Alternatives to Traditional Per-Oral Endoscopy for Screening

Barrett’s esophagus (BE) predisposes patients to esophageal adenocarcinoma. 3 to 6% of individuals with gastro-esophageal reflux disease are estimated to have BE but only 20 to 25% of BE patients are currently diagnosed. The current gold standard for diagnosis of BE is per-oral upper GI endoscopy. As this is not suitable for large-scale screening, a number of alternative methods are currently being investigated: transnasal and video capsule endoscopy, endomicroscopy, cell collection devices like the cytosponge and biomarkers. Some of these are promising, however, well powered studies carried out in relevant screening populations are needed.

Key points

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Currently, diagnosis of Barrett’s esophagus (BE) is dependent on endoscopy; however, this is not suitable for large-scale screening due to the invasive and expensive nature of the test.
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Less invasive tools such as transnasal and video capsule endoscopy are promising alternatives, but high costs are prohibitive for large-scale screening at the moment.
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Nonendoscopic screening methods are less invasive than endoscopic methods and can be more readily carried out in primary care, resulting in higher acceptability for patients.
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Large, randomized trials in the primary care setting are required to determine whether screening for BE is feasible and effective.

Introduction

The incidence of gastroesophageal reflux disease (GERD) has increased worldwide in the last 40 years. One of the complications of GERD is Barrett’s esophagus (BE), where esophageal squamous epithelium is replaced with columnar epithelium (metaplasia), a process that can be viewed as a teleologic adaptation to reflux. BE predisposes patients to esophageal adenocarcinoma (EAC), a cancer with a very poor prognosis, carrying an overall 5-year survival of less than 15%. Furthermore, the incidence of EACs has increased dramatically in high-income countries in the last 30 years. Because GERD and obesity, which are the main risk factors linked to BE and EAC, are still increasing, EAC rates have been projected to also further increase.

More than 50% of EAC cases are diagnosed in patients with GERD, who are presenting with alarm symptoms when the cancer is typically advanced. Furthermore, it is estimated that only 20% to 25% of patients with the premalignant condition BE are diagnosed. Hence, there is little chance of altering the population mortality from EAC through BE surveillance and endoscopic treatment regimens. For those patients who are diagnosed with BE, the impact of surveillance programs is controversial. However, when performed well, surveillance of BE patients can significantly improve EAC outcomes, including cancer-related mortality, especially more recently using outpatient-based endoscopic therapies for early disease, which obviate the requirement for surgical intervention. The question therefore arises whether screening could reduce mortality from esophageal cancer. Screening should be aimed at detecting early stage cancer, when it is easier to treat, or precancerous stages, when development of cancer can be prevented by removing the precancerous lesion. Screening programs have already been implemented for several cancers, for example, cervical or breast cancer.

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