UNCERTAINTY IN BARRETT'S ESOPHAGUS PROGRESSION RATES: IMPACT ON THE EFFICIENCY OF SCREENING AND ABLATION

Purpose: Estimates for the annual progression rate from Barrett’s Esophagus (BE) to esophageal adenocarcinoma (EAC) vary widely and it is also uncertain whether dysplasia and BE can spontaneously regress. These parameters are expected to be important determinants of the effectiveness and efficiency of BE screening and ablation. In this study, we have quantified the impact of different assumptions for BE progression and regression on the effectiveness and efficiency of BE screening and ablation.

Method: We developed four different versions of the UW-MISCAN model for EAC. All four models variants were calibrated to EAC rates in the U.S from 1998-2008. The models differed with respect to the annual progression rate from BE to EAC (0.12% or 0.42%) and whether spontaneous regression of dysplasia and BE was allowed (yes/no). As a consequence of these differences, the BE prevalence also differed between the models to be able to match observed SEER incidence. With each of the models, we estimated the incidence and mortality reduction of a one-time perfect screening with perfect ablation of all detected BE (with or without dysplasia), as well as the number of ablations needed to reach that reduction. 

Result: The reduction in EAC incidence and mortality ranged from 53.5%-65.2% in the four models, with the lowest reduction for the model with a 0.42% annual BE to EAC progression rate, allowing for regression and the highest for the model with a 0.12% annual BE to EAC progression rate, not allowing for regression. Because of the considerably higher BE prevalence in the models with 0.12% progression, the numbers needed to ablate were 169%-231% higher in these models compared to the 0.42% models. Consequently, there was a 6-fold difference in the numbers needed to ablate to prevent 1 EAC death between the models.

Conclusion: The range of BE progression and regression rates reported in literature lead to widely different estimates for the effectiveness and efficiency of BE screening and ablation. Decision-making about implementing BE screening and ablation is therefore greatly hampered by the uncertainty in these parameters.