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Identifying esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus can improve survival in this population, but some lesions are missed at initial endoscopy.

In a systematic review and meta-analysis recently published in , a group led by Tarek Sawas, MD, MPH, of the University of Texas Southwestern Medical Center in Dallas, and Sachin Wani, MD, of the University of Colorado Anschutz Medical Campus in Aurora, estimated the proportion of post-endoscopy esophageal adenocarcinoma (PEEC) arising in the first year after an index diagnosis of non-dysplastic Barrett's esophagus.

Data came from 52 studies including 145,726 patients with a median follow-up of 4.8 years. What Sawas, Wani, and their colleagues found was disturbing, and they elaborated on this in the following interview with the Reading Room.

What was the clinical context in which your group decided to do this review and meta-analysis?

Sawas and Wani: The incidence of EAC has been rising in the past several decades, with only marginal improvements in mortality despite the extensive screening and surveillance efforts.

As in the concept of missed colorectal cancer after colonoscopy, there's a growing literature describing missed Barrett's esophagus-related high-grade dysplasia (HGD) and EAC after upper endoscopy. PEEC was introduced as a possible explanation for this suboptimal outcome, which undermines the effectiveness of screening and surveillance endoscopy practices.

Understanding the magnitude of PEEC is the first critical step in the development of an evidence-based consensus to potentially explain and develop measures to reduce PEEC in clinical practice.

What questions were you seeking to answer?

Sawas and Wani: Our aims in this systematic review and meta-analysis were to estimate the proportion of PEEC in adults with Barrett's esophagus and to conduct a time-trend analysis of PEEC over the past 3 decades to assess if this proportion has changed.

The proportion of PEEC was defined by dividing the number of EAC detected in the first year after index endoscopy over the total number of EAC. Similarly, PEEC with HGD was defined by dividing the number of HGD and EAC in the first year over the total number of HGD and EAC.

What were the most striking findings and did any come as a surprise?

Sawas and Wani: The most striking result was the high proportion of EAC and HGD detection in the first year after the initial diagnosis of non-dysplastic Barrett's esophagus. In fact, our study found that close to one quarter of HGD and EAC cases were diagnosed within a year of a negative upper endoscopy.

This rose to 26% when HGD and EAC were combined. These findings highlight the significant burden of missed HGD/EAC after the index endoscopy.

And we were surprised that the proportion of PEEC has been strikingly rising over the last 3 decades and increased from 5% in the 1990s to 30% currently.

Did the findings align with or differ from those from previous research in this area?

Sawas and Wani: Our work is in alignment with previous research. By performing a meta-analysis, we pooled the body of data from previous research and provided the highest level of evidence to estimate the actual burden of PEEC.

Despite the limits of meta-analyses, is there a strong bottom-line message from yours for gastroenterologists?

Sawas and Wani: The take-away message is that PEEC poses a significant and rising burden in clinical practice and accounts for nearly 25% of all EACs.

What are the clinical implications and will they have any impact in the near future on clinical practice at your center?

Sawas and Wani: Appraisal of the true magnitude of PEEC has laid the foundation for an evidence-based consensus study to standardize the terminology, identification, analysis, and reduction of PEEC cases in clinical practice.

For the present, best-practice recommendations should be implemented. These include adequate inspection time, as well as the use of high-definition white-light endoscopy in conjunction with virtual chromoendoscopy and appropriate sampling of the Barrett's esophagus segment using the Seattle biopsy protocol.

What's the next research step that needs to be taken?

Sawas and Wani: Rising rates of PEEC in recent years call for future research on interventions that focus on quality measures and educational tools designed to improve detection of Barrett's esophagus-related neoplasia.

You can read the abstract of the study here, and about the clinical implications of the study here.