April 21, 2023
Recurrence of intestinal metaplasia and dysplasia after complete endoscopic eradication therapy (EET) of dysplasia or early adenocarcinoma is well documented. Therefore, close surveillance of these patients is necessary.
Practice guidelines published in 2016 recommended that patients undergo frequent endoscopic surveillance after EET, with those treated for high-grade dysplasia or early cancer requiring surveillance every three months for the first year. Recent registry-based modeling studies, however, have suggested that the intervals between surveillance endoscopies could safely be lengthened.
To determine the optimal surveillance intervals for patients after EET, Mayo Clinic researchers and colleagues conducted a large international multicenter modeling study. They used recurrence data from 498 patients who underwent successful EET for dysplastic Barrett esophagus or intramucosal adenocarcinoma. The results of this study were published in Clinical Gastroenterology and Hepatology in 2022.
In this Q&A, gastroenterologist Allon Kahn, M.D., and co-authors answer key questions about this study and its findings. Dr. Kahn is a gastroenterologist at Mayo Clinic's campus in Arizona and served as the study's first author.
Why is this an important research topic right now?
Patients who are successfully treated with EET for Barrett esophagus with dysplasia or early cancer are in a unique position. They have eradicated their disease, so in many ways the hard work is done, and of course they are grateful for this excellent outcome. However, we know that dysplasia or cancer can recur, so patients must now face the prospect of indefinite endoscopic surveillance. The question has always been — how often do we really need to perform these tests?
Before your study results were published, what did available research data suggest were appropriate testing intervals for these patients?
Even through 2022, we did not have much evidence to guide the answer to this question. The last iteration of practice guidelines called for many of these patients to undergo repeat endoscopies every three months for the first year and every six months during the second year after disease remission was achieved. That is a very large number of procedures, each of which carry considerable cost to the patient, both in terms of time and resources. So we have been searching for a way to answer this question more scientifically.
What did your study results show, and how might these findings guide clinical practice or clinical trials in the future?
We examined the medical records for 498 patients undergoing treatment for Barrett esophagus with dysplasia or early cancer at Mayo Clinic and several sites in the United Kingdom. We then tabulated this information and used complex statistical modeling to analyze it. Our goal was to determine how different surveillance schedules affect the likelihood that an individual would have a recurrence of cancer or dysplasia, and how long that recurrence would be present before it was detected by a surveillance endoscopy.
"Our study showed that if patients with high-grade dysplasia or early esophageal cancer had surveillance every six months in the first two years after disease remission, and annually thereafter, no cases of dysplastic recurrence would go undetected for more than six months."
Among individuals who underwent treatment for low-grade dysplasia, our findings suggested that performing endoscopic surveillance at one year, two years and four years after remission was still safe. Both of these strategies, compared with current recommendations, would drastically reduce the number of procedures.
Not long after we published our results in 2022, the American College of Gastroenterology published updated guidelines for the management of Barrett esophagus. The new guidelines incorporated our data and suggested lengthening surveillance intervals so that patients were still safe but did not need to have unnecessary surveillance procedures.
What additional research is needed to further clarify the issues discussed in your article?
Much work remains to be done. Clinicians are still designing surveillance plans based on the diagnosis of high-grade dysplasia, low-grade dysplasia or cancer before treatment and essentially assigning patients to one of two pathways. We need additional research to guide the development of a more personalized approach that could incorporate a number of factors, including genetics, tissue molecular markers and other predictive risk factors. Mayo Clinic researchers, in concert with national and international collaborators, are currently developing an artificial intelligence-powered recurrence prediction tool to help clinicians develop surveillance intervals that are personalized to each individual after endoscopic therapy.
Furthermore, our study and others only look at predictions out to five years post-treatment. There is evidence that recurrence can happen at any time after successful treatment, but there may be patients who can safely stop surveillance after a certain number of years or negative surveillance endoscopies. We are actively examining these issues and look forward to using our findings to further improve patients' experiences.
For more information
Kahn A, et al. Optimized surveillance intervals following successful endoscopic eradication of dysplastic Barrett's esophagus: results of an international cohort study. Clinical Gastroenterology and Hepatology. 2022;20:2763.
Shaheen NJ, et al. Diagnosis and management of Barrett's esophagus: An updated ACG guideline. The American Journal of Gastroenterology. 2022;117:559.
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