:5810257. [PMID: 32193532 DOI: 10.1093/dote/doaa009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett's epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19-4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.
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Maitra I, Date RS, Martin FL. Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments. Clin J Gastroenterol 2020; 13:635-649. [PMID: 32495144 PMCID: PMC7519897 DOI: 10.1007/s12328-020-01135-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.
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Affiliation(s)
- Ishaan Maitra
- School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
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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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Barrie J, Yanni F, Sherif M, Dube AK, Tamhankar AP. Length of Barrett's esophagus in the presence of low-grade dysplasia, high-grade dysplasia, and adenocarcinoma. Surg Endosc 2020; 35:4756-4762. [PMID: 32880012 PMCID: PMC8263447 DOI: 10.1007/s00464-020-07950-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The identification and follow-up of ultra-short Barrett's esophagus (BE) is controversial. BE surveillance guidelines emphasize mainly on long-segment BE. However, in practice a substantial proportion of esophageal adenocarcinoma (EAC) are found close to the gastro-esophageal junction (GEJ). Our study aims to chart the length of BE when low-grade dysplasia (LGD), high-grade dysplasia (HGD) and EAC arise in BE. METHODS Endoscopic findings from all cases with a diagnosis of LGD and HGD in BE between June 2014 and June 2019, and 100 consecutive cases of EAC diagnosed between June 2018 and August 2019, were reviewed. Additionally, 438 consecutive gastroscopies were reviewed to identify 100 cases of non-dysplastic BE. RESULTS 99 cases of LGD and 61 cases of HGD were reviewed. LGD and HGD when diagnosed, was located in BE ≤ 1 cm in 20% and 18% cases, respectively. LGD and HGD when diagnosed, was located in BE ≤ 3 cm in 48.5% and 40.9% cases, respectively. LGD and HGD when diagnosed in BE ≤ 3 cm was found at index endoscopy in 67% and 42% cases, respectively. Of the 100 cases of EAC, only 23 had concurrent visible BE, with BE higher than the level of EAC in seven. EAC when found, had its proximal extent ≤ 1 cm from GEJ in 22% and ≤ 3 cm from GEJ in 40% cases. Of the 100 non-dysplastic BE, 53% were ≤ 1 cm and 78% were ≤ 3 cm long. CONCLUSION Almost 20% of all dysplasia in BE occurs in BE < 1 cm. Over 40% occurs in BE < 3 cm. Similarly, 20% of EAC occurs within 1 cm of GEJ and 40% occur within 3 cm. A majority of dysplasia diagnosed within 3 cm of the GEJ is found on index endoscopy. We propose that all lengths of columnar lined epithelium above the GEJ are recognized as BE and subjected to a thorough biopsy protocol.
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Affiliation(s)
- Jenifer Barrie
- Department of Upper Gastrointestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fady Yanni
- Department of Upper Gastrointestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mohamed Sherif
- Department of Upper Gastrointestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Asha K Dube
- Department of Histopathology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anand P Tamhankar
- Department of Upper Gastrointestinal Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK. .,Academic Unit of Surgery, University of Sheffield, Northern General Hospital, Herries Road, Sheffield, S5 7AU, South Yorkshire, UK.
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Gibbens Y, Iyer PG. What is the optimal surveillance strategy for non-dysplastic Barrett's esophagus? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:369-383. [PMID: 33737800 PMCID: PMC7963123 DOI: 10.1007/s11938-020-00297-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE OF REVIEW There is conflicting data on the effectiveness of the currently recommended endoscopic surveillance strategy in non-dysplastic BE patients. We reviewed the literature to evaluate the (cost) effectiveness of the current surveillance strategy. We also reviewed critical strategies and new technologies which could improve dysplasia detection. RECENT FINDINGS Adherence to the current EGD surveillance guidelines is suboptimal with high rates of missed dysplasia/EAC. The influence of surveillance on EAC mortality appears modest. Careful cleansing, inspection and sampling of the BE mucosa using high resolution while light and (electronic) chromoendoscopy is critical. Newer sampling techniques coupled with computer aided diagnosis and emerging imaging technologies have shown promise in improving dysplasia detection. Personalized surveillance with risk stratification based on risk factors for progression may be on the horizon. SUMMARY Current BE surveillance strategy will likely be further refined and optimized by emerging new technologies in tissue sampling, advanced imaging and risk stratification.
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Affiliation(s)
- Ying Gibbens
- Department of Medicine, Mayo Clinic, Rochester,
Minnesota
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic,
Rochester, Minnesota
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Peters Y, van Grinsven E, van de Haterd M, van Lankveld D, Verbakel J, Siersema PD. Individuals' Preferences for Esophageal Cancer Screening: A Discrete Choice Experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1087-1095. [PMID: 32828222 DOI: 10.1016/j.jval.2020.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 02/26/2020] [Accepted: 03/04/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The increasing incidence of esophageal adenocarcinoma (EAC) and the dismal prognosis has stimulated interest in the early detection of EAC. Our objective was to determine individuals' preferences for EAC screening and to assess to what extent procedural characteristics of EAC screening tests predict willingness for screening participation. METHODS A discrete choice experiment questionnaire was sent by postal mail to 1000 subjects aged 50 to 75 years who were randomly selected from the municipal registry in the Netherlands. Each subject answered 12 discrete choice questions of 2 hypothetical screening tests comprising 5 attributes: EAC-related mortality risk reduction, procedure-related pain and discomfort, screening location, test specificity, and costs. A multinomial logit model was used to estimate individuals' preferences for each attribute level and to calculate expected rates of uptake. RESULTS In total, 375 individuals (37.5%) completed the questionnaire. Test specificity, pain and discomfort, mortality reduction, and out-of-pocket costs all had a significant impact on respondents' preferences. The average expected uptake of EAC screening was 62.8% (95% confidence interval [CI] 61.1-64.5). Severe pain and discomfort had the largest impact on screening uptake (-22.8%; 95% CI -26.8 to -18.7). Male gender (β 2.81; P < .001), cancer worries (β 1.96; P = .01), endoscopy experience (β 1.46; P = .05), and upper gastrointestinal symptoms (β 1.50; P = .05) were significantly associated with screening participation. CONCLUSIONS EAC screening implementation should consider patient preferences to maximize screening attendance uptake. Based on our results, an optimal screening test should have high specificity, cause no or mild to moderate pain or discomfort, and result in a decrease in EAC-related mortality.
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Affiliation(s)
- Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Evi van Grinsven
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michelle van de Haterd
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daan van Lankveld
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Juul Verbakel
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Fitzgerald RC, di Pietro M, O'Donovan M, Maroni R, Muldrew B, Debiram-Beecham I, Gehrung M, Offman J, Tripathi M, Smith SG, Aigret B, Walter FM, Rubin G, Sasieni P. Cytosponge-trefoil factor 3 versus usual care to identify Barrett's oesophagus in a primary care setting: a multicentre, pragmatic, randomised controlled trial. Lancet 2020; 396:333-344. [PMID: 32738955 PMCID: PMC7408501 DOI: 10.1016/s0140-6736(20)31099-0] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of dysplastic Barrett's oesophagus prevents progression to adenocarcinoma; however, the optimal diagnostic strategy for Barrett's oesophagus is unclear. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett's oesophagus. The aim of this study was to investigate whether offering this test to patients on medication for gastro-oesophageal reflux would increase the detection of Barrett's oesophagus compared with standard management. METHODS This multicentre, pragmatic, randomised controlled trial was done in 109 socio-demographically diverse general practice clinics in England. Randomisation was done both at the general practice clinic level (cluster randomisation) and at the individual patient level, and the results for each type of randomisation were analysed separately before being combined. Patients were eligible if they were aged 50 years or older, had been taking acid-suppressants for symptoms of gastro-oesophageal reflux for more than 6 months, and had not undergone an endoscopy procedure within the past 5 years. General practice clinics were selected by the local clinical research network and invited to participate in the trial. For cluster randomisation, clinics were randomly assigned (1:1) by the trial statistician using a computer-generated randomisation sequence; for individual patient-level randomisation, patients were randomly assigned (1:1) by the general practice clinics using a centrally prepared computer-generated randomisation sequence. After randomisation, participants received either standard management of gastro-oesophageal reflux (usual care group), in which participants only received an endoscopy if required by their general practitioner, or usual care plus an offer of the Cytosponge-TFF3 procedure, with a subsequent endoscopy if the procedure identified TFF3-positive cells (intervention group). The primary outcome was the diagnosis of Barrett's oesophagus at 12 months after enrolment, expressed as a rate per 1000 person-years, in all participants in the intervention group (regardless of whether they had accepted the offer of the Cytosponge-TFF3 procedure) compared with all participants in the usual care group. Analyses were intention-to-treat. The trial is registered with the ISRCTN registry, ISRCTN68382401, and is completed. FINDINGS Between March 20, 2017, and March 21, 2019, 113 general practice clinics were enrolled, but four clinics dropped out shortly after randomisation. Using an automated search of the electronic prescribing records of the remaining 109 clinics, we identified 13 657 eligible patients who were sent an introductory letter with 14 days to opt out. 13 514 of these patients were randomly assigned (per practice or at the individual patient level) to the usual care group (n=6531) or the intervention group (n=6983). Following randomisation, 149 (2%) of 6983 participants in the intervention group and 143 (2%) of 6531 participants in the usual care group, on further scrutiny, did not meet all eligibility criteria or withdrew from the study. Of the remaining 6834 participants in the intervention group, 2679 (39%) expressed an interest in undergoing the Cytosponge-TFF3 procedure. Of these, 1750 (65%) met all of the eligibility criteria on telephone screening and underwent the procedure. Most of these participants (1654 [95%]; median age 69 years) swallowed the Cytosponge successfully and produced a sample. 231 (3%) of 6834 participants had a positive Cytosponge-TFF3 result and were referred for an endoscopy. Patients who declined the offer of the Cytosponge-TFF3 procedure and all participants in the usual care group only had an endoscopy if deemed necessary by their general practitioner. During an average of 12 months of follow-up, 140 (2%) of 6834 participants in the intervention group and 13 (<1%) of 6388 participants in the usual care group were diagnosed with Barrett's oesophagus (absolute difference 18·3 per 1000 person-years [95% CI 14·8-21·8]; rate ratio adjusted for cluster randomisation 10·6 [95% CI 6·0-18·8], p<0·0001). Nine (<1%) of 6834 participants were diagnosed with dysplastic Barrett's oesophagus (n=4) or stage I oesophago-gastric cancer (n=5) in the intervention group, whereas no participants were diagnosed with dysplastic Barrett's oesophagus or stage I gastro-oesophageal junction cancer in the usual care group. Among 1654 participants in the intervention group who swallowed the Cytosponge device successfully, 221 (13%) underwent endoscopy after testing positive for TFF3 and 131 (8%, corresponding to 59% of those having an endoscopy) were diagnosed with Barrett's oesophagus or cancer. One patient had a detachment of the Cytosponge from the thread requiring endoscopic removal, and the most common side-effect was a sore throat in 63 (4%) of 1654 participants. INTERPRETATION In patients with gastro-oesophageal reflux, the offer of Cytosponge-TFF3 testing results in improved detection of Barrett's oesophagus. Cytosponge-TFF3 testing could also lead to the diagnosis of treatable dysplasia and early cancer. This strategy will lead to additional endoscopies with some false positive results. FUNDING Cancer Research UK, National Institute for Health Research, the UK National Health Service, Medtronic, and the Medical Research Council.
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Affiliation(s)
- Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK.
| | - Massimiliano di Pietro
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Maria O'Donovan
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Roberta Maroni
- Cancer Research UK and King's College London Cancer Prevention Trials Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Beth Muldrew
- Cancer Research UK and King's College London Cancer Prevention Trials Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Irene Debiram-Beecham
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Marcel Gehrung
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Judith Offman
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Monika Tripathi
- MRC Cancer Unit, Hutchison-MRC Research Centre, University of Cambridge, Cambridge, UK; Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Benoit Aigret
- Cancer Research UK and King's College London Cancer Prevention Trials Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Fiona M Walter
- The Primary Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Greg Rubin
- Institute of Population Health Sciences, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Peter Sasieni
- Cancer Research UK and King's College London Cancer Prevention Trials Unit, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Tan MC, Mansour N, White DL, Sisson A, El-Serag HB, Thrift AP. Systematic review with meta-analysis: prevalence of prior and concurrent Barrett's oesophagus in oesophageal adenocarcinoma patients. Aliment Pharmacol Ther 2020; 52:20-36. [PMID: 32452599 PMCID: PMC7293564 DOI: 10.1111/apt.15760] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/12/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The proportions of patients with oesophageal adenocarcinoma (OAC) diagnosed by Barrett's oesophagus surveillance or with pre-existing Barrett's oesophagus are unclear. AIM To estimate the prevalence of prior and concurrent Barrett's oesophagus diagnosis among patients with OAC or oesophagogastric junction adenocarcinomas (OGJAC). METHODS We searched PubMed and Embase to identify studies published 1966-1/8/2020 that examined the prevalence of prior (≥6 months) or concurrent Barrett's diagnosis (at cancer diagnosis) among OAC and OGJAC patients. Random effects models estimated overall and stratified pooled prevalence rates. RESULTS A total of 69 studies, including 33 002 OAC patients (53 studies) and 2712 patients with OGJAC (28 studies) were included. The pooled prevalence of prior Barrett's oesophagus diagnosis in OAC was 11.8% (95% confidence interval [CI] 8.4%-15.6%). The prevalence of prior Barrett's oesophagus diagnosis was higher in single-centre resection studies (16.0%, 95% CI 8.7%-24.9%) than population-based cancer registry studies (8.4%, 95% CI 5.5%-11.9%). The prevalence of concurrent Barrett's oesophagus in OAC was 56.6% (95% CI 48.5%-64.6%). Studies with 100% early stage OAC had higher prevalence of concurrent Barrett's oesophagus (91.3%, 95% CI 82.4%-97.6%) than studies with <50% early OAC (39.7%, 95% CI 33.7%-45.9%). In OGJAC, the prevalence of prior and concurrent Barrett's oesophagus was 23.2% (95% CI 7.5%-44.0%) and 26.3% (95% CI 17.8%-35.7%), respectively. CONCLUSIONS Most patients with OAC have Barrett's oesophagus. Our meta-analysis found ~12% of OAC patients had prior Barrett's diagnosis, but concurrent Barrett's oesophagus was found in ~57% at the time of OAC diagnosis. This represents a considerable missed opportunity for Barrett's oesophagus screening.
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Affiliation(s)
- Mimi C. Tan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Nabil Mansour
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Donna L. White
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Amy Sisson
- The Texas Medical Center Library, Houston, Texas, USA
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Aaron P. Thrift
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Predicting Progression in Barrett's Esophagus: Is the Holy Grail Within Reach? Am J Gastroenterol 2020; 115:841-842. [PMID: 32287139 PMCID: PMC7274875 DOI: 10.14309/ajg.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Risk stratification in Barrett's esophagus may allow aggressive management of those at "high risk" and reduction in surveillance in at "low" risk. Davison et al. report the results of the independent validation of a multibiomarker panel (TissueCypher assay) performed on biopsy tissue, in a case control study. "High-risk" patients progressed 5 times more than those at "low risk." Sensitivity and specificity for "high-risk" patients were 29% and 86% with a positive predictive value of 23%. A negative predictive value of a "low-risk" score was 96%. These findings may allow more intensive surveillance in those at "high risk." Despite some limitations, this assay is a potentially major advance in the management of Barrett's esophagus patients without dysplasia.
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Franklin J, Jankowski J. Recent advances in understanding and preventing oesophageal cancer. F1000Res 2020; 9. [PMID: 32399195 PMCID: PMC7194479 DOI: 10.12688/f1000research.21971.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
Oesophageal cancer is a common cancer that continues to have a poor survival. This is largely in part due to its late diagnosis and early metastatic spread. Currently, screening is limited to patients with multiple risk factors via a relatively invasive technique. However, there is a large proportion of patients diagnosed with oesophageal cancer who have not been screened. This has warranted the development of new screening techniques that could be implemented more widely and lead to earlier identification and subsequently improvements in survival rates. This article also explores progress in the surveillance of Barrett’s oesophagus, a pre-malignant condition for the development of oesophageal adenocarcinoma. In recent years, advances in early endoscopic intervention have meant that more patients are considered at an earlier stage for potentially curative treatment.
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Affiliation(s)
- James Franklin
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
| | - Janusz Jankowski
- Gastroenterology and Endoscopy Department, Kings Mill Hospital NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
- University of Liverpool, Liverpool, UK
- University of Roehampton, London, UK
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Thiruvengadam SK, Tieu AH, Luber B, Wang H, Meltzer SJ. Risk Factors for Progression of Barrett's Esophagus to High Grade Dysplasia and Esophageal Adenocarcinoma. Sci Rep 2020; 10:4899. [PMID: 32184470 PMCID: PMC7078316 DOI: 10.1038/s41598-020-61874-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 03/01/2020] [Indexed: 12/17/2022] Open
Abstract
Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC). Methods of identifying BE patients at high risk for progression to high-grade dysplasia (HGD) or EAC are needed to improve outcomes and identify who will benefit most from intensive surveillance or ablative therapy. Clinical predictors of BE progression to HGD or EAC are poorly understood, with multiple contradictory studies. We performed a retrospective study which included 460 patients at Johns Hopkins Hospital who underwent at least 2 upper endoscopies 6 months apart showing biopsy-documented BE between 1992 and 2013. Patients with EAC or HGD at the initial endoscopy were excluded. Demographic, clinicopathological, and endoscopic data were collected. Univariate and multivariate Cox proportional hazards analyses with time to progression to HGD and EAC were performed. Among 460 patients included in the study, 132 BE patients developed HGD and 62 developed EAC. Significant EAC risk factors included age, abdominal obesity, caffeine intake, and the presence of HGD. Risk factors for HGD or EAC included age, caffeine intake, and low-grade dysplasia while colonic adenomas trended towards significance. Notably, a history of statin or SSRI usage reduced the risk of EAC or HGD by 49% or 61%, respectively. Our study validated several known and identified several novel risk factors, including a history of colonic adenomas or caffeine usage. Low-grade dysplasia was a risk factor for progression but various endoscopic characteristics were not, suggesting that screening strategies should focus on histology instead. We identified SSRIs as a new potentially chemoprotective medication.
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Affiliation(s)
| | - Alan H Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Gastroenterology and Hepatology, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Brandon Luber
- Division of Bioinformatics and Biostatistics, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hao Wang
- Division of Bioinformatics and Biostatistics, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stephen J Meltzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Graham DY, Tan MC. No Barrett's-No Cancer: A Proposed New Paradigm for Prevention of Esophageal Adenocarcinoma. J Clin Gastroenterol 2020; 54:136-143. [PMID: 31851107 DOI: 10.1097/mcg.0000000000001298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Esophageal adenocarcinoma is inflammation-associated cancer with a recognizable preneoplastic stage, Barrett's. Barrett's describes the metaplastic transformation of esophageal squamous mucosa into columnar epithelium that typically results secondary to mucosal damage caused by acidic gastroduodenal reflux. Continued acid reflux may then result in mucosal inflammation which results in progressive inflammation-induced genetic instability that may eventuate in esophageal adenocarcinoma. Barrett's is the only recognized precursor lesion to esophageal carcinoma. Barrett's mucosa is unique among preneoplastic lesions; ablation therapy results in restitution of a squamous epithelium reducing or eliminating accumulated genetic instabilities and resetting the biological clock progressing toward invasive cancer. However, recurrence of Barrett's after ablation is common. We propose that both Barrett's and recurrence of Barrett's after ablation can be prevented and discuss how current approaches to therapy for gastroesophageal reflux disease, for Barrett's screening, chemoprevention, and ablation therapy all might be reconsidered. We propose (1) improved approaches to Barrett's prevention, (2) universal Barrett's screening by linking Barrett's screening to colon cancer screening, (3) ablation of all Barrett's mucosa along with (4) acid-suppressive-antireflux therapy tailored to prevent development of Barrett's or the recurrence of Barrett's after ablation therapy. We propose that ultimately, treatment decisions for gastroesophageal reflux disease and prevention of Barrett's and esophageal carcinoma should be based on assessing and maintaining esophageal mucosal integrity. This will require development and verification of specific measurements that reliably correlate with prevention of Barrett's. We outline the new research and technical advances needed to cost-effectively achieve these goals.
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Affiliation(s)
- David Y Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX
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Yang Z, Wong IO, Deng W, Chen R, Zhou J, Wei W. Lead-time bias in esophageal cancer screening in high-risk areas in China. Chin J Cancer Res 2020; 32:467-475. [PMID: 32963459 PMCID: PMC7491548 DOI: 10.21147/j.issn.1000-9604.2020.04.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective To investigate what extent lead-time bias is likely to affect endoscopic screening effectiveness for esophageal cancer in the high-risk area in China. Methods A screening model based on the epidemiological cancer registry data, yielding a population-level incidence and mortality rates, was carried out to simulate study participants in the high-risk area in China, and investigate the effect of lead-time bias on endoscopic screening with control for length bias. Results Of 100,000 participants, 6,150 (6.15%) were diagnosed with esophageal squamous dysplasia during the 20-year follow-up period. The estimated lead time ranged from 1.67 to 5.78 years, with a median time of 4.62 years [interquartile range (IQR): 4.07−5.11 years] in the high-risk area in China. Lead-time bias exaggerated screening effectiveness severely, causing more than a 10% overestimation in 5-year cause-specific survival rate and around a 43% reduction in cause-specific hazard ratio. The magnitude of lead-time bias on endoscopic screening for esophageal cancer varied depending on the screening strategies, in which an inverted U-shaped and U-shaped effects were observed in the 5-year cause-specific survival rate and cause-specific hazard ratio respectively concerning a range of ages for primary screening. Conclusions Lead-time bias, usually causing an overestimation of screening effectiveness, is an elementary and fundamental issue in cancer screening. Quantification and correction of lead-time bias are essential when evaluating the effectiveness of endoscopic screening in the high-risk area in China.
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Affiliation(s)
- Zhao Yang
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong 999077, China
| | - Irene Ol Wong
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong 999077, China
| | - Wei Deng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ru Chen
- Cancer Registry Office, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
| | - Jiachen Zhou
- Cancer Registry Office, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China.,Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an 710061, China
| | - Wenqiang Wei
- Cancer Registry Office, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China.,Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
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