From the Guidelines
No, Barrett's esophagus is not cancer, but it is a precancerous condition. Barrett's esophagus occurs when the normal squamous cells lining the esophagus are replaced by intestinal-type columnar epithelium (a process called intestinal metaplasia), typically due to chronic acid reflux damage. While Barrett's esophagus itself is not cancerous, it increases the risk of developing esophageal adenocarcinoma, with patients having approximately 30-40 times higher risk than the general population 1. The progression from Barrett's esophagus to cancer usually follows a sequence: non-dysplastic Barrett's, low-grade dysplasia, high-grade dysplasia, and finally cancer.
Key Considerations
- The degree of dysplasia is the most predictive factor for progression to adenocarcinoma of the esophagus among those with Barrett's esophagus 1.
- Individuals with high-grade dysplasia demonstrate a risk of subsequent adenocarcinoma exceeding 25% 1.
- Regular monitoring through endoscopy with biopsies is recommended for patients with Barrett's esophagus, with frequency depending on the presence and grade of dysplasia 1.
- Treatment focuses on controlling acid reflux with proton pump inhibitors (like omeprazole or esomeprazole), lifestyle modifications (elevating the head of the bed, avoiding late meals, weight loss if overweight), and in some cases, endoscopic treatments like radiofrequency ablation for dysplastic Barrett's to prevent progression to cancer 1.
Management Approach
- Endoscopic therapy is recommended for high-grade dysplasia and early cancer, which should be performed in high-volume centers 1.
- Post-endoscopic submucosal dissection (ESD) surveillance protocols should ideally be harmonized with suggested clinical practice for Barrett's esophagus surveillance 1.
- The objective of surveillance endoscopy is not only to assess for recurrent or metachronous dysplasia but also to assess for recurrent nondysplastic Barrett's esophagus (which can present as subsquamous columnar epithelium) that might require further treatment 1.
From the Research
Definition and Relationship to Cancer
- Barrett's esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia 2.
- It is a precursor to esophageal adenocarcinoma, a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms 2.
- The presence of Barrett's esophagus increases the risk of esophageal adenocarcinoma several-fold 2.
Risk of Progression to Cancer
- The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia 3.
- Risk factors for cancer in Barrett's esophagus include chronic GERD, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity with an intra-abdominal body fat distribution 3.
Diagnosis and Management
- Screening for Barrett's esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines 2.
- Endoscopic eradication therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for patients with high-grade dysplasia 3.
- Endoscopic surveillance at intervals of 3-5 years is recommended for patients with Barrett's esophagus without dysplasia 4, 3.
- Endoscopic ablative therapy (RFA) is the preferred treatment modality for dysplastic Barrett's esophagus 4.
Treatment Options
- For patients with Barrett's esophagus with low-grade dysplasia, radiofrequency ablation (RFA) is the preferred treatment modality, while endoscopic surveillance every 12 months is an acceptable alternative in patients with life-limiting comorbidities 4.
- For most patients with Barrett's esophagus and high-grade dysplasia, RFA is the preferred treatment strategy 4.
- Patients with intramucosal adenocarcinoma (T1a), should be treated with EMR followed by ablative therapy, in order to eradicate the remaining intestinal metaplasia 4.