Original articles—alimentary tract
Adherence to Biopsy Guidelines for Barrett's Esophagus Surveillance in the Community Setting in the United States

https://doi.org/10.1016/j.cgh.2008.12.027Get rights and content

Background & Aims

Current surveillance guidelines for Barrett's esophagus (BE) recommend extensive biopsies to minimize sampling error. Biopsy practice patterns for BE surveillance in the community have not been well-described. We used a national community-based pathology database to analyze adherence to guidelines and to determine whether adherence was associated with dysplasia detection.

Methods

We identified 10,958 cases of established BE in the Caris Diagnostics pathology database from January 2002–April 2007. Demographic, pathologic, and endoscopic data were recorded. Dysplasia was categorized as low grade, high grade, or adenocarcinoma. Adherence was defined as ≥4 esophageal biopsies per 2 cm BE or a ratio ≥2.0. Generalized estimating equation multivariable analysis was performed to assess factors associated with adherence, adjusted for clustering by individual gastroenterologist.

Results

A total of 2245 BE surveillance cases were identified with linked endoscopy reports that recorded BE length and could be assessed for adherence. Adherence to guidelines was seen in 51.2% of cases. In multivariable analysis, longer segment BE was associated with significantly reduced adherence (3–5 cm, odds ratio [OR] 0.14, 95% confidence interval [CI] 0.10–0.19; 6–8 cm, OR 0.06, 95% CI 0.03–0.09; ≥9 cm, OR 0.03, 95% CI 0.01–0.07). Stratified by BE length, nonadherence was associated with significantly decreased dysplasia detection (summary OR 0.53, 95% CI 0.35–0.82).

Conclusions

Adherence to BE biopsy guidelines in the community is low, and nonadherence is associated with significantly decreased dysplasia detection. Future studies should identify factors underlying nonadherence as well as mechanisms to increase adherence to guidelines to improve early detection of dysplasia.

Section snippets

Study Design and Database

We identified patients who underwent surveillance endoscopy for previously diagnosed BE by using a database that had been maintained prospectively by Caris Diagnostics (Irving, TX). This database is derived from all patients referred to Caris Diagnostics, a provider of gastrointestinal pathology services for physicians from community-based freestanding endoscopy centers from 34 states throughout the United States.

We used WinSURGE anatomic pathology software (Computer Trust Corporation, Boston,

Results

Biopsies were received from 278,259 upper endoscopies between January 2002 and April 2007. There were 10,958 cases of BE surveillance performed in 9418 unique patients. Cases were submitted by 668 individual gastroenterologists from 214 community-based endoscopy centers in 34 states. The mean age was 62.3 years (standard deviation, 12.9), and 64.3% of the patients were male.

Endoscopy reports were available and reviewed for 4069 cases (37.1%) (Figure 1). Of these, the length of BE was recorded

Discussion

In this study of a large national community-based pathology database of nearly 11,000 patients with established BE, we found that (1) adherence to the recommended BE surveillance biopsy guidelines in the community is poor, with endoscopists following guidelines only half of the time, and (2) this failure to adhere to the guidelines is associated with reduced detection of dysplasia. These results in and of themselves are not proof that nonadherence to guidelines has an adverse impact on patient

Acknowledgments

Drs Abrams and Kapel contributed equally to this work.

The authors acknowledge the following gastroenterology centers for their participation in the study: Ambulatory Endoscopy of Dallas, Dallas, TX; Arapahoe Gastroenterology, Littleton, CO; Arizona Digestive, Glendale, AZ; Atherton Endoscopy Center, Atherton, CA; Bergen Gastroenterology, Emerson, NJ; Central Maine Endoscopy, Waterville, ME; Charlotte Endoscopy, Port Charlotte, FL; Danbury Surgery Center, Danbury, CT; East Bay Endosurgery Inc,

References (45)

  • G.W. Falk et al.

    Practice patterns for surveillance of Barrett's esophagus in the United States

    Gastrointest Endosc

    (2000)
  • R.E. Sampliner

    Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus

    Am J Gastroenterol

    (2002)
  • A.P. Weston et al.

    Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett's multifocal high-grade dysplasia or adenocarcinoma

    Am J Gastroenterol

    (1999)
  • A. Wong et al.

    Epidemiologic risk factors for Barrett's esophagus and associated adenocarcinoma

    Clin Gastroenterol Hepatol

    (2005)
  • E. Montgomery et al.

    Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation

    Hum Pathol

    (2001)
  • D.A. Corley et al.

    Abdominal obesity and body mass index as risk factors for Barrett's esophagus

    Gastroenterology

    (2007)
  • A.P. Weston et al.

    Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma

    Am J Gastroenterol

    (2000)
  • W.K. Hirota et al.

    Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction: prevalence and clinical data

    Gastroenterology

    (1999)
  • D.K. Rex et al.

    Screening for Barrett's esophagus in colonoscopy patients with and without heartburn

    Gastroenterology

    (2003)
  • A. Kubo et al.

    Marked regional variation in adenocarcinomas of the esophagus and the gastric cardia in the United States

    Cancer

    (2002)
  • H. Pohl et al.

    The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence

    J Natl Cancer Inst

    (2005)
  • A. Jemal et al.

    Cancer statistics, 2007

    CA Cancer J Clin

    (2007)
  • Cited by (0)

    To view this article's video abstract, go to the AGA's YouTube Channel.

    This article has an accompanying continuing medical education activity on page 710. Learning Objectives—After completing this CME activity, the learner should be able to understand further the epidemiology of Barrett's esophagus and adenocarcinoma, and the impact of adherence to biopsy guidelines for Barrett's esophagus in a community setting.

    Conflicts of interest The authors disclose the following: Dr Kapel is a consultant for Caris Diagnostics. Drs Lindberg, Saboorian, and Genta are pathologists for Caris Diagnostics. The remaining authors disclose no conflicts.

    Funding Dr Abrams is supported in part by a K07 award from the National Cancer Institute (CA132892). Dr Neugut is supported in part by a grant from the American Cancer Society (RSGT-01-024-04-CPHPS).

    View full text