Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Gastroesophageal reflux disease (GERD) is a common condition, and we know that it is associated with a condition called Barrett’s esophagus, which is a precancerous condition. But when is it appropriate to send patients [with GERD] for endoscopy to screen them for Barrett’s esophagus? New recommendations come from the American College of Physicians (ACP), who put forth a very pragmatic document titled “Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians.”

As background, we know that reflux disease is very common. Nearly 40% of the US population has a symptom of reflux disease, such as heartburn or regurgitation, at least once a month. And we know that nearly 10% to 15% of those patients experience those symptoms at least weekly, and often more than that. But if you said that everyone with reflux needs to be screened for Barrett’s esophagus, unless that disease was very prevalent and very high risk for progression to cancer, the wheels would come off very quickly from a cost-containment standpoint and in health economics evaluations.

Although we screen and survey for Barrett’s esophagus, we have no data from longitudinal studies that show that we reduce the risk for esophageal cancer or cancer-related death in the patients who undergo surveillance strategies.

We know from recent epidemiologic studies from Europe that for patients with nondysplastic Barrett’s, without low-grade or high-grade dysplasia, those patients have a 0.1% to 0.5% per patient-year risk of progression to more serious disease and cancer. For patients with high-grade dysplasia, the risks are considerably higher: up to 6% to 19% per patient-year. Those patients obviously need to be seen and undergo ablative strategies. Nonetheless, for the overall population of patients with Barrett’s, the risk of progressing to cancer is fairly low. Finally, if you focus only on heartburn, 40% of patients with esophageal cancer do not report any heartburn, so we cannot use heartburn as a predominant screening tool.

There are demonstrable risk factors for Barrett’s esophagus, however, and factors that relate to Barrett’s progressing to cancer. We know [that Barrett’s-related cancer is] a fairly prevalent disease, with a particular bias toward men. More than 80% of the cancers are in men. We know that it has a gender- and age-related bias for men over the age of 50. If we look at patients and say “gastroesophageal reflux disease in men,” there starts to be a strategic risk stratification toward that population. But if you look at women, the risk stratification is not there. In fact, women with GERD have less cancer risk than men who have asymptomatic GERD. Therefore, screening women for Barrett’s esophagus and risk for Barrett’s cancer is equivalent to screening men for breast cancer. When a woman mentions that she has reflux disease and you say, “Bingo. You need to be screened for Barrett’s,” think about it: Do you screen your men for breast cancer? Women, even if they have symptomatic reflux, have the same risk [for esophageal cancer] as men have for breast cancer. This is important as we weigh the cost and economic strategies and as we come to the best practice recommendations from the ACP.

What are the ACP recommendations? First, if patients have classic alarm features — dysphagia; heartburn associated with complications such as bleeding, nausea, and vomiting; obstructive symptoms; or weight loss — those warrant endoscopy. That is a no-brainer. Second, if patients have severe or erosive esophagitis when they undergo endoscopy, and it is not clear whether there is Barrett’s when they have the endoscopy, it is reasonable to bring those people back to document whether they do or do not have Barrett’s. That is true for men and women.

Patients who are not responding to 4-8 weeks of twice-daily dosing of a proton pump inhibitor (PPI), or to once-daily dosing of the extended-release dexlansoprazole, should undergo endoscopy. I think that is a reasonable, pragmatic recommendation. Also, if patients have a history of stricture and have recurrent symptoms, the ACP recommends that those patients be referred for endoscopy.

The rubber hits the road when it gets to “whom do you screen for Barrett’s?” In no circumstance do they recommend that women without alarm features be screened for Barrett’s esophagus. Based on the evidence, that is very pragmatic and gets back to screening men for breast cancer. ACP recommends that men over age 50 years, including those with GERD symptoms but no alarm features, men who have hiatal hernia, and those with some other cofactor, such as smoking, should be screened. We do know that truncal obesity is not as much a risk as is abdominal obesity. So, patients who are obese, who are smokers, who are overweight, who have an elevated body mass index, who are male and over age 50, and who have GERD symptoms — those are patients who should be considered for one-time endoscopy screening for Barrett’s. If they do not have Barrett’s, they do not need to come back.

These best practice strategies should lead to refinements in the referrals from primary care to gastroenterologist. When patients are sent in to be screened for Barrett’s esophagus, it is hard for us to say no to our primary care colleagues. We need to start to turn off the spigot at the home base. Lest we throw stones, however, gastroenterologists also overutilize Barrett’s surveillance strategies. We know that from a number of studies. We need to start being a better team, defining the patients for appropriate screening, and using more cost-economic evaluations. I suspect we would see no change in clinical outcomes. These are best practice recommendations. I hope these will guide you in your next discussions with patients who have GERD when they say, “Isn’t this associated with esophageal cancer? Do I need to be screened?” We can start to put some evidence behind our recommendations. These guidelines from the ACP go a long way toward that; they are written by an excellent group of experts and provide pragmatic recommendations that we can use in our clinical practices.

I am Dr. David Johnson. Thank you again for listening.

References

Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; for the Clinical Guidelines Committee of the American College of Physicians. Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157:808-816.