2017 David Sun Lecture: Screening and Surveillance of Barrett's Esophagus: Where Are We Now and What Does the Future Hold?

Abstract

Barrett's esophagus and esophageal adenocarcinoma continue to present considerable management challenges in the Western world. Despite our best efforts to date, the prognosis of advanced esophageal adenocarcinoma remains poor and far too many individuals with esophageal adenocarcinoma have not had a prior endoscopy to detect Barrett's esophagus. As such, current strategies of screening for Barrett's esophagus and subsequent surveillance need to be further optimized. Screening today is limited to high definition white light endoscopy in high-risk patient populations and as such has multiple limitations. However, a variety of exciting new techniques including risk prediction tools, tethered capsule endomicroscopy, a cytology sponge, breath testing for exhaled volatile organic compounds, and assessment of the oral microbiome are now under study in an effort to develop less expensive population-based screening methods. Similarly, endoscopic surveillance, as currently practiced has a variety of limitations. Inexpensive readily available adjuncts are already available to optimize surveillance including increased inspection time in an effort to detect mucosal or vascular abnormalities, special attention to the right hemisphere of the esophagus, and utilization of narrow band imaging or other electronic chromoendoscopy techniques. To improve endoscopic surveillance, a variety of new paradigms are under study including wide area trans-epithelial sampling, advanced endoscopic imaging, molecular imaging, clinical risk stratification and utilization of biomarkers of increased risk. However, progress will be challenging due to the complexity of esophageal cancer biology and the rarity of progression to cancer among patients with nondysplastic Barrett's epithelium.