Treatment of Barrett's esophagus with high-grade dysplasia

Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process

BACKGROUND & AIMS

Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA.

METHODS

We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement.

RESULTS

Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated.

CONCLUSIONS

We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

The safety and effectiveness of endoscopic and non-endoscopic approaches to the management of early esophageal cancer: a systematic review

INTRODUCTION

Traditionally, management of early cancer (stages 0-IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer.

METHODS

A systematic review of peer-reviewed studies was performed using Cochrane guidelines. Bibliographic databases searched to identify relevant English language studies published in the last 3 years included: PubMed (i.e., MEDLINE and additional sources), EMBASE, CINAHL, The Cochrane Library, the UK Centre for Reviews and Dissemination (NHS EED, DARE and HTA) databases, EconLit and Web of Science. Web sites of professional associations, relevant cancer organizations, clinical practice guidelines, and clinical trials were also searched. Two independent reviewers selected, critically appraised, and extracted information from studies.

RESULTS

The review included 75 studies spanning 3124 patients and 10 forms of treatment. Most studies were of short term duration and non-comparative. Adverse events reported across studies of endoscopic techniques were similar and less significant compared to those in the studies of non-endoscopic techniques. Complete response rates were slightly lower for photodynamic therapy (PDT) relative to the other endoscopic techniques, possibly due to differences in patient populations across studies. No studies compared overall or cause-specific survival in patients who received endoscopic treatments vs. those who received non-endoscopic treatments.

DISCUSSION

Based on findings from this review, there is no single "best practice" approach to the treatment of early esophageal cancer.