Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Etiology and origins of Barrett's epithelium

Are there ethnic differences in the prevalence of Barrett's esophagus?

J.P. Waring (Atlanta)

The incidence of esophageal adenocarcinoma is increasing in many areas of the world, including the United Kingdom, Scotland, Scandinavia, France, Switzerland, Australia and New Zealand [1]. The racial breakdown of the patients is usually not mentioned in these studies, although these populations are predominantly Caucasian. The only studies that look at mixed populations are from the United States. In the United States, the incidence of Barrett's esophagus and esophageal adenocarcinoma seems highest in Caucasians and lowest in African-Americans.

In the early 1980's, several small studies demonstrated that most patients with esophageal adenocarcinoma were Caucasian. Skinner noted that all 20 patients with esophageal adenocarcinoma were Caucasian, as were 21 of 23 patients with benign Barrett's esophagus [2]. Other studies demonstrated similar findings. Caucasian patients made up 34 of 39 patients, 12 of 13 patients, 29 of 32 patients, 15 of 16 patients and all 13 patients with esophageal adenocarcinoma in several small studies [3-7].

Several larger series appeared in the 1990's. A couple of studies had such low incidence of African-American patients that they were not included in the formal analysis [8, 9]. Clark found all 100 of his patients with esophageal adenocarcinoma and carcinoma of the gastric cardia were Caucasian [10]. Chow found that 82% of the 196 patients that developed esophageal adenocarcinoma and carcinoma of the gastric cardia in the Kaiser Health Maintenance Organization in Los Angeles were Caucasian [11]. The races of the other patients were not delineated. Chalasani showed that the prevalence of esophageal adenocarcinoma in African-Americans was low, 8% of esophageal cancers, even at an inner-city hospital with large African-American population [12].

As the incidence of esophageal adenocarcinoma rises in Caucasian men, the difference between races appears larger. Blot reported the first population based United States study and demonstrated a 3:1 white:black ratio for esophageal adenocarcinoma [13]. Devsa updated this data from the National Cancer Institute and showed that the incidence of esophageal adenocarcinoma is fairly stable in African-Americans and Caucasian women [14]. However, the incidence of esophageal adenocarcinoma in Caucasian men has risen 350 percent, from 0.7/100,000 to 3.2/100,000. Caucasian men are now more than 5 times more likely to have esophageal adenocarcinoma than African-Americans. Sharma confirmed that the incidence of esophageal adenocarcinoma is increasing only in Caucasian men. In South Carolina, 49% of esophageal cancer in white men were adenocarcinoma between 1991-1995 compared to 24% from 1981-1985. Esophageal adenocarcinoma was decreasing in African-Americans in this study from 10% in 1981-1985 to 3% in 1991-1995 [15].

Sarr showed that 91% of the patients with benign Barrett's esophagus were Caucasian compared to 81% of patients without Barrett's esophagus [7]. However, as the definition of Barrett's esophagus has evolved to require intestinal metaplasia, the apparent Caucasian predominance becomes greater. In recent studies using these criteria, all 16 patients, 26 of 27 patients, all 16 patients, 58 of 60 patients, and all 12 patients with Barrett's esophagus were Caucasian [16-20]. One study found that 274 of 289 patients with Barrett's esophagus and all 81 with dysplasia or cancer were Caucasian [21]. When specifically looking at short segment Barrett's, all 16 patients , 18 of 19 patients and all 7 patients were Caucasians in three small studies [18-20]. Sharma found that 91 of 95 (96%) patients with short segment Barrett's were Caucasian compared with 81 of 100 (81%) patients with intestinal metaplasia at the cardia [22]. Hirota found 55 of 64 (86%) of his patients with short segment Barrett's were Caucasian compared to 31 of 47 (66%) with intestinal metaplasia at the cardia [23]. There are several large American series of patients with Barrett's esophagus that do not mention the race of the patients [24-26].

One small study suggests that incidence of Barrett's esophagus in Hispanics is similar to that of Caucasians, but nearly all of these patients have short segment Barrett's [27]. The risk of developing cancer for these patients is unknown. Gastroesophageal reflux is uncommon in Asia. Recent studies suggest that Barrett's esophagus is present in small number of patients with chronic reflux symptoms in Taiwan and Saudi Arabia [28,29]. Again, the risk of progression to adenocarcinoma is unknown. Adenocarcinoma is rare, but has been reported in China [30].

In summary, Barrett's esophagus is far more common in Caucasians, particularly if intestinal metaplasia is required for the diagnosis. These racial characteristics are true for long and short segments of Barrett's esophagus. The risk of developing adenocarcinoma also seems to be even more pronounced in Caucasians. The risk of Barrett's esophagus may be similar in Hispanics, but it would appear the risk for esophageal adenocarcinoma is lower. The risk of both problems is probably lowest in African-American and Asian populations, but there does seem to be some risk for these patients with chronic reflux disease.


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16. Spechler SJ, Zeroogian JM, Antonioli DA, et al. Prevalence of metaplasia at the gastro-oesophageal junction. Lancet 1994;344:1533-1536.

17. Sampliner RE. Effect of up to 3 years of lansoprazole on Barrett's esophagus. Am J Gastroenterol 1994;89:1844-1848.

18. Johnston MH, Hammond AS, Laskin W, et al. The prevalence and clinical characteristics of short segments of specialized intestinal metaplasia in the distal esophagus on routine endoscopy. Am J Gastroenterol 1996;91:1507-1511.

19. Weston AP, Krmpotich P, Makdisi WF. Short segment Barrett's esophagus. Am J Gastroenterol 1996;91:981-986.

20. Chalasani N, Wo JM, Hunter JG, Waring JP. Significance of intestinal metaplasia in different areas of esophagus including esophagogastric junction. Dig Dis Sci 1997;42:603-607.

21. Weston AP, Badr AS, Topalovski M, et al. Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma. Am J Gastroenterol 2000;95:387-394.

22. Sharma P, Weston AP, Morales R, et al. Relative risk of dysplasia for patients with intestinal metaplasia in the distal esophagus and gastric cardia. Gut 2000;46:9-13.

23. Hirota WK, Loughney TM, Lazas DJ, et al. Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction: prevalence and clinical data. Gastroenterology 1999;116:277-285.

24. Drewitz DJ, Sampliner RE, Garewal HS. The incidence of adenocarcinoma in Barrett's esophagus:a prospective study of 170 patients followed 4.8 years. Am J Gastroenterol 1997;92:212-215.

25. Katz D, Rothstein R, Schned A, et al. The development of dysplasia and adenocarcinoma during endoscopic surveillance of Barrett's esophagus. Am J Gastroenterol 1998;93:536-541.

26. O'Connor JB, Falk GW, Richter JE. The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: report on the Cleveland Clinic Barrett's Esophagus Registry. Am J Gastroenterol 1999;94:2037-2042.

27. Bersentes K, Fass R, Padda S, et al. Prevalence of Barrett's esophagus in Hispanics is similar to Caucasians. Dig Dis Sci 1998;43:1038-1041.

28. Yeh C, Hsu CT, Ho AS, et al. Erosive esophagitis and Barrett's esophagus in Taiwan: a higher frequency than expected. Dig Dis Sci 1997;42:702-706.

29. Gadour MO, Ayoola EA. Barrett's oesophagus and oesophageal cancer in Saudi Arabia. Trop Gastroenterol 1999;20:111-115.

30. Gao YT, McLaughlin JK, Blot WJ, et al. Risk factors for esophageal cancer in Shanghai, China. Int J Cancer 1994;58:192-196.

Publication date: August 2003 OESO©2015