Barrett's Dysplasia and Mucosal Carcinoma Patients Referred for Photodynamic Therapy --- Do They Come from Surveillance Programs?

Abstract

Introduction: The utility and cost effectiveness of surveillance endoscopy for patients with Barrett's esophagus (BE) has been questioned. Since 1997, we have used photodynamic therapy (PDT) to treat patients with Barrett's high-grade dysplasia and mucosal adenocarcinoma. The aim of this study was to determine if these patients were newly diagnosed or were referred from endoscopic surveillance programs. Methods: We reviewed our experience treating patients with PDT for Barrett's high-grade dysplasia and mucosal adenocarcinoma in order to determine their symptoms at presentation and how many of these patients were newly diagnosed or if they had been detected by surveillance endoscopy. Wilcoxon rank sum tests and Fisher's exact tests were used to compare patient characteristics and outcomes according to endoscopy surveillance status. Results: Since 1997, 90 patients have undergone endoscopic ablation with PDT including sixty patients with Barrett's high-grade dysplasia and 30 mucosal adenocarcinoma patients. Of these 90 patients, 71 were men and the median age was 72 years (age range 50-85 years) with a median series follow up of 1.6 years. Most patients were referred for PDT from endoscopy surveillance programs (49 patients, 54%) where patients had been followed with a diagnosis of BE for a median 5 years. Most of these patients (39 patients; 80%) had symptoms of chronic acid reflux disease. Other symptoms leading to diagnosis were chest pain, bleeding and dysphagia. Forty-one newly diagnosed patients, without previously diagnosed BE, were referred for PDT (46%). Symptoms leading to their endoscopy and diagnosis were bleeding (14 patients; 34%), chest pain (11 patients; 27%), dysphagia (8 patients; 20%) and chronic acid reflux (6 patients; 15%). The only statistically significant difference between these two groups of patients was the Barrett segment length (5 cm for surveillance patients vs. 3 cm for newly diagnosed patients, p<0.001). Conclusions: In this highly selected group, most patients with Barrett's high-grade dysplasia or mucosal adenocarcinoma are referred from endoscopic surveillance programs (54%) and were diagnosed based on their symptoms of chronic acid reflux. Patients newly diagnosed with Barrett's high-grade dysplasia or mucosal adenocarcinomas make up a sizable proportion of our study group (46%). Their lack of typical acid reflux symptoms and significantly shorter BE segments may explain the delay in their diagnosis.