Canadian task force discourages esophageal-cancer screening in GERD patients

Last Updated: 2020-07-16

By Will Boggs MD

NEW YORK (Reuters Health) - The Canadian Task Force on Preventive Health Care recommends against screening of adults with chronic gastroesophageal reflux disease (GERD) for esophageal adenocarcinoma (EAC) and precursor conditions, based on the lack of evidence for benefit.

"Although other risk factors may increase the risk for EAC, relevant trials and cohort studies did not include sufficient data within each category to support modifying our screening recommendation based on these factors, alone or in combination," task force member Dr. Stephane Groulx of the University of Sherbrooke told Reuters Health by email.

GERD is associated with a five to seven times increase in the likelihood of developing EAC, and 60% of patients with EAC report a history of GERD. However, most people with chronic GERD do not develop EAC, and predicting progression remains challenging.

Dr. Groulx and colleagues investigated whether endoscopic screening of patients with chronic GERD without alarm symptoms would detect cancer at an earlier stage, detect precancerous treatable conditions like Barrett esophagus and dysplasia, reduce progression to EAC, or decrease mortality.

Only two retrospective cohort studies assessed the effectiveness of screening versus no screening among patients with chronic GERD. One study found no significant improvement in long-term survival, and one study had insufficient data to determine whether screening reduces stage at diagnosis or mortality.

Five randomized controlled trials and one cohort study comparing different screening modalities found no statistically significant differences in detection rates of confirmed Barrett esophagus or dysplasia among modalities, and there were no cases of EAC.

Given the limited availability of direct evidence on screening effectiveness, the task force also examined studies of the effectiveness of treatment for Barrett esophagus, dysplasia, or stage-1 EAC. Very low- to low-certainty evidence showed that treatments improved eradication or clearance of dysplasia, but the benefit for mortality was unknown, Dr. Groulx and his colleagues report in CMAJ.

There was no evidence on how patients weigh the benefits and harms of screening.

The task force expressed concerns about feasibility and cost of endoscopic screening. Implementing screening could further increase endoscopy wait times and could widen health disparities in recent immigrants, rural or remote populations, and indigenous or low-income groups.

In the face of very low-certainty evidence, the task force strongly recommends not screening adults with chronic GERD for esophageal adenocarcinoma or precursor conditions.

"This recommendation does not apply to people with chronic GERD exhibiting alarm symptoms or to those diagnosed with Barrett esophagus (with or without dysplasia)," Dr. Groulx said. "Clinicians should be aware of alarm symptoms for EAC (dysphagia, odynophagia, recurrent vomiting, unexplained weight loss, anemia, appetite loss or gastrointestinal bleeding) and evaluate, refer, and manage patients accordingly."

"They should also apply clinical judgment for the investigation and management of those unresponsive to GERD treatment or with symptoms suggestive of other upper gastrointestinal disorders (e.g., dyspepsia)," he said.

Dr. Groulx added, "There is a lack of well-designed screening trials due to the low prevalence of EAC and limited probability that GERD patients will progress to cancer. More research to help understand which patients with chronic GERD are most likely to develop EAC, and if screening of specific high-risk groups is of benefit, would be helpful. More information about new, less invasive modalities of screening, harms of screening, patient values and preferences and effectiveness of new early treatment modalities is needed."

Dr. Sander Veldhuyzen van Zanten of the University of Alberta and Alberta Health Services, in Edmonton, Canada, who wrote an accompanying editorial, told Reuters Health by email, "Absence of evidence is not the same as evidence of absence of a benefit, in this case to screen chronic GERD patients with gastroscope. There is no or little evidence; hence, the recommendation by the task force not to routinely screen."

"Large definitive studies to answer this question 'is there benefit to do gastroscopy to detect esophageal cancer in chronic GERD?' will likely never be done," he said.

"What in clinical practice, especially in primary care, is a chronic GERD patient is poorly defined," Dr. van Zanten said. "And this is also true in the literature. Primary-care MDs and specialists are so comfortable in prescribing proton-pump inhibitors (PPIs), but PPIs work in GERD, peptic ulcer disease, dyspepsia, etc. Often little distinction is made between dyspepsia (epigastric pain/discomfort is the main symptom) and GERD (i.e., heartburn)."

SOURCE: https://bit.ly/2ZOuREv and https://bit.ly/2VXJnZL CMAJ, online July 6, 2020.