Surveillance and Mortality in Esophageal Adenocarcinoma
Surveillance and Mortality in Esophageal Adenocarcinoma
Objectives: Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC.
Methods: All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up.
Results: In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64–0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16–0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58–0.76).
Conclusions: Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.
Over the past decades, esophageal adenocarcinoma (EAC) has been shown to have the most rapidly rising incidence of all malignancies in the Western world. Despite improving diagnostic modalities, EAC is frequently detected at an advanced stage, making treatment with a curative intention no longer possible. The incidence of Barrett's esophagus (BE), the premalignant precursor lesion of EAC, is also rising. As the risk of progression to EAC is increased in BE, guidelines recommend participation in an endoscopic surveillance program once a diagnosis of BE is established.
Surveillance participation for BE has been shown to be associated with a lower tumor stage at the time of EAC detection. However, results regarding better survival in surveilled participants are not largely available and conflicting. Two studies were not able to show a survival advantage, including a recently published case–control study. Moreover, studies showing an improvement of mortality in surveillance participants were based on small patient populations and did not perform multivariable analyses.
The objective of the current study was to compare EAC patients with a prior BE diagnosis participating in a surveillance program with patients not participating in such a program. In addition, we identified predictive factors for all-cause mortality at 2-year and 5-year follow-up, including the role of surveillance, in a large nationwide population-based cohort of patients with EAC. Our hypothesis was that mortality was lower in adequately surveilled patients when compared with patients not participating in a surveillance program before EAC diagnosis.
Abstract and Introduction
Abstract
Objectives: Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC.
Methods: All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up.
Results: In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64–0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16–0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58–0.76).
Conclusions: Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.
Introduction
Over the past decades, esophageal adenocarcinoma (EAC) has been shown to have the most rapidly rising incidence of all malignancies in the Western world. Despite improving diagnostic modalities, EAC is frequently detected at an advanced stage, making treatment with a curative intention no longer possible. The incidence of Barrett's esophagus (BE), the premalignant precursor lesion of EAC, is also rising. As the risk of progression to EAC is increased in BE, guidelines recommend participation in an endoscopic surveillance program once a diagnosis of BE is established.
Surveillance participation for BE has been shown to be associated with a lower tumor stage at the time of EAC detection. However, results regarding better survival in surveilled participants are not largely available and conflicting. Two studies were not able to show a survival advantage, including a recently published case–control study. Moreover, studies showing an improvement of mortality in surveillance participants were based on small patient populations and did not perform multivariable analyses.
The objective of the current study was to compare EAC patients with a prior BE diagnosis participating in a surveillance program with patients not participating in such a program. In addition, we identified predictive factors for all-cause mortality at 2-year and 5-year follow-up, including the role of surveillance, in a large nationwide population-based cohort of patients with EAC. Our hypothesis was that mortality was lower in adequately surveilled patients when compared with patients not participating in a surveillance program before EAC diagnosis.
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