New guideline: Don't routinely screen for EAC in patients with chronic GERD
A new guideline from the Canadian Task Force on Preventive Health Care, based on a rigorous systematic review of the latest evidence, found no benefit of routine screening for esophageal adenocarcinoma (EAC) and precursor conditions (Barrett esophagus and dysplasia) in patients with chronic gastroesophageal reflux disease (GERD).
The guideline, published in CMAJ (Canadian Medical Association Journal), recommends physicians in Canada continue current practice to not screen routinely.
"Given the many needs facing the health system, it is important to use services where we know there is benefit," says Dr. Stephane Groulx, assistant clinical professor, Department of Community Health Sciences, Université de Sherbrooke and Chair of the Task Force EAC working group. "We did not find sufficient data to recommend routine screening by upper endoscopy of people with chronic GERD for EAC and precursor conditions, such as Barrett esophagus."
This recommendation does not apply to people with alarm symptoms for esophageal cancer, such as difficulty or pain swallowing, recurrent vomiting, unexplained weight loss, anemia, loss of appetite or gastrointestinal bleeding, or to those who have already been diagnosed with Barrett esophagus.
Barrett esophagus is a condition where the normal lining of the esophagus changes to look more like the lining of the intestine. It is linked to chronic GERD and can lead to the growth of abnormal cells (dysplasia) that may turn into EAC over time much more frequently than GERD alone. It is found in 5%-20% of patients who undergo esophagogastroduodenoscopy (EGD) for chronic GERD.
"Clinicians should be aware of alarm symptoms in patients and conduct appropriate investigation, referral and management of these patients," says Dr. Scott Klarenbach, a member of the working group and professor in the Department of Medicine, University of Alberta. "Physicians who routinely refer patients without alarm symptoms for screening may want to stop, given the lack of evidence showing benefit."
EAC is the most common type of esophageal cancer in Canada and has one of the poorest survival rates among all cancers. The estimated 5-year survival rate is 15%. Unfortunately, most esophageal adenocarcinomas are diagnosed at a late stage of the disease, after alarm symptoms develop. It was hoped that early detection could save lives; unfortunately, the Task Force's rigorous review of available evidence did not identify any benefit from screening.
Although age 50 years or older, male gender, having a family history, white race, abdominal obesity and smoking are factors that may increase the risk of EAC, relevant trials and cohort studies did not provide sufficient data to recommend screening for individuals with one or more of these risk factors.
As the evidence underpinning the guideline was of low- or very-low-certainty, and because screening by endoscopy is costly and may cause harm, the Task Force calls for more research to help understand which patients with chronic GERD are most likely to develop EAC and whether screening of specific high-risk groups provides benefit that outweighs the known harms.
During the development of the guideline, the task force engaged patients to understand values and preferences around screening.
The College of Family Physicians of Canada and the Nurse Practitioner Association of Canada have endorsed the guideline. The Canadian Partnership Against Cancer has provided a statement of support for the guideline.
For the full guideline, podcast, clinician and patient FAQs, visit the EAC guideline page at http://www.canadiantaskforce.ca.
In a related commentary, Dr. Sander Veldhuyzen van Zanten, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, writes "The Task Force's strong recommendation against gastroscopy screening for patients with chronic GERD without alarm symptoms depended in part on the assumption that scarce health resources would need to be expended to implement screening."
He agrees that routine screening of patients younger than 50 who have chronic GERD is unnecessary. However, because gastroscopy is generally a safe and straightforward procedure, he suggests it may be considered in patients older than 50 who have chronic GERD and risk factors such as obesity and smoking.
The Canadian Task Force on Preventive Health Care is an independent panel of health professionals who are experts in clinical preventive health care and guideline methodology. The task force's mandate is to develop and disseminate evidence-based clinical practice guidelines for primary and preventive care.