Abstract
Background and Aims
Less than 10% of patients diagnosed with esophageal adenocarcinoma have a pre-existing Barrett’s esophagus (BE) diagnosis, possibly due to suboptimal performance of guidelines. We examined the prevalence of BE in a previously unscreened primary care population and the potential yield of practice BE screening guidelines.
Methods
This was a retrospective analysis of a prospective cross-sectional study of consecutively recruited unreferred patients from primary care clinics who underwent study upper endoscopy. We examined the performance of BE screening guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and our own modification of guidelines.
Results
We identified 44 BE cases and 469 controls (prevalence, 8.6%). Among 371 patients without GERD symptoms, 25 (6.7%) had BE. The AGA guidelines requiring ≥2 BE risk factors had sensitivity of 100% and specificity of only 0.2%, whereas ACG, ASGE, ESGE, and BSG guidelines (all requiring GERD first) had low sensitivities (38.6%−43.2%), specificities ranging 67.4% to 76.5%, and area under the receiver operating curve (AUROC) of 0.50 to 0.60. Our 2-pronged approach depending on presence of GERD symptoms or absence of GERD symptoms but with other risk factors achieved sensitivity of 81.8%, specificity of 51.2%, and AUROC of 0.66.
Conclusions
Over half of BE cases were without frequent GERD symptoms, but virtually all had at least one known BE risk factor. Practice guidelines requiring GERD symptoms have low sensitivity, whereas those not requiring GERD have low specificity. We have proposed a screening guideline with better use of known risk factors.
Keywords: Barrett’s esophagus, screening, esophageal cancer, epidemiology, practice guidelines
INTRODUCTION
The incidence of esophageal adenocarcinoma has increased over the past 5 decades in Europe, North America, and Australia.1,2 Barrett’s esophagus (BE), a condition in which normal squamous epithelium in the lower esophagus is replaced with columnar intestinal epithelium, is the only known precursor to esophageal adenocarcinoma.3 BE carries a 30- to 125-fold greater risk of esophageal adenocarcinoma compared with the general population.4
Risk factors for BE include frequent gastroesophageal reflux disease (GERD) symptoms, age >50 years, male gender, non-Hispanic white race, tobacco smoking, and obesity (particularly abdominal obesity).5–7 Despite guidelines recommending screening for BE in patients with a combination of these risk factors,8 <10% of patients with newly diagnosed esophageal adenocarcinoma have a pre-existing BE diagnosis.9 This may be due to underused screening with current practice guidelines, inadequate performance characteristics of these guidelines, or unidentified risk factors.10
Most studies that examined BE risk factors evaluated patients referred for endoscopy as part of clinical care, and therefore these patients were likely symptomatic or had other risk factors for gastroesophageal diseases (eg, dyspepsia, older age, smoking, and anemia). Consequently, previously identified BE risk factors that are included in practice guidelines may not be as relevant for predicting BE in patients not referred for endoscopy. Few studies have examined BE risk factors in populations not primarily referred for endoscopy for clinical indications. In 2002, Gerson et al11 consecutively recruited 110 participants without GERD symptoms who were scheduled for colorectal cancer screening to undergo upper endoscopy at the same time as flexible sigmoidoscopy. Of the 110 participants, 27 (24.5%) had BE. In that study of asymptomatic individuals, increased body mass index (BMI) was not associated with risk of BE; however, waist-to-hip ratio (WHR) was not examined.7 Smoking and family history of GERD/BE were not associated with BE. Another study of 961 patients scheduled for screening colonoscopy with no prior history of upper endoscopy reported an overall BE prevalence of 6.8% and 5.6% in a subset of 556 patients without GERD symptoms.12 No analysis was done to identify predictors of BE in patients without GERD. Additionally, a population-based study of 1,000 randomly sampled individuals from northern Sweden found an overall BE prevalence of 1.6%; alcohol and smoking were found to be independently associated with BE.13 Last, a cross-sectional study of 215 employees at a single Veteran Affairs center invited for study endoscopy found only 1 subject with BE (prevalence, 0.4%) and did not examine for BE risk factors.14
No studies have examined the yield of clinical practice guidelines on BE screening. Applying the criteria of practice guidelines in a study in which all comers were screened for BE irrespective of symptoms or referral bias is an appropriate setting to examine the performance characteristics of these guidelines. We, therefore, performed a large, single-center cross-sectional study to examine the prevalence of BE in a previously unscreened primary care population and test the potential yield of current practice guidelines as well as our proposed modifications of these guidelines.
METHODS
Study Population
This is a retrospective analysis of data from a prospective cross-sectional study performed at the Michael E. DeBakey Veteran Affairs Medical Center (MEDVAMC) in Houston, Texas.7 Briefly, we recruited consecutive ambulatory patients from 7 primary care clinics at the MEDVAMC who were eligible for screening colonoscopy from September 1, 2008 to May 8, 2012 to also undergo an upper endoscopy at the time of their screening colonoscopy. None of the patients were primarily referred for endoscopy, and all were approached at the primary care clinic visit and not at the time of colonoscopy. Study eligibility was based on the following: (1) age between 50 and 80 years; (2) no previous or current gastroesophageal surgery or cancer; (3) no active lung, colon, or breast cancer; (4) no current use of anticoagulants, which would be a relative contraindication for mucosal biopsy during endoscopy; (5) no significant liver disease indicated by platelet count <70,000, ascites, or known gastroesophageal varices; and (6) no history of major stroke or mental condition that would limit the ability to answer questions. Of all invited eligible patients, 43% underwent the study endoscopy and completed the study questionnaire.
This research was approved by the Institutional Review Boards for Human Subjects Research for Baylor College of Medicine and the VA Research and Development Committee of the MEDVAMC. All participants provided written informed consent to take part in the study.
Data Collection
All study participants underwent an upper endoscopy with systematic recording of suspected BE according to the Prague C and M criteria, where BE length was defined as the highest value for circumference length (C) or the maximum (M) extent of the endoscopically visualized BE segment.7, 15 At least one targeted biopsy specimen was taken from each area of suspected BE using jumbo biopsy forceps. All study participants completed a survey questionnaire before the study endoscopy with guidance from a trained research assistant. We also measured each participants’ waist and hip circumferences, height, and weight using a standardized protocol17 and calculated WHR and BMI.
Participants were considered a BE case if intestinalized columnar epithelium with goblet cells (confirmed by alcian-periodic acid-Schiff stain) was present in at least one biopsy sample obtained from areas of suspected BE. Dysplasia status (none, low grade, or high grade) in all cases was assessed by 2 expert clinical gastrointestinal pathologists; dysplasia status was then confirmed by the study gastrointestinal pathologist (MR) and recorded. Controls were defined as participants without endoscopically suspected BE on the study endoscopy. Participants with endoscopic BE only (defined by the presence of lesions visibly suspicious for BE in the absence of specialized intestinal epithelium histologically) were excluded from analysis.
Gastric biopsy specimens were examined and graded for features of active and chronic gastritis and gastric atrophy according to the standardized operative link for gastritis assessment system.16 A score of ≥1 on any biopsy from either the antrum or corpus was considered gastritis. Helicobacter pylori positivity was assigned if organisms were seen and active gastritis was identified on histopathology of any of the gastric biopsy specimens.
Race and ethnicity (non-Hispanic white, African-American, Hispanic, other) were self-reported on the questionnaire. The questionnaire also ascertained information on family history of GERD, BE, and esophageal cancer, personal lifetime history of alcohol and tobacco use, and current and past use of medications, including proton pump inhibitors (PPI), H-2 receptor antagonists (H2RA), aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs).
Measurement of GERD Symptoms
A lifetime history of GERD symptoms was ascertained using a slightly modified version of the validated Gastroesophageal Reflux Questionnaire.5, 17 Participants were asked about history of heartburn (“a burning pain or discomfort behind the breastbone in your chest”) or acid regurgitation (“a bitter or sour-tasting fluid coming up into your throat of mouth”). Chronicity and frequency were determined by eliciting further questions about age at onset of symptoms and frequency of symptoms at ages 10 to 19, 20 to 29, 30 to 49, and 50 to 79 years on a 5-point ordinal scale. Cases and controls were considered symptomatic if they reported heartburn or regurgitation occurring ≥1 day per week at any age period18 and asymptomatic if they reported heartburn or regurgitation <1 day per week over their lifetime. GERD symptom duration was defined as the total number of years from age 10 to age at study recruitment in which a participant reported GERD symptoms (heartburn or regurgitation) ≥1 day per week. Duration of weekly GERD symptoms were stratified by none, <5 years, and ≥5 years.
Statistical Analysis
We calculated the prevalence of BE as a proportion in the entire study population as well as the subgroup of individuals who were asymptomatic (for GERD). We compared cases versus controls in the overall population, cases versus controls among asymptomatic only, and symptomatic cases versus asymptomatic cases with respect to several sociodemographic and clinical factors. Sociodemographic factors included age, sex (male, female), race (non-Hispanic white, African-American, Hispanic, other), smoking status (never, former, current), alcohol status (never, former, current), BMI (normal <25, overweight 25–29.9, obese ≥30), and WHR (as tertiles).7 Clinical factors included Hpylori infection, hiatus hernia (none, <3 cm, ≥3 cm), PPI or H2RA use, and NSAID or aspirin use.
We used logistic regression models to estimates odds ratios (OR) and 95% confidence intervals (CI) for associations with BE in the overall study population and in a subsample of those without symptoms, as well as for variables associated with symptomatic BE among all those with BE (ie, a case-only analysis). Variables that were statistically significantly associated with BE risk in univariate analysis were included in the multivariable model.
Sensitivity Analysis
In a sensitivity analysis, we defined symptomatic BE cases as those with GERD or any PPI/H2RA use and asymptomatic BE cases as those without GERD and PPI/H2RA use.
Assessing the Performance of BE Screening Guidelines
We examined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LR), area under the receiver operating characteristic curve (AUROC), and 95% CI of diagnosing BE using the screening guidelines of 5 gastroenterological societies (Table 1).8, 19–22 Sensitivity was calculated by dividing those with BE who would have been referred for screening by all those with BE. Specificity was calculated by dividing those without BE who would not have been referred for screening by all those without BE. PPV was calculated by dividing those with BE who would have been referred for screening by all those who would be referred for screening. NPV was calculated by dividing those without BE who would not have been referred for screening by all those who would not have been referred for screening. Positive LR was calculated by dividing sensitivity by 1-specificity. Negative LR was calculated by dividing 1-sensitivity by specificity. We also examined the sensitivity, specificity, PPV, NPV, positive and negative LR, AUROC, and 95% CI of diagnosing BE with our own modification of the guidelines as a 2-pronged approach: (1) screen all those with GERD symptoms (which was tested by 2 GERD definitions: at least weekly GERD irrespective of chronicity and in those with at least weekly symptoms for 5 years or longer); or (2) screen those with no GERD symptoms (or symptoms <5 years) but with other risk factors (age ≥50 years, male sex, non-Hispanic white race, obese or high WHR, current or past smoking, family history of BE or esophageal cancer).
Table 1.
Clinical practice guidelines for the screening of Barrett’s esophagus (BE) of five major gastroenterological societies.
| Association | Guidelines | Risk Factors |
|---|---|---|
| American College of Gastroenterology19 | Men with GERD and ≥2 risk factors | • age ≥50 years • non-Hispanic white race • WHR >0.9 in men or WHR >0.85 in women • current or past smoking • family history of BE or esophageal adenocarcinoma |
| American Gastroenterological Association8 | Any multiple (≥2) risk factors | • age ≥50 years • male sex • non-Hispanic white race • chronic GERD • Elevated BMI (defined here as overweight/obese) or intra-abdominal distribution of body fat (defined here as WHR >0.9 in men or WHR >0.85 in women) |
| American Society for Gastrointestinal Endoscopy20 | Family history of BE or EAC or GERD plus ≥1 risk factor | • age ≥50 years • male sex • history of smoking • obesity or central adiposity |
| British Society of Gastroenterology21 | GERD and ≥3 risk factors (lower threshold with a family history of BE or EAC) | • age ≥50 years • male sex • non-Hispanic white race • obesity or WHR >0.9 in men or WHR >0.85 in women |
| European Society of Gastrointestinal Endoscopy22 | GERD >5 years and any multiple (≥2) risk factors | • age ≥50 years • male sex • non-Hispanic white race • obesity • family history of BE or EAC |
All analyses were performed using Stata/SE version 15.1 (StataCorp, College Station, Tex, USA), and a 2-tailed p-value of < .05 was considered statistically significant.
RESULTS
We enrolled 513 participants of whom 44 had BE thus giving an overall BE prevalence of 8.6% (95% CI, 6.4%−11.3%). Eighteen participants had endoscopic BE only; 4 underwent repeat endoscopy, none of whom were confirmed to have BE. Among the 44 BE cases, the mean length was 2.39 cm (SD 2.9 cm) with 22.7% having a length ≥3 cm. The prevalence of BE among the 142 participants who reported a history of at least weekly GERD symptoms was 13.4% (95% CI, 8.7%−20.1%) with a mean length of 2.54 cm (SD 0.6 cm) and 26.3% with length ≥ 3 cm. Among the 371 participants without a history of frequent GERD symptoms, 25 were found to have BE (prevalence, 6.7%; 95% CI, 4.6%−9.8%) with a mean length of 2.28 cm (SD 0. 6 cm). No one in the study reported a family history of BE, and 12 (2.3%) reported a family history of esophageal cancer.
Compared with controls, BE cases were more likely to be of non-Hispanic white race or Hispanic ethnicity (p=0.004), have a hiatal hernia (p=0.030), report GERD symptoms ≥5 years in duration (p=0.025), have a higher WHR (p=0.034), and use PPIs or H2RAs (p=0.028; Table 2). In the multivariate model, non-Hispanic white race/ethnicity (adj. OR, 3.25; 95% CI, 1.36–7.77), Hispanic race/ethnicity (adj. OR, 3.41; 95% CI, 1.09–10.66), and GERD ≥ 5 years (adj. OR 1.95; 95% CI, 1.01–3.78) were independently associated with risk of BE (Table 3).
Table 2.
Sociodemographic and clinical characteristics of controls without Barrett’s esophagus (BE) versus cases with BE, asymptomatic controls versus asymptomatic BE cases, and asymptomatic BE cases versus symptomatic BE cases recruited from a primary care population.
| All controls N=469 |
All cases N=44 |
P value | Asymptomatic controls N=346 |
Asymptomatic cases N=25 |
P value | Asymptomatic cases N=25 |
Symptomatic cases N=19 |
P value | |
|---|---|---|---|---|---|---|---|---|---|
| Age, mean (SD, years) | 61.6 (6.7) | 60.7 (5.5) | 0.192 | 61.9 (6.8) | 60.7 (6.1) | 0.193 | 60.7 (6.1) | 60.6 (4.7) | 0.479 |
| Stratified age | |||||||||
| <60 years | 169 (36.0%) | 14 (31.8%) | 0.577 | 120 (34.7%) | 8 (32.0%) | 0.785 | 8 (32.0%) | 6 (31.6%) | 0.976 |
| ≥60 years | 300 (64.0%) | 30 (68.2%) | 226 (65.3%) | 17 (68.0%) | 17 (68.0%) | 13 (68.4%) | |||
| Sex | |||||||||
| Male | 452 (96.4%) | 44 (100.0%) | 0.199 | 339 (98.0%) | 25 (100.0%) | 0.473 | 25 (100.0%) | 19 (100.0%) | 1.000 |
| Female | 17 (3.6%) | 0 (0.0%) | 7 (2.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| Race | |||||||||
| Non-Hispanic White | 216 (46.1%) | 30 (68.2%) | 0.004 | 153 (44.2%) | 18 (72.0%) | 0.009 | 18 (72.0%) | 12 (63.2%) | 0.712 |
| African-American | 202 (43.1%) | 7 (15.9%) | 156 (45.1%) | 3 (12.0%) | 3 (12.0%) | 4 (21.1%) | |||
| Hispanic | 45 (9.6%) | 7 (15.9%) | 31 (9.0%) | 4 (16.0%) | 4 (16.0%) | 3 (15.8%) | |||
| Other | 6 (1.3%) | 0 (0.0%) | 6 (1.7%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| GERD presence/duration | |||||||||
| None | 346 (73.8%) | 25 (56.8%) | 0.025 | --- | --- | --- | --- | --- | --- |
| <5 years | 3 (0.6%) | 1 (2.3%) | --- | --- | --- | --- | |||
| ≥5 years | 120 (25.6%) | 18 (40.9%) | |||||||
| Smoking Status | |||||||||
| Never smoker | 119 (25.4%) | 10 (22.7%) | 0.832 | 93 (26.9%) | 5 (20.0%) | 0.705 | 5 (20.0%) | 5 (26.3%) | 0.765 |
| Former smoker | 226 (48.2%) | 20 (45.5%) | 162 (46.8%) | 11 (44.0%) | 11 (44.0%) | 9 (47.4%) | |||
| Current smoker | 122 (26.0%) | 14 (31.8%) | 90 (26.0%) | 9 (36.0%) | 9 (36.0%) | 5 (26.3%) | |||
| Missing | 2 (0.4%) | 0 (0.0%) | 1 (0.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| Alcohol drinking status | |||||||||
| Never Drinker | 29 (6.2%) | 1 (2.3%) | 0.691 | 23 (6.7%) | 0 (0.0%) | 0.385 | 0 (0.0%) | 1 (5.3%) | 0.275 |
| Former Drinker | 168 (36.1%) | 15 (34.1%) | 123 (35.9%) | 7 (28.0%) | 7 (28.0%) | 8 (42.1%) | |||
| Current Drinker | 268 (57.5%) | 28 (63.6%) | 196 (57.1%) | 18 (72.0%) | 18 (72.0%) | 10 (52.6%) | |||
| Missing | 1 (0.2%) | 0 (0.0%) | 1 (0.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| Waist-to-hip ratio | |||||||||
| 1st Tertile | 170 (36.8%) | 88 (18.2%) | 0.034 | 122 (35.9%) | 5 (20.0%) | 0.262 | 10 (40.0%) | 9 (47.4%) | 0.344 |
| 2nd Tertile | 157 (34.0%) | 17 (38.6%) | 116 (34.1%) | 10 (40.0%) | 9 (36.0%) | 3 (15.8%) | |||
| 3rd Tertile | 135 (29.2%) | 19 (43.2%) | 102 (30.0%) | 10 (40.0%) | 6 (24.0%) | 7 (36.8%) | |||
| BMI | |||||||||
| Normal | 73 (15.6%) | 5 (11.4%) | 0.702 | 60 (17.3%) | 2 (8.0%) | 0.376 | 2 (8.0%) | 3 (15.8%) | 0.617 |
| Overweight | 165 (35.2%) | 24 (54.6%) | 120 (34.7%) | 8 (32.0%) | 8 (32.0%) | 9 (47.4%) | |||
| Obese | 231 (49.3%) | 15 (34.1%) | 166 (48.0%) | 15 (60.0%) | 15 (60.0%) | 7 (36.8%) | |||
| H. pylori infection | |||||||||
| No | 297 (63.3%) | 28 (63.6%) | 0.967 | 211 (61.0%) | 14 (56.0%) | 0.622 | 14 (56.0%) | 14 (73.7%) | 0.227 |
| Yes | 172 (36.7%) | 16 (36.4%) | 135 (39.0%) | 11 (44.0%) | 11 (44.0%) | 5 (26.3%) | |||
| PPI or H2RA use | |||||||||
| No | 338 (72.5%) | 25 (56.8%) | 0.028 | 292 (84.9%) | 18 (72.0%) | 0.090 | 18 (72.0%) | 7 (36.8%) | 0.020 |
| Yes | 128 (27.5%) | 19 (43.2%) | 52 (15.1%) | 7 (28.0%) | 7 (28.0%) | 12 (63.2%) | |||
| GERD or PPI/H2RA use | |||||||||
| No | 294 (62.7%) | 18 (40.9%) | 0.005 | --- | --- | --- | --- | --- | --- |
| Yes | 175 (37.3%) | 26 (59.1%) | --- | --- | --- | --- | |||
| NSAID or ASA use | |||||||||
| None | 431 (92.1%) | 41 (93.2%) | 0.924 | 322 (93.1%) | 23 (92.0%) | 0.922 | 23 (92.0%) | 18 (94.7%) | 1.00 |
| Less than daily | 3 (0.6%) | 0 (0.0%) | 2 (0.6%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| At least daily | 32 (6.8%) | 3 (6.8%) | 20 (5.8%) | 2 (8.0%) | 2 (8.0%) | 1 (5.3%) | |||
| Missing | 3 (0.5%) | 0 (0.0%) | 2 (0.6%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |||
| Circumference BE Length, mean (cm, SD) | --- | --- | --- | --- | --- | --- | 1.5 (3.1) | 1.2 (2.5) | 0.359 |
| Maximum BE Length, mean (cm, SD) | --- | --- | --- | --- | 2.28 (3.1) | 2.5 (2.7) | 0.613 | ||
| Dysplasia (low grade or high grade) | |||||||||
| No | --- | --- | --- | --- | 20 (80.0%) | 17 (89.5%) | 0.680 | ||
| Yes | --- | --- | --- | --- | 5 (20.0%) | 2 (10.5%) | |||
Table 3.
Multivariate odds ratios and 95% confidence intervals (CI) for odds of Barrett’s esophagus (BE) in the primary care population and asymptomatic patients only as well as odds of GERD symptoms or PPI use in all BE cases.
| All Cases and Controls | Asymptomatic Cases and Controls | All Cases* | |
|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Age (ref: < 60 years) | 1.06 (0.52–2.17) | 0.83 (0.32–2.13) | 0.83 (0.19–3.62) |
| Race (ref: African-American) | |||
| Non-Hispanic white | 3.25 (1.36–7.77) | 5.65 (1.59–20.10) | 1.32 (0.15–11.79) |
| Hispanic | 3.41 (1.09–10.66) | 6.39 (1.32–30.98) | 2.01 (0.18–22.14) |
| GERD Presence/Duration (ref: no GERD) | |||
| < 5 years | 4.44 (0.39–50.50) | --- | --- |
| ≥ 5 years | 1.95 (1.01–3.78) | --- | --- |
| Smoking Status (ref: never smoker) | |||
| Former Smoker | 0.93 (0.40–2.13) | 1.19 (0.39–3.62) | 0.39 (0.05–3.01) |
| Current Smoker | 1.28 (0.53–3.12) | 1.57 (0.48–5.10) | 0.67 (0.07–6.24) |
| WHR (ref: 1st tertile) | |||
| 2nd Tertile | 1.89 (0.77–4.59) | 1.67 (0.54–5.15) | 0.69 (0.15–3.16) |
| 3rd Tertile | 2.22 (0.91–5.41) | 1.68 (0.53–5.31) | 1.60 (0.34–7.48) |
Odds of having GERD symptoms or PPI use
In 371 participants without a history of frequent GERD symptoms, only race/ethnicity was associated with BE (p=0.009). In multivariate analysis, non-Hispanic whites (adj. OR, 5.65; 95% CI, 1.59–20.10) and Hispanics (adj. OR, 6.39; 95% CI, 1.32–30.98) had statistically significantly higher risk of BE compared with African-Americans.
In a BE case-only analysis, the only significant difference between symptomatic and asymptomatic cases on univariate analysis was a higher use of PPI or H2RA among symptomatic cases (p=0.020). There was no difference in overall BE length between symptomatic and asymptomatic cases (2.28 cm vs 2.54 cm; p=0.774).
Sensitivity Analysis
We found 310 participants with neither GERD nor PPI/H2RA use among whom we identified 18 with BE (prevalence, 5.8%; 95% CI, 3.7%−9.0%). There was a trend toward a higher proportion of those of non-Hispanic white race/ethnicity among BE cases than controls (72.2% vs 43.2%; p=0.059; Supplementary Table 1). There were no other significant variables on univariate analysis among asymptomatic cases and controls without frequent GERD symptoms and PPI/H2RA use.
Assessing the Performance of BE Screening Guidelines
The American Gastroenterological Association (AGA) recommends referral for screening in persons with any multiple BE risk factors with no particular hierarchy (age ≥50, GERD symptoms, male sex, non-Hispanic white race, and elevated BMI or intra-abdominal distribution of body fat).8 In this primary care population, all 44 BE cases had at least one of these 5 risk factors; 12 cases (27.2%) had 2 or 3 risk factors; 23 cases (52.3%) had 4 risk factors; and 9 cases (20.5%) had all 5 risk factors. When we applied at least any 2 risk factors, the sensitivity of this guideline was 100.0%, but the specificity was 0.2% (Table 4). In examining the yield of different permutations of any 2 risk factors, GERD with another risk factor had the highest specificity of about 76%, whereas non-Hispanic white race in conjunction with another (non-GERD) risk factor had the next highest specificity of around 55%. After GERD and race, the specificity of being overweight/obese or having a high WHR combined with another risk factor decreased significantly to 8% to 9%, whereas the specificity of age ≥50 years and male sex was 5.8%. When restricting the requirement to at least 3 risk factors, the sensitivity decreased to 88.6% and specificity increased to 5.5%. With at least 4 risk factors, the sensitivity was 72.7% and specificity was 46.3%, whereas they were 20.5% and 87.8%, respectively, when requiring all 5 risk factors.
Table 4.
Sensitivities, specificities, positive predictive values, negative predictive values, positive likelihood ratios, negative likelihood ratios, areas under the receiver operating characteristic, and 95% confidence intervals of Barrett’s esophagus screening guidelines for five gastrointestinal societies in an unscreened primary care population.
| Guidelines | Sensitivity (95% CI) | Specificity (95% CI) | PPV (95% CI) | NPV (95% CI) | +LR (95% CI) | −LR (95% CI) | AUROC (95% CI) |
|---|---|---|---|---|---|---|---|
| American College of Gastroenterology | |||||||
| Men with GERD and ≥ 2 risk factorsǂ | 38.6% (24.4%–54.5%) | 76.5% (72.5%–80.3%) | 13.4% (8.0%–20.6%) | 93.0% (90.0%–95.3%) | 1.65 (1.10–2.47) | 0.80 (0.63–1.02) | 0.58 (0.50–0.65) |
| American Gastroenterological Association | |||||||
| Multiple risk factors | |||||||
| ≥2 of any risk factorsΣ | 100.0% (92.0%–100.0%) | 0.2% (0.0%–1.2%) | 8.6% (6.3%–11.4%) | 100.0% (2.5%–100.0%) | 1.00 (1.00–1.01) | 0.00 (--) | 0.50 (0.50–0.50) |
| ≥50 years and male | 97.7% (88.0%–99.9%) | 5.8% (3.8%–8.3%) | 8.9% (6.5%–11.8%) | 96.4% (81.7%–99.9%) | 1.04 (0.99–1.09) | 0.39 (0.05–2.84) | 0.52 (0.49–0.54) |
| Male and overweight/obesity or high WHR | 97.7% (88.0%–99.9%) | 9.2% (6.7%–12.2%) | 9.2% (6.7%–12.2%) | 97.7% (88.0%–99.9%) | 1.08 (1.02–1.13) | 0.25 (0.03–1.76) | 0.53 (0.51–0.56) |
| ≥50 years and overweight/obese or high WHR | 95.5% (84.5%–99.4%) | 8.3% (6.0%–11.2%) | 8.9% (6.5%–11.8%) | 95.1% (83.5%–99.4%) | 1.04 (0.97–1.12) | 0.55 (0.14–2.19) | 0.52 (0.49–0.55) |
| Male and non-Hispanic white | 68.2% (52.4%–81.4%) | 55.0% (50.4%–59.6%) | 12.5% (8.6%–17.3%) | 94.9% (91.5%–97.2%) | 1.52 (1.21–1.90) | 0.58 (0.37–0.90) | 0.62 (0.54–0.69) |
| ≥50 years and non-Hispanic white | 68.2% (52.4%–81.4%) | 54.6% (50.0%–59.2%) | 12.3% (8.5%–17.2%) | 94.8% (91.5%–97.1%) | 1.50 (1.20–1.88) | 0.58 (0.38–0.91) | 0.61 (0.54–0.69) |
| Non-Hispanic white and overweight/obese or high WHR | 65.9% (50.1%–79.5%) | 55.7% (51.0%–60.2%) | 12.2% (8.4%–17.1%) | 94.6% (91.2%–96.9%) | 1.49 (1.17–1.88) | 0.61 (0.40–0.93) | 0.61 (0.53–0.68) |
| Male and chronic GERD | 40.9% (26.3%–56.8%) | 76.5% (72.4%–80.3%) | 14.1% (8.6%–21.3%) | 93.2% (90.3%–95.5%) | 1.74 (1.18–2.58) | 0.77 (0.60–0.99) | 0.59 (0.51–0.66) |
| ≥50 years and chronic GERD | 40.9% (26.3%–56.8%) | 75.5% (71.3%–79.3%) | 13.5% (8.2%–20.5%) | 93.2% (90.1%–95.5%) | 1.67 (1.13–2.46) | 0.78 (0.61–1.01) | 0.58 (0.51–0.66) |
| Overweight/obese or high WHR and chronic GERD | 38.6% (24.4%–54.5%) | 75.5% (71.3%–79.3%) | 12.9% (7.7%–19.8%) | 92.9% (89.9%–95.3%) | 1.58 (1.05–2.36) | 0.81 (0.64–1.03) | 0.57 (0.50–0.65) |
| Non-Hispanic white and chronic GERD | 27.3% (15.0%–42.8%) | 86.8% (83.4%–89.7%) | 16.2% (8.7%–26.6%) | 92.7% (89.9%–95.0%) | 2.06 (1.21–3.52) | 0.84 (0.70–1.01) | 0.57 (0.50–0.64) |
| ≥3 risk factorsΣ | 88.6% (75.4%–96.2%) | 5.5% (3.7%–8.0%) | 8.1% (5.8%–10.9%) | 83.9% (66.3%–94.5%) | 0.94 (0.84–1.05) | 2.05 (0.83–5.07) | 0.47 (0.42–0.52) |
| ≥4 risk factorsΣ | 72.7% (57.2%–85.0%) | 46.3% (41.7%–50.9%) | 11.3% (7.8%–15.5%) | 94.8% (91.0%–97.3%) | 1.35 (1.11–1.65) | 0.59 (0.36–0.96) | 0.59 (0.52–0.67) |
| ≥5 risk factorsΣ | 20.5% (9.8%–35.3%) | 87.8% (84.5%–90.7%) | 13.6% (6.4%–24.3%) | 92.2% (89.3%–94.5%) | 1.68 (0.90–3.16) | 0.91 (0.78–1.06) | 0.54 (0.48–0.60) |
| American Society for Gastrointestinal Endoscopy | |||||||
| Family hx of BE/EAC or GERD and ≥ 1 risk factor± | 43.2% (28.3%–59.0%) | 71.6% (67.3%–75.7%) | 12.5% (7.7%–18.8%) | 93.1% (89.9%–95.5%) | 1.52 (1.05–2.20) | 0.79 (0.61–1.03) | 0.57 (0.50–0.65) |
| British Society of Gastroenterology | |||||||
| GERD and ≥ 3 risk factors** | 40.9% (26.3%–56.8%) | 75.7% (71.5%–79.5%) | 13.6% (8.3%–20.7%) | 93.2% (90.2%–95.5%) | 1.68 (1.14–2.48) | 0.78 (0.61–1.00) | 0.58 (0.51–0.66) |
| European Society of Gastrointestinal Endoscopy | |||||||
| GERD>5 years and multiple risk factors | |||||||
| ≥2 risk factors* | 40.9% (26.3%–56.8%) | 75.1% (70.9%–78.9%) | 13.3% (8.1%–20.3%) | 93.1% (90.1%–95.5%) | 1.64 (1.11–2.42) | 0.79 (0.61–1.01) | 0.58 (0.50–0.66) |
| ≥3 risk factors* | 36.4% (22.4%–52.2%) | 82.9% (79.2%–86.2%) | 16.7% (9.8%–25.6%) | 93.3% (90.4%–95.5%) | 2.13 (1.37–3.31) | 0.77 (0.61–0.96) | 0.60 (0.52–0.67) |
| ≥4 risk factors* | 13.6% (5.2%–27.4%) | 92.1% (89.3%–94.4%) | 14.0% (5.3%–27.9%) | 91.9% (89.1%–94.2%) | 1.73 (0.77–3.87) | 0.94 (0.83–1.06) | 0.53 (0.48–0.58) |
age ≥50 years, male sex, non-Hispanic white race, obesity, or first degree relative with BE or EAC.
age ≥50 years, male sex, non-Hispanic white race, or obesity or high WHR. Lower threshold in family history of BE or EAC.
age >50 years, male sex, current or previous smoking, or obesity or high WHR.
age >50 years, non-Hispanic white race, high WHR, current or previous smoking, or family history of BE or EAC.
age ≥50 years, male sex, non-Hispanic white race, chronic GERD, or elevated BMI (defined here as overweight or obese) or intra-abodminal distribution of body fat (defined here as high WHR).
Abbreviations: CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; +LR, positive likelihood ratio; −LR, negative likelihood ratio; AUROC, area under the receiver operating characteristic.
The American College of Gastroenterology (ACG), American Society for Gastrointestinal Endoscopy (ASGE), British Society of Gastroenterology (BSG), and European Society of Gastrointestinal Endoscopy (ESGE) guidelines all recommend screening in patients with GERD symptoms and multiple risk factors. Requiring GERD as an initial qualifying criterion allowed for a maximum sensitivity of only 38.6% to 43.2% with each societal guideline. Following these 4 guidelines, none of the 25 asymptomatic BE cases would have been diagnosed.
In examining our own modification of the screening guideline as a 2-pronged procedure (screen those with GERD symptoms irrespective of duration [as per our study definition], and those with no GERD symptoms but with other [non-GERD] risk factors), we found that the sensitivity with this 2-step approach among those with GERD and among those with no GERD symptoms but with ≥5 risk factors was 81.8% whereas the specificity was 51.2% with an AUROC of 0.66 (95% CI, 0.60–0.73; Table 5). We also tested this 2-step approach requiring chronic GERD symptoms (≥5 years) for the first step and found the sensitivity among those with chronic GERD and among those with GERD symptoms <5 years but with ≥5 risk factors was 79.5% whereas the specificity was 51.8% with an AUROC of 0.66 (95% CI, 0.59–0.72).
Table 5.
Sensitivities, specificities, positive predictive values, negative predictive values, positive likelihood ratios, negative likelihood ratios, areas under the receiver operating characteristic, and 95% confidence intervals of proposed Barrett’s esophagus (BE) screening guidelines in an unreferred primary care population.
| Screen those with frequent GERD symptoms irrespective of duration OR screen those with no GERD symptoms who have other BE risk factors* | ||||
| ≥3 risk factors | ≥4 risk factors | ≥5 risk factors | ≥6 risk factors | |
| Sensitivity (95% CI) | 100.0% (92.0%–100.0%) | 88.6% (75.4%–96.2%) | 81.8% (67.3%–91.8%) | 43.2% (28.3%–59.0%) |
| Specificity (95% CI) | 2.3% (1.2%–4.2%) | 17.1% (13.8%–20.8%) | 51.2% (46.5%–55.8%) | 72.9% (68.7%–76.9%) |
| PPV (95% CI) | 8.8% (6.4%–11.6%) | 9.1% (6.6%–12.2%) | 13.6% (9.7%–18.3%) | 13.0% (8.0%–19.6%) |
| NPV (95% CI) | 100.0% (71.5%–100.0%) | 94.1% (86.8%–98.1%) | 96.8% (93.7%–98.6%) | 93.2% (90.1%–95.5%) |
| +LR (95% CI) | 1.02 (1.01–1.04) | 1.07 (0.95–1.20) | 1.68 (1.42–1.98) | 1.59 (1.10–2.31) |
| −LR (95% CI) | 0.00 (--) | 0.67 (0.29–1.56) | 0.36 (0.19–0.67) | 0.78 (0.60–1.01) |
| AUROC (95% CI) | 0.51 (0.50–0.52) | 0.53 (0.48–0.58) | 0.66 (0.60–0.73) | 0.58 (0.50–0.66) |
| Screen those frequent GERD symptoms ≥ 5 years OR screen those with GERD symptoms <5 years who have other BE risk factors* | ||||
| ≥ 3 risk factors | ≥ 4 risk factors | ≥ 5 risk factors | ≥ 6 risk factors | |
| Sensitivity (95% CI) | 100.0% (92.0%–100.0%) | 86.4% (72.6%–94.8%) | 79.5% (64.7%–90.2%) | 40.9% (26.3%–56.8%) |
| Specificity (95% CI) | 2.3% (1.2%–4.2%) | 17.3% (14.0%–21.0%) | 51.8% (47.2%–56.4%) | 80.2% (69.3%–77.5%) |
| PPV (95% CI) | 8.8% (6.4%–11.6%) | 8.9% (6.4%–12.0%) | 13.4% (9.5%–18.2%) | 12.7% (7.7%–19.3%) |
| NPV (95% CI) | 100.0% (71.5%–100.0%) | 93.1% (85.6%–97.4%) | 96.4% (93.3%–98.4%) | 93.0% (89.9%–95.4%) |
| +LR (95% CI) | 1.02 (1.01–1.04) | 1.04 (0.92–1.18) | 1.65 (1.38–1.97) | 1.55 (1.05–2.28) |
| −LR (95% CI) | 0.00 (--) | 0.79 (0.37–1.70) | 0.39 (0.22–0.71) | 0.80 (0.62–1.03) |
| AUROC (95% CI) | 0.51 (0.50–0.52) | 0.52 (0.46–0.57) | 0.66 (0.59–0.72) | 0.57 (0.50–0.65) |
age ≥ 50 years, male, non-Hispanic white race, obese or high waist-to-hip ratio, current or past smoking, family history of BE or esophageal cancer
Abbreviations: CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; +LR, positive likelihood ratio; −LR, negative likelihood ratio; AUROC, area under the receiver operating characteristic.
DISCUSSION
In this study of consecutively recruited primary care patients, the BE prevalence was 8.6% in the overall unreferred population and the significant predictors of BE were non-Hispanic white race (3.3-fold increased odds) and Hispanic ethnicity (3.8-fold increased odds) compared with African-American race as well as a suggested higher BE risk associated with a high WHR. Among those without a history of GERD symptoms (defined as at least weekly heartburn or regurgitation from age 10), the prevalence of BE was 6.7%, and race/ethnicity was the only factor associated with BE with 5-fold increased odds in non-Hispanic whites and 6-fold increased odds in Hispanics compared with African-Americans.
Although there are no studies comparing screening with no screening for BE with regard to overall or esophageal adenocarcinoma specific mortality, societal guidelines try to stratify BE patients based on risk factors and the assumption that screening will lead to the enrollment of BE patients in surveillance programs and ultimately reduce esophageal adenocarcinoma incidence and related mortality. All guidelines, except those for the AGA, condition screening based on the presence of GERD symptoms (AGA guidelines recommend screening in those with multiple [any ≥2] risk factors that may include but is not conditional on a history of GERD symptoms). In this unreferred primary care population, 27.7% reported a history of frequent GERD symptoms, among whom 13.4% were found to have BE. Therefore, all 19 cases of BE with frequent GERD (43.2% of all BE cases in our study population) would have been captured by the screening guidelines set forth by the ACG, ASGE, and the AGA (ie, sensitivity of 100% among those with GERD), and all but one (94.7%) of symptomatic BE cases would have been screened as per guidelines of the BSG and the ESGE.8, 19, 21, 22
Our data show that conditioning BE screening guidelines on the presence of GERD symptoms (or the lack of conditioning in the case of the AGA) comes at a heavy price as far as the performance of these screening guidelines. BE occurred in a large proportion without frequent GERD symptoms (56.8% of all BE cases in our study) which would lead to an underdiagnosis of BE if guidelines recommend that only those with frequent GERD symptoms are referred for screening.9, 23 Therefore, the guidelines by the ASGE, ACG, BSG, and ESGE which all recommend screening only those with GERD and multiple other risk factors had a high specificity in this study population of 75% to 78% but a low sensitivity ranging 39% to 43%. Whereas, the AGA, whereas having 100% sensitivity, had virtually no specificity (only 0.2%) as BE risk factors were so prevalent in this study population. All screening guidelines had a low AUROC ranging 0.50 to 0.60.
Our proposed modifications of the current guidelines build on their strengths and attempt to mitigate the weaknesses. Given that frequent (at least weekly) GERD symptoms capture a little bit less than half of BE cases, we proposed screening those with frequent GERD symptoms as the first of a 2-pronged approach. Regarding those without GERD symptoms, we proposed screening patients with multiple risk factors (age ≥50 years, male sex, non-Hispanic white race, obesity or high WHR, previous or current smoking history, and family history of BE or esophageal cancer). We found screening all those with frequent GERD symptoms and those without GERD symptoms but with 5 or more risk factors would render the best possible performance for the entire 2-pronged approach (sensitivity of 81.8%, specificity of 51.2%, and AUROC of 0.66). Additionally, it seems that with regard to specificity and PPV in this study population, the most important risk factors after GERD are non-Hispanic white race, followed by obesity, then male sex or age ≥50 years. However, in a meta-analysis of over 13,400 obese patients undergoing preoperative EGD, the prevalence of BE was only 0.9%, and so obesity alone may not be a major risk factor for BE.24 Clearly, further study in larger and different populations is required.
Less than 10% of patients with esophageal adenocarcinoma have a history of BE,9 and only 61% of patients with esophageal adenocarcinoma report a history of GERD symptoms, therefore suggesting that the focus of BE screening on GERD as the main risk factor should be broadened.23, 25 However, Barrett’s screening has direct healthcare costs (eg, cost of endoscopy, pathology, sedation, facility fees) and direct non-healthcare costs (eg, transportation and lost wages).26 Most studies that have found endoscopic screening to be cost-effective are based on only screening individuals with GERD with cost ranging from $10,440-$12,332 per quality-adjusted life-year (QALY) gained.27–29 It has previously been proposed that upper endoscopy be performed for initial BE screening at the time of the first screening colonoscopy around age 50;30 however, a cost-effectiveness study found that this strategy required $95,559 per QALY saved.31 Using our proposed 2-pronged approach to BE screening may be more effective at preventing esophageal adenocarcinoma than current guidelines and may be more cost-effective than widespread population screening, however further studies are needed.
No participants in this study reported a family history of BE, which is considered a major risk factor for BE by the ACG, ASGE, BSG, and ESGE. Although familial BE has been shown to be associated with an increased risk of BE in an individual with a pooled BE prevalence of 23.4%,32 a general lack of family history knowledge calls into question the utility of family history of BE as a sole risk factor for screening purposes. The 2004 HealthStyles Survey of 4,345 participants by the Centers for Disease Control and Prevention demonstrated that 96.3% of respondents believe family history is important for their own health, however only 29.8% reported actively collecting information to develop a family health history.33 Another study of 309 participants at the University of Leeds showed that 9% considered their spouse as a first-degree relative, and only 3% named their children as first-degree relatives.34 In our study, only 2.3% of participants reported a family history of esophageal cancer, all of whom did not have BE on study endoscopy. Thus, only specificities for societal guidelines that listed family history of esophageal adenocarcinoma as a risk factor were affected and only minimally (eg, 75.9% to 76.5% for the ACG). Although family history of BE or esophageal adenocarcinoma is a major risk factor for BE and those with a family history should continue to be screened, recommendations for BE screening should be broadened beyond this given the low prevalence of family history of BE or esophageal adenocarcinoma.
Our study had a few limitations. The initial study and participant recruitment were performed during 2008 to 2012 in a veteran population, which contained a lower proportion of females at that time, and almost no patients had no risk factors for BE. Although BE prevalence (8.6%) in our largely older male population is consistent with results from a recent meta-analysis,32 whether our findings are generalizable to populations with lower BE prevalence require additional study. There may have been recall bias with regard to GERD as symptoms were reported on questionnaire; however, questionnaires were collected before the study endoscopy which reduced the likelihood of recall bias. Additionally, indication for use of PPI or H2RA (such as GERD, dyspepsia, or PUD) was not available, and there may have been misclassification bias of asymptomatic and symptomatic BE cases. Numbers may have been too small to detect differences between asymptomatic BE cases and controls, and asymptomatic and symptomatic BE cases. We did not have additional information on participants who were approached but did not agree to be included in the study, therefore we were unable to perform an intention-to-screen analysis. Last, our study population was a representative sample of the MEDVAMC population, and therefore testing of these risk factors and guidelines in different populations is required.
Strengths of our study included using a consistent and strict definition to diagnose BE and excluding all those with BE on endoscopy only (ie, without intestinal metaplasia on biopsy) to avoid misclassification. Additionally, we reduced the likelihood of recall bias by having participants complete the risk factor surveys before the study endoscopy.
In conclusion, we found a high prevalence of BE of 8.6% in an unreferred primary care population. Over half of BE cases were without significant GERD symptoms, but virtually all had at least one known risk factor for BE. Therefore, practice guidelines that require GERD symptoms have low sensitivity, whereas those not requiring GERD have very low specificity. Better use of known risk factors is required for primary prevention of esophageal adenocarcinoma; we propose testing a 2-pronged approach with different thresholds for those with and without GERD symptoms.
Supplementary Material
Acknowledgements
We would like to acknowledge and thank our two gastrointestinal pathologists, Gordana Vestovsek and Paula Parente, for their assistance.
Grant Support: This work is funded in part by National Institutes of Health grant NCI R01 116845, and the Texas Digestive Disease Center NIH DK58338. Dr. El-Serag is also supported by NIDDK K24–04-107. This research was supported in part with resources at the VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (#CIN 13–413), at the Michael E. DeBakey VA Medical Center, Houston, TX. The opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the US government or Baylor College of Medicine.
Acronyms and Abbreviations
- BE
Barrett’s esophagus
- GERD
gastroesophageal reflux disease
- BMI
body mass index
- WHR
waist-to-hip ratio
- MEDVAMC
Michael E. DeBakey Veteran Affairs Medical Center
- PPI
proton pump inhibitor
- H2RA
H-2 receptor antagonist
- NSAID
non-steroidal anti-inflammatory drug
- OR
odds ratio
- CI
confidence interval
- PPV
positive predictive value
- NPV
negative predictive value
- LR
likelihood ratio
- AUROC
area under the receiver operating characteristic curve
- AGA
American Gastroenterological Association
- ACG
American College of Gastroenterology
- ASGE
American Society of Gastrointestinal Endoscopy
- BSGE
British Society of Gastroenterology
- ESGE
European Society of Gastrointestinal Endoscopy
Footnotes
Conflict OF Interest: The authors report no personal or financial conflicts of interest.
(i) Guarantor of the Article: Hashem B. El-Serag
(iii) All authors approved the final version of the manuscript.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424. [DOI] [PubMed] [Google Scholar]
- 2.Thrift AP, Whiteman DC. The incidence of esophageal adenocarcinoma continues to rise: analysis of period and birth cohort effects on recent trends. Ann Oncol 2012;23:3155–61. [DOI] [PubMed] [Google Scholar]
- 3.Spechler SJ. Barrett’s esophagus and esophageal adenocarcinoma: pathogenesis, diagnosis, and therapy. Med Clin North Am 2002;86:1423–45. [DOI] [PubMed] [Google Scholar]
- 4.Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 2011;365:1375–83. [DOI] [PubMed] [Google Scholar]
- 5.Thrift AP, Kramer JR, Qureshi Z, et al. Age at onset of GERD symptoms predicts risk of Barrett’s esophagus. Am J Gastroenterol 2013;108:915–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Thrift AP. Barrett’s esophagus and esophageal adenocarcinoma: How common are they really? Dig Dis Sci 2018;63. [DOI] [PubMed] [Google Scholar]
- 7.Kramer JR, Fischbach LA, Richardson P, et al. Waist-to-hip ratio, but not body mass index, is associated with an increased risk of Barrett’s esophagus in white men. Clin Gastroenterol Hepatol 2013;11:373–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Association AG, Spechler SJ, Sharma P, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology 2011;140:1084–91. [DOI] [PubMed] [Google Scholar]
- 9.Wenker TN, Tan MC, Liu Y, et al. Prior diagnosis of Barrett’s esophagus is infrequent, but associated with improved esophageal adenocarcinoma survival. Dig Dis Sci 2018;63:3112–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hammad TA, Thrift AP, El-Serag HB, et al. Missed opportunities for screening and surveillance of Barrett’s esophagus in veterans with esophageal adenocarcinoma. Dig Dis Sci 2019;64:367–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Gerson LB, Shetler K, Triadafilopoulos G. Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology 2002;123:461–7. [DOI] [PubMed] [Google Scholar]
- 12.Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology 2003;125:1670–7. [DOI] [PubMed] [Google Scholar]
- 13.Ronkainen J, Aro P, Storskrubb T, et al. Prevalence of Barrett’s esophagus in the general population: an endoscopic study. Gastroenterology 2005;129:1825–31. [DOI] [PubMed] [Google Scholar]
- 14.El-Serag HB, Peterson NJ, Carter J, et al. Gastroesophageal reflux among different racial groups in the United States. Gastroenterology 2004;126:1692–9. [DOI] [PubMed] [Google Scholar]
- 15.Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology 2006;131:1392–9. [DOI] [PubMed] [Google Scholar]
- 16.Rugge M, Meggio A, Pennelli G, et al. Gastritis staging in clinical practice: the OLGA staging system. Gut 2007;56:631–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Locke GR, Talley NJ, Weaver AL, et al. A new questionnaire for gastroesophageal reflux disease. Mayo Clin Proc 1994;69:539–47. [DOI] [PubMed] [Google Scholar]
- 18.Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900–20. [DOI] [PubMed] [Google Scholar]
- 19.Shaheen NJ, Falk GW, Iyer PG, et al. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016;111:30–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Qumseya B, Sultan S, Bain P, et al. ASGE guideline on screening and surveillance of Barrett’s esophagus. Gastrointest Endosc 2019;90:335–9. [DOI] [PubMed] [Google Scholar]
- 21.Fitzgerald RC, di Pietro M, Ragunath K, et al. British society of gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014;63:7–42. [DOI] [PubMed] [Google Scholar]
- 22.Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett’s esophagus: European Society of Gastrointestinal Endoscopy position (ESGE) statement. Endoscopy 2017;49:191–8. [DOI] [PubMed] [Google Scholar]
- 23.Bhat SK, McManus DT, Coleman HG, et al. Oesophageal adenocarcinoma and prior diagnosis of Barrett’s oesophagus: a population-based study. Gut 2015;64:20–5. [DOI] [PubMed] [Google Scholar]
- 24.Qumseya B, Gendy S, Wallace A, et al. Prevalence of Barrett’s esophagus in obese patients undergoing pre-bariatric surgery evaluation: a systematic review and meta-analysis. Endoscopy 2020. [DOI] [PubMed] [Google Scholar]
- 25.Chak A, Faulx A, Eng C, et al. Gastroesophageal reflux symptoms in patients with adenocarcinoma of the esophagus or cardia. Cancer 2006;107:2160–6. [DOI] [PubMed] [Google Scholar]
- 26.Inadomi JM, Saxena N. Screening and surveillance for Barrett’s esophagus: is it cost-effective? Dig Dis Sci 2018;63:2094–2104. [DOI] [PubMed] [Google Scholar]
- 27.Inadomi JM, Sampliner R, Lagergren J, et al. Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis. Ann Intern Med 2003;138:176–186. [DOI] [PubMed] [Google Scholar]
- 28.Nietert PJ, Silverstein MD, Mokhashi MS, et al. Cost-effectiveness of screening a population with chronic gastroesophageal reflux. Gastrointest Endosc 2003;57:311–8. [DOI] [PubMed] [Google Scholar]
- 29.Gerson LB, Groeneveld PW, Triadafilopoulos G. Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2004;2:868–79. [DOI] [PubMed] [Google Scholar]
- 30.Graham DY, Tan MC. No Barrett’s-no cancer: a proposed new paradigm for prevention of esophageal adenocarcinoma. J Clin Gastroenterol 2020;54:136–43. [DOI] [PubMed] [Google Scholar]
- 31.Gupta N, Bansal A, Wani SB, et al. Endoscopy for upper GI cancer screening in the general population: a cost-utility analysis. Gastrointest Endosc 2011;74:610–24. [DOI] [PubMed] [Google Scholar]
- 32.Qumseya BJ, Bukannan A, Gendy S, et al. Systematic review and meta-analysis of prevalence and risk factors for Barrett’s esophagus. Gastrointest Endosc 2019;90:707–17. [DOI] [PubMed] [Google Scholar]
- 33.Awareness of family health history as a risk factor for disease--United States, 2004. MMWR Morb Mortal Wkly Rep. Volume 53: Centers for Disease Control and Prevention, 2004:1044–7. [PubMed] [Google Scholar]
- 34.Lim JNW, Hewison J. Do people really know what makes a family history of cancer? Health Expect 2014;17:818–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.