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Limitations of current Barrett's screening criteria

The urgent need to include additional predictors in identifying high-risk persons for BE and EAC screening is becoming more and more clear. Here, the authors observe that 39% of EAC cases did not report heartburn - a required component of current screening eligibility.
Limitations of current Barrett's screening criteria

Clinical Gastroenterology and Hepatology (2021), doi: https://doi.org/10.1016/j.cgh.2021.10.039

Limitations of Heartburn and other Societies’ Criteria in Barrett’s Screening for Detecting De-novo Esophageal Adenocarcinoma

Sawas T, Zamani SA, Killcoyne S, Dullea A, Wang KK, Iyer PG, FitzgeraldRC, Katzka DA.

ABSTRACT

Background and aim: Despite extensive Barrett’s esophagus (BE) screening efforts, most patients with esophageal adenocarcinoma (EAC) present de novo. It is unclear how much of this problem is due to insensitivity or poor applications of current screening guidelines. We aimed to evaluate the sensitivity of guidelines by determining the proportion of prevalent EAC cases that meet the American College of Gastroenterology (ACG) or the British Society of Gastroenterology (BSG) guidelines for BE screening and determine whether changes to criteria would enhance detection.

Methods: A retrospective single center cohort from the United States (n=663) and a prospective multicenter cohort from the United Kingdom (n=645) were independently collected and analyzed. Screening eligibility was determined as patients with chronic reflux and at least two or more risk factors as defined by the guidelines. We calculated the proportion of screening eligible patients then compared BE/EAC risk factors between screening eligible and ineligible  atients using Chi2 or Student’s t-test as appropriate.

Results: In the Mayo clinic cohort, 54.9% and in the UK cohort, 38.9% of EAC cases were not identified by ACG or BSG screening criteria, respectively. Among patients who did not meet the screening criteria, lack of heartburn was observed in 86.5% in the Mayo clinic cohort and 61.4% in the UK cohort. Other risk factors that were lacking included obesity (defined as BMI=30 kg/m2)and family history. Eliminating chronic reflux from the ACG/BSG criteria improvedeligibility for screening from 45.1% to 81.3%, P<0.001 in the Mayo Clinic cohort and from 61.1% (n = 394) to 81.5% (n = 526, P<0.001) in the UK cohort. However, reflux may be difficult to ascertain from the history and by including proton pump inhibitor use status in addition to the BSG criteria, screening eligibility improved by 10.0% in the UK cohort (n = 459, P < 0.001.

Conclusion: ACG/BSG BE screening guidelines have limited ability to detect prevalent EAC. An optimized approach to identifying the individuals most suitable for EAC screening needs to be implemented, particularly one that does not rely on chronic reflux symptoms.