Barrett's esophagus is a condition that develops in approximately 10-15% of patients with chronic gas-troesophageal reflux disease and is the only known major risk factor for esophageal adenocarcinoma. The incidence of esophageal adenocarcinoma has increased by 350% over the last 3 decades and the reasons for this dramatic increase are unclear. At the time of cancer diagnosis up to 50% of patients will have advanced regional or distant metastatic disease, with little or no chance of cure. The overall 5-year survival rate with advanced disease remains poor at <10%. Several studies have demonstrated an early stage of diagnosis and a marked improvement in the survival of patients with esophageal cancer detected by routine endoscopic surveillance in patients known to have pre-existing Barrett's esophagus. The aim of endoscopic surveillance in patients with Barrett's esophagus is the early diagnosis of esophageal cancer, when it is still potentially curable. The desired outcome is to further decrease the mortality rate associated with esophageal adenocarcinoma and identify and screen populations at risk for the development of dysplasia arising from Barrett's esophagus. This is the principle of the current screening and surveillance guidelines set out by several societies, including the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the European Society of Gastrointestinal Endoscopy. However, as most patients with Barrett's esophagus do not develop adenocarcinoma, the cost effectiveness of endoscopic screening and surveillance strategies is questionable. To date, no prospective, randomized trials have been performed to evaluate the effectiveness of surveillance, the survival benefit in patients undergoing surveillance or the subsequent impact on healthcare costs. In this article, we focus on the basic principles and reasoning underlying the surveillance guidelines for Barrett's esophagus. In particular, that the disease is clinically important and has a high prevalence; the transition to adenocarcinoma could have a high death and/or disability rate; early diagnosis of adenocarcinoma should reduce mortality; and the screening method should be easily applied, safe, relatively inexpensive, and applicable to a large number of patients. We then review arguments for and against screening and surveillance as they apply to these principles and discuss the current literature that reviews the effectiveness of such surveillance strategies, including an outline of cost analysis.
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