BARRETT'S ESOPHAGUS NEW GUIDELINES 

July 30, 2012 — An international group of almost 100 experts has developed consensus statements on the best ways to diagnose and treat esophageal precancer and early cancer, with their statements published in the August issue of Gastroenterology. Esophageal adenocarcinoma (EA) has become more common in the last few decades among patients with Barrett's esophagus (BE), yet EA remains rare, and little agreement has been reached on how to treat or prevent the deadly cancer, the researchers write.

Cathy Bennett, from Queens University, Belfast, United Kingdom, and colleagues conducted a review and analysis of 11,904 papers and put draft statements through an anonymous 4-vote process to develop statements strongly agreed or agreed to by at least 80% of experts on the consensus panel. Of 91 draft statements developed during the evidence-based Delphi process, 81 achieved consensus, and the researchers arrived at 20 final statements on diagnosis, epidemiology, surveillance, treatment, and prevention of BE, high-grade dysplasia (HGD), and EA.

Many of the statements focus on having good endoscopy equipment, use of endoscopy rather than open surgery, and the importance of tissue sampling. For BE and EA endoscopy, physicians insert a thin tube with a video camera and necessary instruments into the throat, which avoids the need for chest surgery.

Eight of the statements, summarized below, are directly applicable to the clinic today:

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.

"This work represents the most far-reaching, inclusive, and informative consensus process on evaluation and management of BE with HGD/early cancer published to date," the researchers write. "Most of the findings are clinically relevant and the high degree of consensus achieved for most of the questions indicates that many of the statements are appropriate for immediate use in guiding clinical activity."

The researchers also write that the consensus process revealed some areas in which "urgent research is needed, including evaluation of genetic markers to determine cancer risk," and that much of the published research they analyzed is of moderate or poor quality.

In an editorial published in the same journal issue, Rebecca C. Fitzgerald, MD, from the MRC Cancer Cell Unit, Hutchison-MRC Research Centre in Cambridge, United Kingdom, and Joel H. Rubenstein, MD, from the Division of Gastroenterology at the University of Michigan Medical School in Ann Arbor, note, "Rather than definitive, omniscient guidance, the end result of the consensus document can best be viewed as a synthesis of interpretations of an imperfect knowledge base by a set of experts at a particular point in time. Until higher quality studies are conducted, the consensus recommendations are a commendable effort to summarize the best available data for management of patients with early neoplastic Barrett's esophagus."

The researchers write that EA is the most rapidly growing cause of cancer deaths and that people with BE are at least 20 times more likely to progress to EA than people without BE, which "is defined as the replacement of distal esophageal squamous mucosa with metaplastic columnar epithelium," the researchers write. Still, EA's rarity means that many gastroenterologists may see few or no patients with the disease, which highlights the importance of having consensus guidelines.

Potential limitations of the study include the underrepresentation of some geographical areas and not using a standard template for comments from experts, the authors note.

Funding for the research was provided by the International Society of Diseases of the Esophagus, British Society of Gastroenterology, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Association of Upper Gastrointestinal Surgeons, Fight Oesophageal Reflux Together, German Society of Endoscopy, Netherlands Association of Hepatogastroenterologists, and Oesophageal Cancer Fund of Ireland. Full conflict of interest information is provided on the journal's Web site. The editorialists have disclosed no relevant financial relationships.

Gastroenterology. 2012;143:282-284, 336-346. Article full text, Editorial full text