Evidence of Benefit
Squamous Cell Cancer
Adenocarcinoma of the Esophagus
Evidence of Harm
Squamous Cell Cancer
Squamous cell carcinoma of the esophagus does not have a highly prevalent
predisposing condition, although the incidence increases in persons who have
had long-standing exposure to tobacco and alcohol,[1] achalasia,[2] head and
neck squamous cell cancer attributable most likely to long-standing alcohol
and/or tobacco exposure,[3] tylosis,[4,5] history of lye ingestion,[6] celiac
sprue,[7] and, in South America and China, hot liquid ingestion.[8] The
etiological role of human papillomavirus infection in squamous cell cancer is
under study.[9,10]
Efforts at early detection of squamous cell cancer of the esophagus have
concentrated on cytological or endoscopic screening of populations in countries
where there is a high incidence. Although these programs have demonstrated
that it is possible to detect squamous cell cancers in an early asymptomatic
stage, no data on efficacy (e.g., mortality reduction) have been published.
Esophageal cytological screening studies have been reported from China,[11,12]
Iran,[13] South Africa,[14,15] Italy,[16] and Japan.[17] In the United States,
such efforts have been focused on individuals perceived to be at higher
risk.[18,19] Studies of primary endoscopic screening have been reported from
France [20] and Japan.[21]
Comparisons of both Chinese and U.S. cytological diagnoses with concurrent
histological findings showed low (14% to 36%) sensitivities for the cytological
detection of biopsy-proven cancers. Specificity ranged from 90% to 99% with a
positive predictive value of 23% to 94%.[22] The development of uniform and
accurate cytological criteria will require formal cytological-histological
correlation studies of esophageal lesions. Such studies should become more
feasible with the increasing availability of endoscopy in high-risk
populations.
The efficacy of surveillance cytology or endoscopy for high-risk patients with
tylosis or long-standing achalasia is not known.
Adenocarcinoma of the Esophagus
Considerable debate has ensued concerning the risk of cancer in patients with Barrett
esophagus. Prospective studies have reported annual esophageal cancer
incidence rates ranging from 0.2% to 1.9%.[23] Concern over publication bias
has led some authors to suggest that the risk may be lower than the literature
suggests.[24] A risk of 0.5% per year for development of adenocarcinoma is now
thought to be a reasonable estimate for Barrett esophagus.[25]
Barrett esophagus is strongly associated with gastroesophageal reflux disease
(GERD), and the changes of Barrett esophagus can be found in approximately
10% of patients who have GERD. However, GERD is very common; surveys have
found that approximately 20% of adult Americans experience symptoms of GERD,
such as heartburn, at least once each week.[26] The likelihood of finding
Barrett esophagus on endoscopy is related to the duration of symptoms of
gastroesophageal reflux. In a series of 701 individuals, 4% of those with
symptoms for less than 1 year had Barrett esophagus on endoscopy, whereas
Barrett esophagus was found in 21% of those with more than 10 years of
symptoms of GERD. It has been estimated that physicians identify only
approximately 5% of the population who have Barrett esophagus.[27] There is insufficient evidence that population screening for Barrett esophagus reduces cancer mortality.[28,29]
Surveillance of Barrett esophagus involves the use of tests to identify
preneoplastic changes or curable neoplasms in patients who are known to have
Barrett esophagus. Certain factors are essential in the implementation of an
effective surveillance protocol, including low risk of the surveillance method,
correct histological diagnosis of dysplasia, proof that surgical resection for
high-grade dysplasia will decrease the risk of cancer, and successful resection
of cancer. The interval between endoscopic evaluations is typically determined
by histologic findings, in accordance with published guidelines by
gastroenterological committees.[30] GERD should be treated prior to
surveillance endoscopy to minimize confusion caused by inflammation in the
interpretation of biopsy specimens. The technique of random, four-quadrant
biopsies taken every 2 cm in the columnar-lined esophagus for standard
histological evaluation has been recommended by some clinicians. For patients
with no dysplasia, surveillance endoscopy at an interval of every 2 to 3 years
has been recommended.[30] For patients with low-grade dysplasia, surveillance
every 6 months for the first year has been recommended, followed by annual
endoscopy if the dysplasia has not progressed in severity. For patients with
high-grade dysplasia, two options have been recommended: surgical
resection or repeated endoscopic evaluation until the diagnosis of intramucosal
carcinoma is made. Although widely adopted in clinical practice, these
practices are based on uncontrolled series and the opinion of expert
gastrointestinal endoscopists and pathologists.
Other techniques to potentially identify dysplastic epithelium that could then
be sampled extensively include chromoendoscopy [31] and laser-induced
fluorescence spectroscopy.[29,32]
Evidence of Harm
Screening for esophageal cancer by the use of blind nonendoscopically directed balloon cytological sampling for squamous cell carcinoma is minimally inconvenient and uncomfortable. Endoscopic screening for esophageal adenocarcinoma is expensive, inconvenient, and usually requires sedation.
Complications such as perforation and bleeding can occur. The incidence of complications including perforation, respiratory arrest, and myocardial infarction, has been estimated to be 0 to 13 per 10,000 procedures with an associated mortality of 0 to 0.8 per 10,000 procedures.[33,34]
Individuals who are informed they have Barrett esophagus may consider themselves to be ill even though their risk of developing cancer is very low.
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