If you’re living with Barrett’s esophagus, a precursor to esophageal cancer, you have a lot of healthcare choices to make.
New clinical practice guidelines may make some of those choices easier when made with your healthcare team.
Published in the journal Gastroenterology, the “Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett’s Esophagus and Related Neoplasia” has updated evidence-based guidance for Barrett’s esophagus patients. The American Gastroenterological Association (AGA) authored the revised guidelines.
A primer on Barrett’s esophagus
Barrett’s esophagus happens when prolonged acid reflux damages the protective lining of the esophagus, causing it to redden and thicken. The esophagus is a swallowing tube that links the mouth and the stomach. Consistent irritation can cause tissue damage and changes to the esophagus on a cellular level.
Clinically speaking, this damage can make the lining of the esophagus look more like the lining of the intestines. This is called intestinal metaplasia, where tissue in one part of the body replaces itself with tissue found elsewhere biologically. Though the risk is minimal, metaplasia can increase the risk for cancer.
Metaplasia can progress to dysplasia, which indicates the presence of precancerous cells that can be reversible. Dysplasia is considered low-grade or high-grade, depending on the degree of cellular change.
The latest guidelines for Barrett’s esophagus patients address an array of concerns for this population. Among them is how to consider the option of undergoing endoscopic eradication therapy for potential esophageal cancer risk reduction.
Endoscopic eradication therapy consists of minimally invasive procedures, such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), followed by ablation (burning or freezing) techniques.
Key guideline takeaways
Here’s what patients with Barrett’s esophagus need to know about the guidelines:
- For patients with low-grade dysplasia, it may be appropriate to either remove or monitor the cells. This is a decision doctors and patients should make together after discussing the risks and benefits of treatment. “While the benefit is clear for patients with high-grade dysplasia, we suggest considering endoscopic eradication therapy for patients with low-grade dysplasia after clearly discussing the risks and benefits of endoscopic therapy,” said guideline author Dr. Tarek Sawas. “A patient-centered approach ensures that treatment decision is made collaboratively, taking into account both the medical evidence and the patient’s preferences and values. Surveillance is a reasonable option for patients who place a higher value on harms and a lower value on the uncertain benefits regarding reduction of esophageal cancer mortality.”
- For patients with high-grade dysplasia, AGA recommends endoscopic therapy to remove the abnormal precancerous cells.
- Most patients undergoing endoscopic eradication can be safely treated with EMR, which has a lower risk of adverse events. Patients who undergo ESD can face an increased risk of strictures and perforation. AGA recommends reserving ESD primarily for lesions suspected of harboring cancers invading more deeply into the wall of the esophagus, or those who have failed EMR.
- Patients with Barrett’s esophagus (dysplasia or early cancer) should be treated and monitored by expert endoscopists and pathologists who have experience in Barrett’s neoplasia (or irreversible abnormal cell growth that leads to cancer).
The importance of the doctor-patient conversation
Another guideline author, Dr. Joel Rubenstein, emphasizes that the decision to get endoscopic eradication therapy comes down to an individual’s preferences and comfort level, as well as their doctor’s recommendations.
“We (healthcare providers) need to have a conversation with patients in clinic prior to when they show up in the endoscopy unit on a gurney,” Dr. Rubenstein said. “Patients need to be fully aware of the risks and benefits, both in the short term but also in the long run, to decide which treatment approach is best for them. This decision often comes down to personal factors and values.”
What’s more, when patients are in touch with their healthcare providers, they can take steps to better prevent or manage Barrett’s esophagus, and thereby lower their risk for dysplasia and esophageal cancer.
Another takeaway from the new guidelines is that tobacco use and obesity are risk factors for esophageal adenocarcinoma. Therefore, losing weight and quitting smoking can improve clinical outcomes.
A final takeaway from the guidelines is that patients should be aware of how best to manage acid reflux, which can cause that initial damage to the esophagus. The guidelines note that an optimal treatment plan is one that is well-rounded, including both medication and lifestyle changes.
