Reply

Abstract

We thank Drs Fernandez-Esparrach and Panes for their review of our study. They point out that there is a growing body of evidence showing that endoscopic treatment of Barrett's esophagus (BE) is safe and effective. For those who do not undergo treatment, endoscopic surveillance is the standard of practice. As physicians and patients try to determine whether or not surveillance or endoscopic therapy is appropriate, they are informed by guidelines from gastroenterological societies. The 2008 guidelines from the American College of Gastroenterology (ACG; Am J Gastroenterol 2008;103:788–797) have been the most commonly referenced document for the last 3 years. In March 2011, the American Gastroenterological Association (AGA; Gastroenterology 2011;140:1084–1091) released the AGA Medical Position Statement on the Management of Barrett's Esophagus, which goes beyond the ACG guideline with regard to low-grade dysplasia (LGD) and nondysplastic BE. Although there were no recommendations for endoscopic treatment for patients with nondysplastic BE or with LGD in the ACG paper, the Medical Position Statement states that “although endoscopic eradication therapy is not suggested for the general population of patients with BE in the absence of dysplasia, we suggest that RFA with or without endoscopic mucosal resection (EMR) should be a therapeutic option for select individuals with non-dysplastic BE who are judged to be at increased risk for progression to HGD or cancer.” It also states that “endoscopic eradication therapy with RFA should also be a therapeutic option for treatment of patients with confirmed LGD.” The AGA position paper points out that the recommendation that is made takes into consideration endpoints other than reduction in cancer deaths. For example, an intermediate endpoint such as sustained elimination of Barrett's mucosa at 5 years may be an acceptable clinical outcome. As the authors state, “there is no consensus and there remains an area of controversy influenced by various and legitimate but different points of views.”I believe that this document represents a “tipping point.” In Malcolm Gladwell's best seller, The Tipping Point, he writes that, “with social changes that mark every-day life, there is a critical mass of opinion at which a group moves to change.” I believe there are at least 5 reasons that we are “tipping” with regard to endoscopic therapy of BE. First, there is new scientific information about the safety, efficacy, and durability of RFA in patients with BE (N Engl J Med 2009;360:2277–2288). Second, cost-effectiveness models and quality-of-life studies support endoscopic therapy (Gastro-enterology 2009;136:2101–2114; Endoscopy 2009;41:1–9). Third, there is increasing satisfaction among clinicians and patients with the procedure. Fourth, there is a continued awareness of the limitations of surveillance. Falk pointed out that “at least half of the patients who develop high-grade dysplasia (HGD) and/or cancer had 2 consecutive initial endoscopies without dysplasia” (Clinical Gastroenterol Hepatol 2006;4:556–572). Fifth, respected leaders in the field explain that endoscopic treatment is supported by the same rationale that supports colonoscopic polypectomy (Gastroenterology 2011;140:386–388).More scientific studies, particularly with biomarkers, will provide better data. But even now, there is enough information for a clinician to meet with his/her patient to help guide them to a thoughtful decision. We thank Drs Fernandez-Esparrach and Panes for their review of our study. They point out that there is a growing body of evidence showing that endoscopic treatment of Barrett's esophagus (BE) is safe and effective. For those who do not undergo treatment, endoscopic surveillance is the standard of practice. As physicians and patients try to determine whether or not surveillance or endoscopic therapy is appropriate, they are informed by guidelines from gastroenterological societies. The 2008 guidelines from the American College of Gastroenterology (ACG; Am J Gastroenterol 2008;103:788–797) have been the most commonly referenced document for the last 3 years. In March 2011, the American Gastroenterological Association (AGA; Gastroenterology 2011;140:1084–1091) released the AGA Medical Position Statement on the Management of Barrett's Esophagus, which goes beyond the ACG guideline with regard to low-grade dysplasia (LGD) and nondysplastic BE. Although there were no recommendations for endoscopic treatment for patients with nondysplastic BE or with LGD in the ACG paper, the Medical Position Statement states that “although endoscopic eradication therapy is not suggested for the general population of patients with BE in the absence of dysplasia, we suggest that RFA with or without endoscopic mucosal resection (EMR) should be a therapeutic option for select individuals with non-dysplastic BE who are judged to be at increased risk for progression to HGD or cancer.” It also states that “endoscopic eradication therapy with RFA should also be a therapeutic option for treatment of patients with confirmed LGD.” The AGA position paper points out that the recommendation that is made takes into consideration endpoints other than reduction in cancer deaths. For example, an intermediate endpoint such as sustained elimination of Barrett's mucosa at 5 years may be an acceptable clinical outcome. As the authors state, “there is no consensus and there remains an area of controversy influenced by various and legitimate but different points of views.” I believe that this document represents a “tipping point.” In Malcolm Gladwell's best seller, The Tipping Point, he writes that, “with social changes that mark every-day life, there is a critical mass of opinion at which a group moves to change.” I believe there are at least 5 reasons that we are “tipping” with regard to endoscopic therapy of BE. First, there is new scientific information about the safety, efficacy, and durability of RFA in patients with BE (N Engl J Med 2009;360:2277–2288). Second, cost-effectiveness models and quality-of-life studies support endoscopic therapy (Gastro-enterology 2009;136:2101–2114; Endoscopy 2009;41:1–9). Third, there is increasing satisfaction among clinicians and patients with the procedure. Fourth, there is a continued awareness of the limitations of surveillance. Falk pointed out that “at least half of the patients who develop high-grade dysplasia (HGD) and/or cancer had 2 consecutive initial endoscopies without dysplasia” (Clinical Gastroenterol Hepatol 2006;4:556–572). Fifth, respected leaders in the field explain that endoscopic treatment is supported by the same rationale that supports colonoscopic polypectomy (Gastroenterology 2011;140:386–388). More scientific studies, particularly with biomarkers, will provide better data. But even now, there is enough information for a clinician to meet with his/her patient to help guide them to a thoughtful decision. Radiofrequency Ablation for Nondysplastic Barrett's Esophagus: To Treat or Not to Treat?GastroenterologyVol. 140Issue 7PreviewFleischer DE, Overholt BF, Sharma VK, et al. (The Mayo Clinic, Scottsdale, Arizona). Endoscopic radiofrequency ablation for Barrett's esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy 2010;42:781–789. Full-Text PDF