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Treatment and Management

Barrett’s esophagus can progress to esophageal adenocarcinoma – a highly lethal esophageal cancer. Treatment of Barrett’s esophagus using endoscopic eradication therapy is a highly effective procedure that can reduce the risk of progression from Barrett’s esophagus to cancer. However, treatment may not be indicated if the risk of cancer is minimal, because Barrett’s esophagus poses no other health risks. Those who do not receive treatment following a diagnosis of Barrett’s esophagus should undergo regular surveillance endoscopies to ensure that any evidence of progression to cancer is detected and treated.

The frequency of surveillance for Barrett’s esophagus or the decision to treat the condition depends on the individual’s risk of cancer progression – this risk is determined by the degree of dysplasia (abnormal cell growth) indicated during biopsy analysis in conjunction with additional risk factors. All patients with high-grade dysplasia are recommended for treatment, and patients with confirmed low-grade dysplasia are generally recommended for treatment as well. The appropriate treatment or surveillance of individuals who do not have dysplasia, or for whom dysplasia is uncertain, may be best informed by more personalized risk assessment.

Refer to Cancer Risk and Dysplasia Grading to learn more.

Endoscopic eradication therapy

Endoscopic eradication therapy (EET) is an effective, minimally invasive treatment of Barrett’s esophagus. EET is a combination of two therapies: endoscopic mucosal resection and ablation. In endoscopic mucosal resection, a large but thin area of esophageal tissue containing any worrisome areas is removed during an endoscopy. Ablative techniques then remove any remaining Barrett’s esophagus tissue. When the tissue heals, normal esophageal tissue returns, making EET a very effective and durable treatment for Barrett’s esophagus. One benefit of treating Barrett’s esophagus with EET before it has a chance to progress is that it can prevent the need for more aggressive cancer treatments, such as esophagus surgery (esophagectomy), which involves the removal of some or all of the esophagus.

Refer to Treatment Procedures to learn more about what to expect during treatment.

Endoscopic surveillance

 All Barrett’s esophagus patients undergo periodic endoscopic surveillance, which is intended to uncover evidence of progression to cancer before cancer actually develops. Just as during diagnosis, a physician will perform an upper endoscopy and take biopsy tissue samples for inspection by pathologists. Individuals thought to be at higher risk of developing cancer in the future are recommended for surveillance most frequently, or receive treatment.

ACG guidelines for surveillance frequency 

Dysplasia grading5-year risk (progression to high-grade dysplasia or cancer) Frequency of surveillance
Non-dysplastic Barrett’s esophagus 3.15% 3-5 years depending on segment length
Indefinite for dysplasia (with controlled reflux) 7.5%1-year surveillance
Low-grade dysplasia8.5%6-12-month surveillance or treatment with EET

Personalized risk stratification informs treatment

The frequency of endoscopic surveillance can also be informed by indications of cancer progression risk in addition to dysplasia. For example, the ACG treatment guidelines recommended frequency of surveillance for non-dysplastic Barrett’s esophagus depending on segment length. ACG recommends surveillance every five years for patients with short-segment Barrett’s esophagus and every three years for patients with long-segment Barrett’s esophagus. However, upon consideration of additional risk factors and consultation with the patient, clinicians often recommend more frequent surveillance.

A new risk stratification tool, TissueCypher, reveals molecular indications of risk that cannot normally be detected by a pathologist, and can help personalize management for each patient. A high- and low-risk TissueCypher score can be combined with dysplasia grading and other risk factors to upgrade or downgrade a patient’s risk of progression and, ultimately, their care plan. The 2022 ACG clinical practice updates highlights the use of TissueCypher for risk stratification of patients with non-dysplastic Barrett’s esophagus, noting that a high-risk TissueCypher score was associated with an annual rate of progression of 6.9% in non-dysplastic patients, which is higher than the annual progression risk of patients with low-grade dysplasia.

Possible patient care pathways based on personalized cancer risk

A clinician may consider different pathways for treatment of Barrett’s esophagus based on the results of a TissueCypher risk assessment, in conjunction with dysplasia and other clinical risk factors. See how management of Barrett’s esophagus could be impacted by a high/intermediate-risk or low-risk score*:

*The following are not recommendations for medical treatment. Any change in therapy should be made by the clinician in consultation with the patient.

Treatment is recommended for patients with low-grade dysplasia Barrett’s esophagus if it is confirmed by a second expert pathologist. However, surveillance every 12 months is also an option.

  • With a high-risk TissueCypher score: Consider treatment
  • With a low-risk TissueCypher score: Consider short interval surveillance

Surveillance every three to six months is recommended for patients who are indefinite for dysplasia until acid reflux has been managed. If dysplasia still cannot be confirmed or ruled out, surveillance is recommended every 12 months. 

  • With a high-risk TissueCypher score: Rule out prevalent disease, consider treatment
  • With a low-risk TissueCypher score: Consider Surveillance

Surveillance every five years is recommended for patients with short-segment Barrett’s esophagus and every three years for patients with long-segment Barrett’s esophagus.  

  • With a high-risk TissueCypher score: Rule out prevalent disease, consider treatment or more frequent surveillance
  • With a low-risk TissueCypher score: Surveillance
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