Post written by Theresa H. Nguyen, MD, from the Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
The focus of our study was to examine the prevalence of Barrett’s esophagus 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.
Barrett’s esophagus (BE) is the only known precursor to esophageal adenocarcinoma. Those with BE have a 30- to 125-fold greater risk of esophageal adenocarcinoma compared with the general population. For this reason, practice guidelines recommend screening patients with risk factors for BE, including frequent gastroesophageal reflux disease (GERD) symptoms, age >50 years, male gender, non-Hispanic white race, tobacco smoking, and obesity (particularly abdominal obesity). However, despite these screening practice guidelines, <10% of patients with newly diagnosed esophageal adenocarcinoma have a pre-existing diagnosis of BE. This may be due to under use of screening recommendations by current practice guidelines, inadequate performance characteristics of these guidelines, or unidentified risk factors for BE.
We found a high prevalence of BE (8.6%) in our unreferred primary care population. All practice guidelines, except those from the AGA, condition screening based on the presence of GERD symptoms; however, BE occurred in a large proportion without frequent GERD symptoms in our study (56.8% of all BE cases). 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 75-78% but a low sensitivity ranging 39-43%. Conversely, the AGA, which had 100% sensitivity, had virtually no specificity (only .2%) as BE risk factors were highly prevalent in this study population. Our proposed modifications with a 2-pronged approach build on the strengths of the current guidelines and attempt to mitigate the weaknesses. We found screening all those with frequent GERD symptoms and those without GERD symptoms but with 5+ risk factors would render the best possible performance, with a sensitivity of 81.8% and specificity of 51.2% (Table 5). We propose testing the performance of this 2-pronged approach for BE screening in other populations.
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