SCREENING AND SURVEILLANCE IN PATIENTS WITH BARRETT'S ESOPHAGUS FOR EARLY DETECTION OF ESOPHAGEAL ADENOCARCINOMA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Friday, January 8, 2016
Foyer, G/F (Jockey Club School of Public Health and Primary Care Building at Prince of Wales Hospital)

Hla-Hla Thein, MD, MPH, PhD1, Yao Qiao, MSc MPH2, Ayaz Hyder, PhD3, Sandy Bae, MPH2, Wasifa Zarin, MPH4, Tyler O'Neill, D.V.M., M.Sc1, Norman Marcon, MD, FRCP(C)5 and Lincoln Stein, MD, PhD6, (1)Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, (2)University of Toronto, Toronto, ON, Canada, (3)Ohio State University, Columbus, OH, (4)St. Michael's Hospital, Toronto, ON, Canada, (5)Department of Medicine, University of Toronto, Toronto, ON, Canada, (6)Ontario Institute for Cancer Research, Toronto, ON, Canada
Purpose: Although endoscopic surveillance of patients with Barrett’s esophagus (BE) has been widely implemented for early detection of esophageal adenocarcinoma (EAC), its justification has been debated. This systematic review aimed to evaluate screening practice, benefits, safety, and cost-effectiveness of surveillance for patients with BE.

Method(s): MEDLINE, EMBASE, EconLit, Scopus, Cochrane, and CINAHL were searched for published human studies that examined screening practices, benefits, safety, and cost-effectiveness of surveillance among patients with BE. Reviewers independently reviewed eligible full-text study articles and conducted data extraction and quality assessment, with disagreements resolved by consensus. Random effects meta-analyses were performed to assess the incidence of EAC, EAC/high-grade dysplasia (HGD) and annual stage-specific transition probabilities detected among BE patients under surveillance, and relative risk of mortality among EAC patients detected during surveillance compared with those not under surveillance. To explore source of heterogeneity both within and between studies included in meta-analyses for incidence rate of EAC and EAC/HGD, we conducted random effects meta-regression using a linear mixed model based on maximum likelihood method.

Result(s): Fifty-one studies with 11,028 subjects were eligible; the majority of included studies were of high quality based on the Newcastle-Ottawa quality scale. Among BE patients undergoing endoscopic surveillance, pooled EAC incidence per 1000 person-years of surveillance follow-up was 5.5 (95% confidence interval [CI]: 4.2-6.8) and pooled EAC/HGD incidence was 7.7 (95% CI: 5.7-9.7). Pooled relative mortality risk among surveillance-detected EAC patients compared with non-surveillance-detected EAC patients was 0.386 (95% CI: 0.242-0.617). Pooled annual stage-specific transition probabilities from non-dysplastic BE to low-grade dysplasia (LGD), HGD, and EAC were 0.019, 0.003, and 0.004, respectively. There was, however, insufficient scientific evidence on safety and cost-effectiveness of surveillance for BE patients.

Conclusion(s): Our findings confirmed a low incidence rate of EAC among BE patients undergoing surveillance and a reduction in mortality by 61% among those who received regular surveillance and developed EAC. Although surveillance in BE patients has been a controversial issue, our findings provide scientific evidence of detection of precancerous LGD and HGD to support the practice of endoscopic surveillance recommended by multiple gastroenterology societies. Due to knowledge gaps, it is important to assess safety of surveillance and health care resource use and costs to supplement existing evidence and inform a future policy decision for surveillance programs.

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