Clinical Question: What is the prognosis for patients who have long-segment Barrett’s esophagus with intestinal metaplasia?

Setting: Outpatient (specialty)

Study Design: Cohort (prospective)

Synopsis: In this long-term, follow-up study, investigators enrolled 105 Dutch patients with at least 3 cm of Barrett’s esophagus, no cancer or high-grade dysplasia, and specialized intestinal metaplasia in a biopsy specimen. Previous studies have shown that only patients with specialized intestinal metaplasia are at risk for progression to cancer or high-grade dysplasia, and that this risk is greater with longer segments of Barrett’s esophagus. Thus, this is a particularly high-risk subset among all patients with Barrett’s esophagus.

Patients were followed for a mean of 12.7 years. Forty-six patients underwent two or more repeat endoscopies; the other 59 had one or no repeat endoscopies during the follow-up period. The physicians of all 105 patients were contacted and asked whether each patient was alive, whether the patient had been diagnosed with esophageal cancer, and, if he or she died, what the cause of death was. Follow-up was complete, with a total of 1,329 patient-years.

Although 72 patients died during the follow-up period, only three died of esophageal cancer. Five patients were diagnosed with high-grade dysplasia and six were diagnosed with cancer during the follow-up period, an average of 0.8 percent per year. Some patients may have died with esophageal cancer or high-grade dysplasia that was undetected because not all had regular endoscopy.

Bottom Line: Esophageal cancer is uncommon, even in patients with long segment Barrett’s esophagus and intestinal metaplasia. Whether intensive endoscopic surveillance improves clinical outcomes is unclear. Nevertheless, endoscopic surveillance remains the standard of care in most countries. (Level of Evidence: 1b–)