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AGA Clinical Practice Update on Reducing Rates of Post-Endoscopy Esophageal Adenocarcinoma: Commentary

  • Sachin Wani
    Correspondence
    Correspondence Address correspondence to: Sachin Wani, MD, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Mail Stop F735, 1635 Aurora Court, Room 2.031, Aurora, Colorado 80045. fax: 720-848-2749.
    Affiliations
    Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
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  • C. Prakash Gyawali
    Affiliations
    Division of Gastroenterology, Washington University in St Louis, St Louis, Missouri
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  • David A. Katzka
    Affiliations
    Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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      Esophageal adenocarcinoma (EAC) has sobering incidence and mortality statistics over the last several decades. The incidence of EAC has risen 7-fold from 1975 to 2016, according to data from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute.
      • Kolb J.
      • Han S.
      • Scott F.I.
      • et al.
      Early onset esophageal adenocarcinoma presents with advanced stage disease but has improved survival compared with older individuals.
      Despite screening and surveillance programs and improved treatment paradigms for Barrett’s esophagus (BE), as much as 40% of EACs present with advanced disease, with a dismal 5-year survival rate.
      • Thrift A.P.
      Barrett's esophagus and esophageal adenocarcinoma: how common are they really?.
      Several factors contribute to this. Curable EAC has no reliable presenting symptom, and population-based screening of at-risk individuals is not effective because of low EAC incidence. Targeted screening for BE within gastroesophageal reflux disease (GERD) populations also has limitations, as only 7%–10% of individuals with chronic GERD have BE, nearly 40% of EAC patients describe no history of GERD, and up to 50% of patients with short-segment BE lack GERD symptoms.
      • Qumseya B.
      • Sultan S.
      • et al.
      ASGE Standards of Practice Committee
      ASGE guideline on screening and surveillance of Barrett's esophagus.
      In addition, use of endoscopy as a screening tool is compromised by expense, facility/physician expertise needed, and limited effectiveness, because >90% of EACs do not have a prior BE diagnosis.
      • Spechler S.J.
      • Katzka D.A.
      • Fitzgerald R.C.
      New screening techniques in barrett's esophagus: great ideas or great practice?.
      Broadening the at-risk population to include risk factors independent of GERD (age >50 years, male sex, white race, cigarette smoking, and central obesity) would incur increased resource utilization, costs, and potential harm from endoscopy.

      Abbreviations used in this paper:

      ADR (adenoma detection rate), AGA (American Gastroenterological Association), BE (Barrett’s esophagus), CRC (colorectal cancer), DDR (dysplasia detection rate), EAC (esophageal adenocarcinoma), GERD (gastroesophageal reflux disease), HGD (high-grade dysplasia), NDR (neoplasia detection rate), PCCRC (post-colonoscopy colorectal cancer), PEEC (post-endoscopy esophageal adenocarcinoma)
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