March 1st, 2010
When Should We Stop Surveillance of Barrett’s Patients?
Some of my patients who have undergone successful ablation therapy for Barrett’s esophagus ask a really good question: If I haven’t had Barrett’s for years, why do I need to keep having endoscopies?”
I admit, I do not have a uniform answer for that, nor do GI society guidelines. I would say that for patients who have never had dysplasia, surveillance is difficult to justify anyway, so we should “cut them loose” once we are sure their Barrett’s is gone. But I’ve heard many experts say that patients who have had dysplasia can never be let out of surveillance.
Why should we approach patients who had dysplasia any differently than those who had adenomatous polyps? After all, adenomas are dysplastic and, as with dysplastic Barrett’s (especially low-grade Barrett’s), are associated with only modest cancer risk. Moreover, when we remove an adenoma, we no longer worry about that site; rather, we worry about the rest of the colon because that is where recurrence takes place. After ablation, Barrett’s is gone, so why the continued intensive surveillance?
I don’t buy the argument that Barrett’s is left behind; missed buried glands are rare in patients whose biopsies are all negative after ablation. Furthermore, even oncologists consider cancer patients cured after 5 years of disease-free survival and no longer put them through surveillance imaging and blood tests.
So why are gastroenterologists resistant to the concept of “cutting loose” our Barrett’s patients, even after 5 or more years of negative endoscopies and biopsies? Let me know what you think. I have thick skin, so pile it on!