Review
Risk of Esophageal Adenocarcinoma and Mortality in Patients With Barrett's Esophagus: A Systematic Review and Meta-analysis

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Background & Aims

As the risk of esophageal adenocarcinoma (EAC) and mortality in patients with Barrett's esophagus (BE) are important determinants of the potential yield and cost-effectiveness of BE surveillance, clarification of these factors is essential. We therefore performed a systematic review and meta-analysis to determine the incidence of EAC and mortality due to EAC in BE under surveillance.

Methods

Databases were searched for relevant cohort studies in English language that reported EAC risk and mortality due to EAC in BE. Studies had to include patients with histologically proven BE, documented follow-up, and histologically proven EAC on surveillance. A random effects model was used with assessment of heterogeneity by the I2-statistic and of publication bias by Begg's and Egger's tests.

Results

Fifty-one studies were included in the main analysis. The overall mean age of BE patients was 61 years; the mean overall proportion of males was 64%. The pooled estimate for EAC incidence was 6.3/1000 person-years of follow-up (95% confidence interval, 4.7–8.4) with considerable heterogeneity (P < .001; I2 = 79%). Nineteen studies reported data on mortality due to EAC. The pooled incidence of fatal EAC was 3.0/1000 person-years of follow-up (95% confidence interval, 2.2–3.9) with no evidence for heterogeneity (P = .4; I2 = 7%). No evidence of publication bias was found.

Conclusions

Patients with BE are at low risk of malignant progression and predominantly die due to causes other than EAC. This undermines the cost-effectiveness of BE surveillance and supports the search for valid risk stratification tools to identify the minority of patients that are likely to benefit from surveillance.

Section snippets

Search Strategy

PubMed, EMBASE, and Web of Science databases were systematically searched for cohort studies reporting on EAC risk and mortality due to EAC in patients with BE, published between 1966 and September 2008. The following keywords were used for: (1) BE: Barrett's esophagus, Barrett's metaplasia, Barrett's mucosa, Barrett's epithelium, columnar-lined esophagus, specialized intestinal metaplasia; (2) EAC: esophageal adenocarcinoma, esophageal cancer, esophageal neoplasm, esophageal malignancy,

Results

The search strategy yielded 7200 abstracts, of which 190 were relevant to the review topic and subsequently reviewed. Following evaluation of the full text papers, 51 articles met the inclusion criteria and were included in the final analysis.2, 11, 12, 14, 15, 17, 18, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69

Discussion

Both the incidence rate of progression to EAC and mortality due to EAC are critical factors for the cost effectiveness of surveillance.13, 19 Our meta-analysis showed that the overall estimate of the incidence of EAC in patients with BE was 6.3 cases per 1000 pyrs and that the overall incidence of EAC and HGD combined was 10.2/1000 pyrs, which corresponded to an annual risk of 0.6% and 1.0%, respectively. Furthermore, the overall estimate of mortality due to EAC in patients with BE was 3.0/1000

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  • Cited by (0)

    This article has an accompanying continuing medical education activity on page e32. Learning Objectives—At the end of this activity, the learner should recognize the low risk of esophageal adenocarcinoma in Barrett's esophagus and appreciate that no randomized trials have compared surveillance to a no surveillance strategy.

    Conflict of interest The authors disclose no conflicts.

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