American Family Physician,
Feb 15, 2005
by Mark Ebell
Clinical Question: Which men with Barrett's esophagus are at greatest risk of progression to high-grade dysplasia or cancer?
Setting: Outpatient (specialty)
Study Design: Cohort (prospective)
Synopsis: The authors identified 550 patients who underwent
endoscopy for any reason and were diagnosed with Barrett's esophagus
between 1990 and 2003. The study took place at a Veterans Affairs
hospital, 99 percent of participants were men, and 93 percent were
white. Patients ranged in age from 28 to 86 years (mean age = 63
years). At the initial endoscopy, 77 percent had no dysplasia, 18
percent had low-grade dysplasia, and 5 percent had unifocal high-grade
dysplasia. Helicobacter pylori infection was absent in 345 patients,
present in 72 patients, and a history of H. pylori eradication was
identified in 60 patients. Patients with cancer, dysplasia-associated
lesion or mass, or intramucosal cancer at enrollment were excluded (n =
28).
Of the 550 patients initially identified, 28 had a diagnosis of
malignancy, 173 had no follow-up endoscopy, 15 died from other causes,
and 10 were lost to follow-up, leaving 324 for the study. It is unknown
whether outcomes were assessed blindly. Patients with newly diagnosed
low-grade dysplasia or unifocal high-grade dysplasia had optimized
medical therapy and were re-endoscoped at 12 to 24 weeks (for patients
with low-grade dysplasia) or four to eight weeks (for patients with
high-grade dysplasia). Patients with persistent high-grade dysplasia
had surveillance at three- to six-month intervals, while those with
low-grade dysplasia or regression to normal had surveillance at six- to
12-month intervals. Although patients were followed for up to 130
months based on the Kaplan-Meier curves, the mean or median duration of
follow-up or the number of follow-up endoscopies was not given.
Results were presented in several ways. Independent risk factors
for high-grade dysplasia or cancer at the initial endoscopy
were
increased age, greater length of Barrett's esophagus (especially
greater than 6 cm), and never having been diagnosed with H. pylori
infection. The independent risk factors for progression of Barrett's
esophagus to high-grade dysplasia or cancer were length, initial
histology, histology at follow-up, and H. pylori status. The risk was
low for patients with no dysplasia on the initial endoscopy (i.e., 2.4
percent if the length is less than 6 cm; 6.8 percent if the length is
more than 6 cm) or with low-grade dysplasia only (i.e., 5.3 percent
with length of less than 6 cm). All other groups had at least a 35
percent risk of progression.
Bottom Line: Patients with no dysplasia on the initial endoscopy or
with low-grade dysplasia only and Barrett's esophagus length of less
than 6 cm have a very low risk of progression to high-grade dysplasia
or malignancy. (Level of Evidence: 2b)
Study Reference: Weston AP, et al. Risk stratification of Barrett's
esophagus: updated prospective multivariate analysis. Am J
Gastroenterol September 2004;99:1657-66.
Used with permission from Ebell M. Length and dysplasia predict BE
progression in men. Accessed online November 24, 2004, at:
http://www.InfoPOEMs.com.
COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group
