Implemention of minimally invasive nonendoscopic detection of Barrett esophagus, combined with improved detection of dysplasia, may lead to more complete identification of patients who are at risk for esophageal adenocarcinoma, according to an opinion article in Annals of Internal Medicine.
Professional societies currently recommend endoscopic screening followed by endoscopic surveillance for the detection of dysplasia or early-stage esophageal adenocarcinoma, as retrospective study results suggest that this modestly improves mortality related to esophageal adenocarcinoma. However, the increasing mortality rates and incidences of esophageal adenocarcinoma have not been appropriately modified using this strategy.
“In fact, 90% of patients with [esophageal adenocarcinoma] continue to be diagnosed outside screening and surveillance programs despite the presence of [Barrett esophagus] in 60% of [esophageal adenocarcinomas] at diagnosis,” the authors of the article noted.
Reasoning behind these disparities may be due to some patients lacking key symptoms associated with esophageal adenocarcinoma, the lack of endoscopic evaluation of patients at risk for Barrett esophagus, and the expenses and limitations associated with endoscopy.
These, and additional factors, have led to the need for a paradigm shift in Barrett esophagus screening and early detection of dysplasia or esophageal adenocarcinoma in this patient population.
One such noninvasive esophageal sampling device that is being studied is a capsule-enclosed, compressed, spherical piece of string-attached polyurethane foam that deposits into the stomach approximately 5 minutes after swallowing. These devices may also be balloons, and allow for esophageal cytology samples to be analyzed for biomarkers that are linked to Barrett esophagus and esophageal adenocarcinoma.
These devices, although not commercially available yet, are swallowable by more than 90% of patients, do not require sedation, and can be administered by a nurse in an office setting, according to case-control studies that have been conducted in referral populations.
In addition to the cost-effectiveness of these devices, these tests increased diagnosis of Barrett esophagus, early-stage esophageal adenocarcinoma, and dysplasia in a large community-based clinical trial conducted in the UK.
Although increasing access and participation to these minimally invasive tests can lead to improvements in detection rates, the risk for false-positive results, patient anxiety, medical expenses for confirmation testing, and potential adverse effects from endoscopic evaluation must all be taken into consideration.
“[I]nnovative methods for dysplasia detection in [Barrett esophagus], including improvements in mucosal sampling and advanced imaging or artificial intelligence approaches in combination with biomarkers, will need to be paired with improved risk prediction of progression to [esophageal adenocarcinoma] in patients with [Barrett esophagus] but without dysplasia to increase the effectiveness of endoscopic surveillance,” the authors noted.
“[E]ncouraging progress in the nonendoscopic detection of [Barrett esophagus] will potentially lead to a more complete identification of those at risk for [esophageal adenocarcinoma] and, when paired with improved dysplasia detection and risk prognostication, could lead to meaningful advances in [esophageal adenocarcinoma] outcomes, an elusive goal for many decades,” concluded the authors.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Iyer PG, Katzka DA. Nonendoscopic detection of Barrett esophagus and esophageal adenocarcinoma: recent advances and implications. Ann Intern Med. Published online May 4, 2021. doi: 10.7326/M20-7164