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BE progresses to cancer at only 0.12% per year

Clinical Question:
What is the annual incidence rate of esophageal carcinoma among patients with Barrett's esophagus?

Bottom Line:
These results found a very low rate of progression to cancer among patients with Barrett's esophagus (BE). The high rate of detection during the first year after diagnosis with BE (probably related to an initial misdiagnosis) suggests a possible role for repeat endoscopy at 6 months or 1 year. But widespread enthusiasm for surveillance of all patients with BE should be tempered by these findings. (LOE = 1b)

Reference:
Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch-Jensen P. Incidence of adenocarcinoma among patients with Barrett's esophagus. N Engl J Med 2011;365(15):1375-1383.  [PMID:21995385]

Study Design:
Cohort (prospective)

Funding:
Foundation

Setting:
Population-based

Synopsis:
Previous studies addressing this question used small selected populations of patients, and took place largely in referral and university settings. They estimated an annual incidence of esophageal cancer of 0.5% to 0.6% among patients with BE. This study, which included the entire Danish population over a period of 17 years, provides by far the best evidence to date regarding this question. The authors used data from the Danish Pathology Registry to identify patients with BE, low-grade dysplasia, and high-grade dysplasia. They used the Danish Cancer Registry to identify incident cases of esophageal adenocarcinoma occurring subsequent to the diagnosis of BE. There were a total of 11,028 patients with BE, of whom 69% were men; the median patient age was 63 years. Patients were followed up for a median of 5.2 years following diagnosis of BE. A total of 193 incident cancers were diagnosed, but 131 were diagnosed during the first year of follow-up, likely because they was present at the time of the BE diagnosis but were overlooked by the operator or because the wrong part of the esophagus was sampled. After the first year, the incidence rate of malignancy was 0.12% per year, far lower than in previous studies. The rate was somewhat higher in men (0.15% vs 0.05%) and in older patients (0.02% in patients aged 30 to 49 years, 0.1% in 50- to 69-year-olds, and 0.18% in those 70 years and older). Patients with low-grade dysplasia during their initial endoscopy also had a higher incidence of cancer (0.51% per year). Interestingly, the use of proton pump inhibitors did not result in a lower rate of progression, although the study was somewhat underpowered for that comparison.

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