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Abstract and Introduction
Abstract
Although endoscopic surveillance of patients with Barrett's oesophagus has been widely implemented, its effectiveness is debateable. The recently reported low annual oesophageal adenocarcinoma risk in population studies, the failure to identify most Barrett's patients at risk of disease progression, the poor adherence to surveillance and biopsy protocols, and the significant risk of misclassification of dysplasia all tend to undermine the effectiveness of current management, in particular, endoscopic surveillance programmes, to prevent or improve the outcomes of patients with oesophageal adenocarcinoma. The ongoing increase in incidence of Barrett's oesophagus and consequent growth of the surveillance population, together with the associated discomfort and costs of endoscopic surveillance, demand improved techniques for accurately determining individual risk of oesophageal adenocarcinoma. More accurate techniques are needed to run efficient surveillance programmes in the coming decades. In this review, we will discuss the current knowledge on the epidemiology of Barrett's oesophagus, and the challenging epidemiological dilemmas that need to be addressed when assessing the current screening and surveillance strategies.
Introduction
In 1952, the incidence of oesophageal adenocarcinoma (OAC) was low enough that an OAC in Barrett's oesophagus (BO) merited a case report. OAC has now become the fifth leading cause of cancer-related death in men worldwide, with its incidence continuing to rise inexorably in the Western world.
The dismal prognosis of OAC has focused interest on BO, its precursor lesion and a very common condition in western countries. BO is defined by replacement of oesophageal squamous epithelium by columnar epithelium with intestinal metaplasia as a consequence of gastro-oesophageal reflux disease (GORD). The cascade of GORD to BO and ultimately OAC offers attractive targets for screening and surveillance. These interventions aim to decrease mortality and improve survival related to OAC by early detection and treatment of either dysplastic BO tissue or early cancer. Endoscopic surveillance of BO has been recommended in various guidelines by different gastroenterological societies, and as such, has been widely implemented. However, as current evidence for either improved survival or cost effectiveness is equivocal at best, the efficacy of BO surveillance remains the subject of heated debate. This uncertainty also limits the basis for population BO screening.
In view of new epidemiological data that have become available since the development of surveillance guidelines, reconsideration of effective preventive strategies for BO patients seems justified. This review will provide an overview of our current knowledge on the epidemiology of BO and the challenging epidemiological dilemmas that need to be addressed when reassessing screening and surveillance strategies.
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