Barrett's esophagus precedes esophageal cancer, but not all patients require removal of abnormal cells

The new American Gastroenterological Association (AGA) Clinical Practice for Endoscopic Eradication Therapy of Barrett's Esophagus and Associated Neoplasia, published in the Journal of Gastroenterology sets updated recommendations for patients with Barrett's esophagus.

Barrett's esophagus, a precursor to esophageal cancer, is a condition in which cells in the esophagus are replaced by non-carcinogenic abnormal cells. These cells can progress to a condition called dysplasia, which in turn can become cancerous. Dysplasia is considered low-grade or high-grade depending on the degree of cellular changes.

"Although the benefit is clear for patients with high-grade dysplasia, we suggest considering endoscopic eradication therapy for patients with low-grade dysplasia after a clear discussion of the risks and benefits of endoscopic therapy," said guideline author Dr. Tarek Savvas, assistant professor of internal medicine at Southwestern Medical Center University of Texas.

"A patient-centered approach promotes shared decision making about treatment, taking into account both medical evidence and the patient's preferences and values. Surveillance is a reasonable option for patients who place greater value on harms and less value on uncertain benefits in reducing cancer mortality esophagus."

Endoscopic eradication therapy involves minimally invasive procedures such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), followed by ablation techniques (burning or freezing).

Key management takeaways:

• For patients with low-grade dysplasia, either cell removal or cell monitoring may be appropriate. This decision should be made jointly by doctors and patients after discussing the risks and benefits of treatment.
• For patients with high-grade dysplasia, the AGA recommends endoscopic therapy to remove abnormal precancerous cells. Most patients undergoing endoscopic eradication can be safely treated with EMR, which has a lower risk of adverse events.
• Patients undergoing ESD may face an increased risk of strictures and perforations. The AGA recommends using ESD primarily for lesions suspected of having cancer invading deeper into the esophageal wall or for those in whom EMR has failed.
• Patients with Barrett's esophagus (dysplasia or early cancer) should be treated and followed by experienced endoscopists and pathologists experienced in Barrett's neoplasia.

"We need to have discussions with patients in the clinic before they end up in the endoscopy unit on a stretcher. Patients need to be fully aware of the risks and benefits in both the short and long term to decide on the best approach for them "This decision often comes down to personal factors and values," added guide author Dr. Joel Rubenstein, director of the Barrett's Esophagus Program at the University of Michigan.

The guide provides the following general implementation guidelines:

• Smoking and obesity are risk factors for esophageal adenocarcinoma, so counseling patients to quit smoking and lose weight may help improve outcomes.
• In patients with Barrett's esophagus, reflux control should be optimized with both medication and lifestyle changes.