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Volume: Barrett's Esophagus
Chapter: Screening and surveillance

Should Barrett's patients undergo colorectal screening?

J. Lagergren (Stockholm)

In several case series [1-4], Barrett's esophagus has been linked to neoplasia of the colon. A high proportion of patients with Barrett's esophagus developed colon cancer in these series. A true association between Barrett's esophagus and colon neoplasia might give reason to recommend screening for colon cancer in patients with Barrett's esophagus as proposed in some reports [1-5]. However, the clinically detected cases of Barrett's esophagus represent the "tip of an iceberg" of a much larger pool of undetected prevalent cases [6] and there is an apparent risk of selection bias in the case series since the insidious symptoms of the developing colon neoplasia could increase the likelihood that the Barrett's esophagus will be diagnosed. Due to the strong link between esophageal adenocarcinoma and Barrett's esophagus, any association between Barrett's metaplasia and colon cancer should be reflected as an association also with esophageal adenocarcinoma. A study which compared esophageal adenocarcinoma and squamous cell carcinoma patients from cancer registers with regard to their lifetime history of colorectal cancer [5], showed a significant excess in the former group (but only in men). But this study was conditional on a sufficient length of survival after the colorectal cancer to develop esophageal cancer. With the casecontrol design approach used, the probability of important difference in survival after colon cancer in the subpopulations that generated the esophageal adenocarcinomas and squamous cell carcinomas, respectively, would result in a spurious difference in their association with colorectal cancer.

Results from more detailed and larger studies are in conflict with the positive findings. In three controlled studies, endoscopic examinations of all subjects failed to confirm an excess risk for colorectal adenoma in patients with Barrett's esophagus [7-9]. Furthermore, in a large cohort study, no increased risk of esophageal adenocarcinoma was found among patients with colon cancer [10].

In view of the relatively weak evidence of an association between Barrett's esophagus and colorectal cancer and the negative results in several larger studies, my opinion is that there is currently no need to recommend colorectal screening in Barrett patients.


1. Sontag SJ, Schnell TG, Chejfec G, et al. Barrett's oesophagus and colonic tumours. Lancet 1985;1:946-949.

2. Robertson DAF, Ayres RCS, Smith CL. Screening for colonic cancer in patients with Barrett's oesophagus. Br Med J 1989;298:650.

3. Kingston RD, Kiff RS, Walsh SH. Barrett's oesophagus and colonic cancer. Lancet 1988;1:63.

4. Howden CW, Hornung CA. A systematic review of the association between Barrett's esophagus and colon neoplasms. Am J Gastroenterol 1995;90:1814-1819.

5. Vaughan TL, Kiemeney LALM, McKnight B. Colorectal cancer in patients with esophageal adenocarcinoma. Cancer Epidemiol Biomark Prev 1995;4:93-97.

6. Cameron AJ, Zinsmeister AR, Ballard DJ, Carney JA. Prevalence of columnar-lined (Barrett's) esophagus. Gastroenterology 1990;99:918-922.

7. Laitikari R, Laippala P, Isolauri J. Barrett's esophagus is not a risk factor for colonic neoplasia: a case-control study. Ann Med 1995;27:499-502.

8. Cauvin JM, Goldfain D, Le Rhun M, et al. Multicentre prospective controlled study of Barrett's oesophagus and colorectal adenomas. Lancet 1995;346:1391-1394.

9. Poorman JC, Lieberman DA, Ippoliti AF, Weber LJ, Weinstein WM. The prevalence of colonic neoplasia in patients with Barrett's esophagus: prospective assessment in patients 50-80 years old. Am J Gastroenterol 1997;92:592-596.

10. Lagergren J, Nyrén O. No association between colonic cancer and adenocarcinoma of the oesophagus. A populationbased cohort study in Sweden. Gut 1999;44:819-821.

Publication date: August 2003 OESO©2015