From the AGA Journals

Esophageal cancer screening isn’t for everyone: Study

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One size doesn’t fit all

Over the past decades we have seen an alarming rise in the incidence of esophageal adenocarcinoma, mostly diagnosed at an advanced stage when curative treatment is no longer an option. Esophageal adenocarcinoma develops from Barrett’s esophagus that, if known to be present, can be surveilled to detect dysplasia and cancer at an early and curable stage.

Dr. R.E. Pouw

Therefore, Barrett’s esophagus and early esophageal adenocarcinoma would be ideal screening targets since this could prevent significant disease burden and health care costs. However, optimal screening strategies should be personalized, cost effective, and most importantly cause no harm to healthy subjects.

Whereas currently screening for Barrett’s esophagus focused on White males with gastroesophageal reflux, little was known about screening in non-White and non-male populations. Identifying who and how to screen poses a challenge, and in real life such studies looking at varied populations would require many patients, years of follow-up, much effort and substantial costs. Rubenstein and colleagues used three independent simulation models to simulate many different screening scenarios, while taking gender and race into account. The outcomes of this study, which demonstrate that one size does not fit all, will be very relevant in guiding future strategies regarding screening for Barrett’s esophagus and early esophageal adenocarcinoma. Although the study is based around endoscopic screening, the insights gained from this study will also be relevant when considering the use of nonendoscopic screening tools.

R.E. Pouw, MD, PhD, is with Amsterdam University Medical Centers. She disclosed having been a consultant for MicroTech and Medtronic and having received speaker fees from Pentax.



Endoscopic screening for esophageal adenocarcinoma (EAC), may not be a cost-effective strategy for all populations, possibly even leading to net harm in some, according to a comparative cost-effectiveness analysis.

Several U.S. guidelines suggest the use of endoscopic screening for EAC, yet recommendations within these guidelines vary in terms of which population should receive screening, according study authors led by Joel H. Rubenstein, MD, of the Lieutenant Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Mich. Their findings were published in Gastroenterology. In addition, there have been no randomized trials to date that have evaluated endoscopic screening outcomes among different populations. Population screening recommendations in the current guidelines have been informed mostly by observational data and expert opinion.

Existing cost-effectiveness analyses of EAC screening have mostly focused on screening older men with gastroesophageal reflux disease (GERD) at certain ages, and many of these analyses have limited data regarding diverse patient populations.

In their study, Dr. Rubenstein and colleagues performed a comparative cost-effectiveness analysis of endoscopic screening for EAC that was restricted to individuals with GERD symptoms in the general population. The analysis was stratified by race and sex. The primary objective of the analysis was to identify and establish the optimal age at which to offer endoscopic screening in the specific populations evaluated in the study.

The investigators conducted their comparative cost-effectiveness analyses using three independent simulation models. The independently developed models – which focused on EAC natural history, screening, surveillance, and treatment – are part of the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network. For each model, there were four cohorts, defined by race as either White or Black and sex, which were independently calibrated to targets to reproduce the EAC incidence in the United States. The three models were based on somewhat different structures and assumptions; for example, two of the models assumed stable prevalence of GERD symptoms of approximately 20% across ages, while the third assumed a near-linear increase across adulthood. All three assumed EAC develops only in individuals with Barrett’s esophagus.

In each base case, the researchers simulated cohorts of people in the United States who were born in 1950, and then stratified these individuals by race and sex and followed each individual from 40 years of age until 100 years of age. The researchers considered 42 strategies, such as no screening, a single endoscopic screening at six specified ages (between 40 and 65 years of age), and a single screening in individuals with GERD symptoms at the six specified ages.

Primary results were the averaged results across all three models. The optimal screening strategy, defined by the investigators, was the strategy with the highest effectiveness that had an incremental cost-effectiveness ratio of less than $100,000 per quality-adjusted life-year gained.

The most effective – yet the most costly – screening strategies for White men were those that screened all of them once between 40 and 55 years of age. The optimal screening strategy, however, was one that screened individuals with GERD twice, once at age 45 years and again at 60 years. The researchers determined that screening Black men with GERD once at 55 years of age was optimal.

By contrast, the optimal strategy for women, whether White or Black, was no screening at all. “In particular, among Black women, screening is, at best, very expensive with little benefit, and some strategies cause net harm,” the authors wrote.

The investigators wrote that there is a need for empiric, long-term studies “to confirm whether repeated screening has a substantial yield of incident” Barrett’s esophagus. The researchers also noted that their study was limited by the lack of inclusion of additional risk factors, such as smoking, obesity, and family history, which may have led to different conclusions on specific screening strategies.

“We certainly acknowledge the history of health care inequities, and that race is a social construct that, in the vast majority of medical contexts, has no biological basis. We are circumspect regarding making recommendations based on race or sex if environmental exposures or genetic factors on which to make to those recommendations were available,” they wrote.

The study was supported by National Institutes of Health/National Cancer Institute grants. Some authors disclosed relationships with Lucid Diagnostics, Value Analytics Labs, and Cernostics.

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