Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

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Volume: Barrett's Esophagus
Chapter: Adenocarcinomas

In the delineation framework of a preventive strategy, should screening endoscopy be indicated in all patients with gastroesophageal reflux symptoms?

J. Lagergren (Stockholm)

Since the poor survival rates for adenocarcinoma of the esophagus and gastric cardia [1] are improved only by early tumor detection [2], it is important to identify high-risk persons in whom endoscopic surveillance might be warranted. Recently, symptomatic reflux and obesity were identified as strong independent risk factors for these tumors, particularly for esophageal adenocarcinoma [3, 4]. Since reflux symptoms are common [5] and adenocarcinomas are still rare diseases, endoscopic surveillance in reflux patients would rapidly overtax available health care resources [3]. The possible benefits of endoscopic surveillance should exceed the costs and inconveniences for patients and health care systems. Symptoms severe enough to be associated with a risk of esophageal adenocarcinoma eight times as high as normal were reported by 9% of our control subjects. If endoscopic surveillance were restricted to men older than 40 who had symptoms of reflux that were so severe as to entail a risk 20 times as high as normal, our calculations revealed that a Swedish physician would need to follow more than 1,400 such patients for one year to encounter a single case of esophageal adenocarcinoma; such a policy would surely overtax the available health care resources [3].

In a re-analysis of Swedish nationwide case-control data, we estimated the number of endoscopies needed to identify one esophageal or cardia adenocarcinoma in persons with various combinations of both obesity and reflux [6]. Based on the prevalence of reflux and obesity among the control subjects, we estimated the sizes of risk strata in the Swedish population. Our complete and nationwide case ascertainment allowed calculations of incidence rates in each strata. The number needed to survey annually to identify one adenocarcinoma was calculated as 1/(incidence rate). Risk of both esophageal and cardia adenocarcinoma increased dose-dependently with increasing body mass index (BMI) and reflux severity (Table I). The risks combined in a multiplicative manner. Among obese persons (BMI > 30 kg/m2) with reflux symptoms, odds ratio (OR) was 184 (95% CI, 36949) for esophageal adenocarcinoma and 12.5 (95% CI, 3.0-51) for cardia adenocarcinoma compared with lean persons (BMI < 22 kg/m2) without reflux. Among persons with BMI = 25 kg/m2 and severe (severity score > 4) and long-standing (> 20 years) reflux symptoms, OR was 103 (95%CI, 21.5-492) for esophageal adenocarcinoma and 16.6 (95%CI, 3.4-82) for cardia adenocarcinoma. We then estimated the number needed to detect one esophageal or cardia adenocarcinoma. Given the marked male (8:1) predominance, the rarity of tumors in younger persons, and the demanding curative surgery, surveillance is not justified in women or persons younger than 50 or older than 79 years. Thus, the group to evaluate is men of ages 50-79 with high BMI and reflux symptoms. Table II shows the prevalence of various constellations of BMI and reflux symptomatology among our male control subjects aged 50-79 years, the estimated adenocarcinoma incidence in the strata exhibiting these constellations in the Swedish population, and the number needed to survey to detect one esophageal or cardia adenocarcinoma per year. Six percent had the combination of BMI = 25 kg/m2 and reflux symptoms, but only 0.3% of persons with reflux had BMI > 30 kg/m2.

Table I. Reflux symptom and body mass index (BMI) and risk of esophageal and gastric cardia adenocarcinoma*.

Table II. Efforts needed to identify esophageal or gastric cardia adenocarcinoma among men aged 50-79 years at different levels of body mass index (BMI) and reflux symptoms.

The number of persons needed to survey to detect one adenocarcinoma varied from 2,189 in the former stratum, to 594 in the latter. Thus, if 60 obese men aged 50-79 with reflux symptoms, are followed for 10 years, one esophageal or cardia adenocarcinoma will be observed. The size of this latter high-risk group, 0.3% of the male population between 50 and 79 years, is seemingly manageable, but the number of patients included in surveillance programs tends to accumulate with time.

In conclusion, we have identified a limited group with a relative risk that greatly exceeds that of the general population. Endoscopic surveillance for esophageal or cardia adenocarcinoma in this group would, however, consumes considerable health care resources. Given the poor results of treatment of the cancer when it occurs, surveillance may still be considered, especially if the incidence of these tumors continues to increase. Importantly, from our data we conclude that screening endoscopy can not be recommended in other groups of persons with reflux symptoms.


1. Boring CC, Squires TS, Tong T. Cancer statistics, 1993. CA-Cancer J Clinicians 1993;43:7-26.

2. Altorki NK, Skinner DB. Adenocarcinoma in Barrett's esophagus. Semin Surg Oncol 1990;6:274-278.

3. Lagergren J, Bergström R, Lindgren A, Nyrén O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999;340:825-831.

4. Lagergren J, Bergström R, Nyrén O. The association between body mass and adenocarcinoma of the esophagus and gastric cardia. Ann Int Med 1999;130:883-890.

5. Locke GR, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology 1997;112:1448-1456.

6. Lagergren J, Ye W, Bergström R, Nyrén O. The combination of symptomatic gastroesophageal reflux and obesity as an indicator of the need for endoscopic surveillance for adenocarcinoma of the esophagus and gastric cardia. JAMA, in press.

Publication date: August 2003 OESO©2015