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Drogo
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Quote Drogo Replybullet Topic: Screening
    Posted: 11†Nov†2011 at 1:20am
This was posted on Medscape during the week. I think it is advocating less ongoing screening for Barretts patients. What do others think?

This is the cover paragraph with their special report. This article addresses whether there is too much screening--at least, I think that what it is discussing. Again, this is Medscape's material but they indicated it could be shared, printed, emailed, so here it is.

Medscape Special Report Ė November 9, 2011

Barrett Esophagus
From Medscape Gastroenterology

Expert Commentary and Insight

Barrett Esophagus: Are We Screening Too Often?

Barrett Esophagus and Cancer: Not A Clear Link

Risk for Progression to Cancer in Barrett Esophagus

Esophageal Cancer: New Ideas About Risk and Management
An Expert Interview With Jaffer A. Ajani, MD

Recent News

Cancer Risk in Barrett Esophagus Lower Than Expected

Barrett Esophagus Poses Less Cancer Risk Than Thought

Guidelines for Your Practice

Screening for Barrett Esophagus

Want More Information on Barrett Esophagus? Bookmark the Barrett Esophagus Center for the latest news and perspectives.

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From Medscape Gastroenterology > Johnson on Gastroenterology
Barrett Esophagus: Are We Screening Too Often?
David A. Johnson, MD
Authors and Disclosures
Posted: 11/04/2011
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Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School.

Surveillance and diagnosis are part of the mainstay of evaluation for Barrett's esophagus (BE) in patients with reflux disease. This has been predicated on knowing that BE is a precancerous condition associated with progression to cancer at an estimated incidence of 0.4%-0.5% per year, and to high-grade dysplasia at 0.9% per year. The incidence that we quote to patients is 1.5% yearly progression to high-grade dysplasia cancer.

Those studies were done some time ago, and 2 new, very large epidemiologic studies are changing the waterfront of BE. One was published in the Journal of the National Cancer Institute [1] in July; this study came from Ireland. It was a very large database, including all patients with BE, capturing data from more than 8000 patients. The mean duration of follow-up was 7 years (range: 1-20 years). The de novo progression to cancer from BE (excluding incident cancers) at 1 year was 0.13%. This incidence is very low and very different from 0.4%-0.5% per year, which had estimated the risk to be 30-40 times that of the general population. The risk is now down to 10-11 times the risk in the general population.

The most recent study, published in The New England Journal of Medicine [2] in October, shows essentially the same information, this time coming from a study in Denmark that included all patients with BE, and excluded cancer found within the first year after diagnosis. The mean follow-up was 6 years, and the rate of progression to cancer was 0.12% per year. Progression to cancer was 3 times more common in men than women. The risk in women was inordinately low.

Let me put this in perspective for you. If you look at cost modeling studies that have been done in the past (one that comes to mind is from 2003 in the Annals of Internal Medicine [3]) they found that screening or surveillance of BE was effective from a cost standpoint, at 5-year intervals if the incident cancer risk was ≥ 1.9% per year. At 1.9%, we are talking about 4 times the rates that are being reported now. The incident rate is considerably lower than 0.1%-0.13%, the rate at which it was cost-effective to screen at 5-year intervals. The current guidelines recommend 3-year follow-up for BE. This raises the question: is it cost-effective at the present time, when, because of dollar restrictions we are tossing out things like Pap smears and prostate-specific antigen tests? Surveillance in BE is certainly now subject to cost evaluation.

Throw in the most recent study that comes from a Dr. Wani and colleagues,[4] a 5-site multicenter study that looked at the progression from low-grade dysplasia to cancer. Data were analyzed for 210 patients, and specimens were reviewed by centralized pathologists. The progression rate from low-grade dysplasia to esophageal adenocarcinoma (with a follow-up of 6 years) was 0.44% per year. In progression to cancer risk, this group did not differ from patients who had no low-grade dysplasia at study entry. The study also reiterated that there is terrible concordance for agreement on low-grade dysplasia. The kappa value was 0.14, which indicates poor agreement. Intra-observer variability was very high. This study raises red flags about the paradigm of 6-month evaluations for patients with low-grade dysplasia.

No cancers were evident in the low-grade dysplasia patients within 2 years of the diagnosis of low-grade dysplasia, so it also raises the question, could we potentially lengthen out the surveillance of low-grade dysplasia patients to longer intervals? We return to the bottom line. In the present day, no data suggest that patients with BE die at a higher rate than patients without BE. No data say that patients with BE under surveillance die at a lower rate than patients without surveillance. Even for esophageal adenocarcinomas, the risk for death doesn't seem to be higher in patients with BE under surveillance strategies.

The take-home message is that we need to re-evaluate the evaluation of risk in BE, and guideline committees need to incorporate these data, recognizing that these data are all European, and the biopsy protocols are different in Europe. The definition of intestinal dysplasia is not requisite for the diagnosis of BE in Europe as it is in the United States. These data raise a number of important questions about the relative risk for patients with BE. Do they need surveillance if they don't have dysplasia? Do patients with dysplasia need surveillance at lengthened intervals?

These findings suggest that we should not be ablating patients with low-grade dysplasia or metaplasia outside of research protocols. Certainly in clinical practice, I don't think that should be the standard of care, nor would it be justifiable in the present day based on the cost evaluation and the relative risks for these patients.

There is a lot on the plate for discussion. BE guidelines committees should convene in a more rapid fashion and reassess the relative risk, and provide guidance so we can achieve cost-effective medicine for our patients with BE.

So, let's pause, take a step back, and look at BE with a lot less concern than we used to. There is no question that BE is a precancerous condition and that it is associated with adenocarcinoma of the esophagus. As the biologic behavior of BE has become better understood, the relative clinical significance has dwindled. In your next conversation with your patients with BE, put this into perspective and evaluate the strategies for surveillance. Hopefully, the guidelines will also provide us with some meaningful changes in the not-too-distant future.

I'm Dr. David Johnson. Thanks again for listening.

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chrisrob
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Quote chrisrob Replybullet Posted: 11†Nov†2011 at 9:23am
Hi again Danielle,

We discussed the NEJM report of the Denmark study cited in this article a few weeks ago.
The worrying aspect is that it will probably lead to recommendations to increase the period between surveillance scopes. It will save NHS a lot of money. But will it increase anxiety in patients? After all, if the risk of developing cancer is only one in 200 per year, how do we know we're not the one in 200?

A study using BOC's UKBOR data has revealed that those with rhesus negative blood type are at greater risk than those with rhesus positive. So it may be that those of us who are rhesus positive will have less frequent screening as a compromise?

The other worrying aspect of this report is "These findings suggest that we should not be ablating patients with low-grade dysplasia." ie. HALO will be restricted to HGD even more than presently - instead of moving towards the possibility of HALO for all.

The concern is, those who make the decisions on these issues may be guided more by financial considerations than conideration for patient anxiety.

Chris


Edited by chrisrob - 11†Nov†2011 at 9:25am
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Quote jcombs99 Replybullet Posted: 11†Nov†2011 at 2:30pm
D and C
ASK the doctor IF he OR his kids had BE would he ablate ? I DID   !!!!!!!
   I've been saying this all along " It's all about the MONEY "... I got new ins. on 9/1 and HALO on 9/5 and was worried BECAUSE you never know what the bill will be (sell my car)... Well by now I THINK I have all the bills BUT will post if I'm wrong .
Almost the same price with my ins. as a EGD.. .Thats means EGD with Sedition then Halo 90 ...

(USA)...Cheap HGD Jeff

Edited by jcombs99 - 11†Nov†2011 at 2:41pm
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lizthebob
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Quote lizthebob Replybullet Posted: 11†Nov†2011 at 6:47pm
I know I've said it before but as one of the very small percentage who has gone on to develop cancer, screening has literally saved my life. If I had nlt been screened or they had left it more than 6 months I would not be here to tell the tale, and I am a low risk woman and a young one and one who doesn't smoke or drink.
For me I'm glad screening saved my life.
I work at the hospital where I received my treatment and I was horrified last week to see they are cutting back on screening. Isn't one life saved worth it?
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Quote Cinders Replybullet Posted: 11†Nov†2011 at 10:55pm
Thats my main worry, that the financial restrictions being put into place, will completely change our chances of having the correct procedure........I am two thirds of the time between scans, and cant help wondering if I should pay to have another
 opinion rather than wait for another 6 months, to know whats going on inside!!  But I know the consultant I am under has a real attitude to anyone having private treatment................and where i live there is no other way of having another opinion...............living in an isolated part of Scotland.
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Quote jcombs99 Replybullet Posted: 12†Nov†2011 at 6:23pm
C
   You always have to look at the cost of it and if you think it's worth it ..If you just have barretts I wouldn't do it BUT make sure it's 6 months!!! Maybe next time TRAVEL and get one at a year and let the NHS do at 2 years and DON"T tell them thats all .
I just found out Meditcare which EVERYONE is on at 65 wants to limit your hospital stay to 10 to 25 days a YEAR depending on the state you live in .They want to insure everyone with POOR health care ...

Take Care
JEFF

Edited by jcombs99 - 12†Nov†2011 at 6:25pm
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Quote johnd Replybullet Posted: 12†Nov†2011 at 7:17pm
I am just a layman, but so far as I am aware, the treatment and monitoring in the NHS is dictated by NICE, which basically lays down what you can and can't have. If NICE say you can have it, I think that's it. If there is someone on the forum who understand how treatment is approved, please put us to rights.

If NICE do decide to decrease the monitoring, it will have to justify it based on good evidence. They will find it hard because the stats on oesophageal cancer are not great. I understand that there are critics of monitoring, who say it holds no guarantee of detection and some cancers just come out of the blue. There's a lot of arguments out there, new studies etc which will all be considered.

Personally, and as a total panicker, I think that I will choose to pay for a private gastroscopy at a cost of £1200 inbetween NHS scopes, so it works out £600 p.a.   Damn annoying - so its goodbye smartphone, big telly and all other silly luxuries. Well - the odd guitar may slip through the net ....
55yo, diagnosed 2011 at 5cm Barrett's, 3cm as at 2013 (?), so far non-D
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Quote Cinders Replybullet Posted: 12†Nov†2011 at 11:33pm
Thanks for your messages..............great to know there is such support out there...........living in an isolated part of the world has its drawbacks, and my GP tends to ask me what would I like to do??!! Not a lot of help really when I am having one of my panics about cancer, which happens every time I lose another friend to the disease!! My daughter lost a university friend two days ago, who was 40 ...................no justice in the world at all!!
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Quote Yaya Replybullet Posted: 05†Jun†2019 at 9:31pm
Hi Jeff,

Im the mother of a 19 years old daughter with 1 cm of segment of Barrett no displasic! I would like to eradicate it and my daughter too and not to wait until is progressed!! Also she doesnít want to take PPI all her life! So l understand what do you said!
We are living in USA ( Miami) if by any chance you know a good surgeon to eradicate it will be amazing! She had also a small hernia ( around 3 cm) !
Thank you so much for your understanding and help !
Lydia( yaya)
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