Age- and sex-specific yield of Barrett's esophagus by endoscopy indication

doi:10.1016/j.gie.2009.06.035

Gastrointestinal Endoscopy

Volume 71, Issue 1, January 2010, Pages 21-27

https://doi.org/10.1016/j.gie.2009.06.035 Get rights and content

Background

Barrett's esophagus is a precursor of esophageal adenocarcinoma, both of which are associated with GERD. Screening GERD patients for Barrett's esophagus has been suggested, but it is not known which patients should be screened and at what age.

Objective

To determine the age-specific yield of endoscopy for Barrett's esophagus stratified by sex and indication for endoscopy.

Design

Retrospective cross-sectional study.

Setting

National Endoscopic Database of the Clinical Outcomes Research Initiative (CORI).

Patients

A total of 155,641 patients undergoing their first endoscopy at one of the CORI sites for clinical indications.

Main Outcome Measurements

Age-specific yield of Barrett's esophagus.

Results

Among white men with GERD, the yield of Barrett's esophagus increases steeply from early adulthood (2.1% in the third decade of life) to middle adulthood (9.3% in the sixth decade) and then plateaus (the difference for the eighth decade minus the sixth decade is −1.1%; 95% CI, −3.9% to 1.7%). There is no difference in the yield of Barrett's esophagus between middle-aged white women with GERD and white men without GERD (difference is −0.46%; 95% CI, −1.23% to 0.31%).

Limitations

Possible bias by selection for endoscopy and the potential for misclassification of GERD status.

Conclusions

The yield of upper endoscopy for the diagnosis of Barrett's esophagus increases rapidly among white men with GERD until approximately age 50 and then reaches a plateau. White women with GERD are at no increased risk compared with white men without GERD.

Section snippets

CORI

CORI was established to study the use and outcomes of endoscopy in diverse practice settings. Sixty-five adult practice sites, representing 500 physicians, submit more than 250,000 reports annually to the CORI National Endoscopic Database, including 100,000 upper endoscopy reports. Practice sites include private practice (79% of reports), academic sites (10%), and Veterans Affairs sites (11%). All participating sites agree to use a standardized computerized report generator to create all

Results

The total study cohort comprised 155,641 unique patients undergoing a first documented upper endoscopy at one of 35 sites (Table 1). The majority were performed in the private practice setting on white non-Hispanics, with slightly more men than women. Overall, 48,476 (31.1%) were undergoing upper endoscopy for evaluation of GERD or screening for Barrett's esophagus (GERD screenees). Of the entire study cohort, 7804 (5.0%) were suspected by the endoscopist of having Barrett's esophagus, and

Discussion

From these retrospective analyses of a large, national endoscopic database, we found a substantially increased yield of Barrett's esophagus in middle adulthood compared with early adulthood among white men with GERD, with a plateau in yield after approximately age 50. It is therefore likely that the metaplastic event occurs at some point between the ages of 20 and 50 in most patients. Another important finding is the yield of endoscopy in women with GERD. In women younger than the age of 30, no

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Cited by (58)

Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis
2022, Gastroenterology
Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision.
We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained.
Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm.
The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.
Quality in Barrett's Esophagus: Diagnosis and Management
2022, Techniques and Innovations in Gastrointestinal Endoscopy
The field of Barrett's esophagus has been flourishing with major advances in quality clinical practices and technological innovations in both diagnosis and treatment. Gaps in the current screening practices have the potential to be addressed with novel nonendoscopic screening platforms. The foundation for diagnosis and detection in Barrett's esophagus is a high-quality endoscopic examination. These exam components can be summarized as the 5 L's: to identify and document Landmarks, measure and document Length of the Barrett's segment; to Look for subtle irregularities with careful inspection; to document and target visible Lesions; and finally assess each Level of Barrett's segment for occult or subtle dysplastic abnormalities using a protocol such as Seattle protocol. Key tools in endoscopic surveillance are a high-resolution endoscope and either chromoendoscopy with acetic acid or virtual chromoendoscopy. Available adjunctive techniques for detection include other enhanced endoscopic imaging, wide area transepithelial sampling, and tissue-based biomarkers, and artificial intelligence is just on the horizon. Endoscopic eradication therapy is now positioned as the standard strategy for high grade dysplasia and intramucosal carcinoma in Barrett's esophagus in an organ sparing approach. Selected patients with confirmed low-grade dysplasia may also benefit from treatment. Tissue acquiring approaches include endoscopic mucosal resection and endoscopic submucosal dissection. Nontissue acquiring modalities include radiofrequency ablation, cryotherapy, and hybrid APC. This comprehensive review details best practices for diagnosis and treatment in Barrett's esophagus and highlights innovations that are poised for the clinical arena.
Progress in Screening for Barrett's Esophagus: Beyond Standard Upper Endoscopy
2021, Gastrointestinal Endoscopy Clinics of North America
Optimizing Management of Patients With Barrett's Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling
2020, Clinical Gastroenterology and Hepatology
Citation Excerpt :
These studies were limited by the use of a single model/natural history,8,9 and they examined fewer competing management strategies. In our analysis, we simulated cohorts of 60-year-old BE patients because the mean/median age of BE patients at diagnosis is older than 60 years.23,24 In all strategies, the stop age of surveillance was assumed to be 80 years.
Endoscopic treatment is recommended for patients with Barrett’s esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients.
We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY).
In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY).
Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.
Validation and Comparison of Tools for Selecting Individuals to Screen for Barrett's Esophagus and Early Neoplasia
2020, Gastroenterology
Guidelines suggest endoscopic screening of individuals who are at increased risk for Barrett’s esophagus (BE) and esophageal adenocarcinoma. Tools based on clinical factors are available for identifying patients at risk, but only some have been validated. We aimed to compare and validate available tools.
We performed a prospective study of 1241 patients, ages 40 to 79 years, presenting either for their first esophagogastroduodenoscopy (EGD) or their first endoscopic therapy of early neoplastic BE, from April 2015 through June 2018. We calculated risk scores for 6 previously published tools (the Gerson, Locke, Thrift, Michigan BE pREdiction Tool [M-BERET], Nord-Trøndelag Health Study [HUNT], and Kunzmann tools). We also investigated the accuracy of frequency and duration of gastroesophageal reflux disease (GERD), using data from a randomly selected 50% of patients undergoing their first EGD. We compared the ability of all these tools to discriminate patients with BE and early neoplasia from patients without BE, using findings from endoscopy as the reference standard.
BE was detected in 81 of 1152 patients during their first EGD (7.0%). GERD symptoms alone identified patients with BE with an area under the receiver operating characteristic curve (AuROC) of 0.579. All of the tools were more accurate in identifying patients with BE than the frequency and duration of GERD (AuROC for GERD, 0.579 vs range for other tools, 0.660–0.695), and predicted risk correlated well with observed risk (calibration). The AUROCs of the HUNT tool (0.796), the M-BERET (0.773), and the Kunzmann tool (0.763) were comparable in discriminating between patients with early neoplasia (n = 94) vs no BE. Each tool was more accurate in discriminating BE with early neoplasia than GERD frequency and duration alone (AuROC, 0.667; P < .01).
The HUNT, M-BERET, and Kunzmann tools identify patients with BE with AuROC values ranging from 0.665 to 0.695, and discriminate patients with early neoplasia from patients without BE with AuROC values ranging from 0.763 to 0.796. These tools are more accurate than frequency and duration of GERD in identifying individuals at risk for neoplastic BE.
Low Prevalence of Suspected Barrett's Esophagus in Patients With Gastroesophageal Reflux Disease Without Alarm Symptoms
2019, Clinical Gastroenterology and Hepatology
Citation Excerpt :
Participating endoscopists use a structured computerized endoscopic report generator to produce endoscopic reports. The data that are transmitted from the local site to the National Endoscopic Database do not contain most patient or provider identifiers and qualify as a Limited Data Set under 45 C.F.R. Section 164.514(e).8 After completion of quality control checks, data from all sites are merged in the data repository for analysis.
Esophagogastroduodenoscopy (EGD) is frequently used to evaluate gastroesophageal reflux disease (GERD) without alarm symptoms, although the benefits are not clear. We aimed to determine the prevalence of uncomplicated GERD as an indication for EGD, the demographic characteristics of these patients, and the endoscopic outcomes of these procedures.
We collected endoscopy data from a large national database of 543,103 EGDs performed at 82 sites from 2003 through 2014. We identified patients with GERD without alarm symptoms (dysphagia, bleeding, vomiting, or weight loss). Endpoints included the prevalence of endoscopically suspected Barrett’s esophagus (sBE) and suspected long-segment BE (sLSBE), defined as ≥3 cm.
We found that 73,535 EGDs (13.5%) were performed for a primary indication of GERD without alarm symptoms: only 4122 patients (5.6%) had sBE, and of these, 24.2% had sLSBE. Significant risk factors for sBE and sLSBE included male sex, age, and white race. Other findings included peptic ulcers in 1337 patients (1.8%) and suspected tumors (47 esophageal, 42 gastric, 13 duodenal tumors, 2 others) in 101 patients.
In an analysis of a large cohort of patients undergoing EGD, uncomplicated GERD accounted for almost 14% of EGDs; within this population, only 23.6% were white men older than 50 years, who have an increased risk of BE and esophageal adenocarcinoma. The prevalence of sBE is lower than in prior time periods—this raises questions about the utility of EGD to detect BE in patients with uncomplicated GERD. Guidelines for management of uncomplicated GERD should account for these observations.

View all citing articles on Scopus

: DISCLOSURE: The following authors received research support for this study: G. Eisen: Executive Codirector of CORI, a nonprofit organization that receives funding from federal and industry sources; CORI has received support from the following entities to support the infrastructure of the practice-based network: AstraZeneca, Bard International, Pentax USA, ProVation, Endosoft, GIVEN Imaging, and Ethicon. The commercial entities had no involvement in this research. This potential conflict of interest has been reviewed and managed by the Oregon Health and Science University Conflict of Interest in Research Committee. All other authors disclosed no financial relationships relevant to this publication. This project was supported with funding from NIDDK UO1 CA 89389-01 and R33-DK61778-01. J.H.R. is the Damon Runyon-Gordon Family Clinical Investigator and is supported in part by the Damon Runyon Cancer Research Foundation (CI-36-07), and was supported by NIDDK 1K23DK079291.

: If you would like to chat with an author of this article, you may contact Dr. Rubenstein at [email protected].

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Original articleClinical endoscopyAge- and sex-specific yield of Barrett's esophagus by endoscopy indication

Background

Objective

Design

Setting

Patients

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

CORI

Results

Discussion

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastroenterology

Am J Gastroenterol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Clin Gastroenterol Hepatol

Am J Gastroenterol

Clin Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Original article
Clinical endoscopy
Age- and sex-specific yield of Barrett's esophagus by endoscopy indication