David A. Johnson, MD

Experts provide valuable insight to both sides of the argument.

Best-care practice in screening and intervention for nondysplastic Barrett esophagus (BE) is undetermined. Two recognized experts in BE therapeutic interventions have provided a point-counterpoint debate on the use of radiofrequency ablation (RFA) for nondysplastic BE. Highlights are as follows:

Pros

• Endoscopic surveillance of BE is ineffective in reducing the risk for neoplastic progression, unproven to reduce esophageal adenocarcinoma (EAC)-related deaths, and not cost-effective.
• RFA has been shown to be highly effective in reducing histologic progression and development of cancer in patients with dysplasia and is durable in patients without dysplasia.
• The number-needed-to-treat to avoid cancer progression in patients with nondysplastic BE is 45, assuming a 5-year durability of RFA.

Cons

• Progression of nondysplastic BE to cancer seems to be cumulative but not linear; the estimated lifetime risk for cancer is as low as 1%. Performing RFA in all patients with nondysplastic BE would constitute overtreatment of millions of people.
• RFA eradication is lower for nondysplastic BE compared with dysplastic BE, and some reports show high recurrence of intestinal metaplasia.
• Results of cost-effectiveness studies are mixed, but the continuous nature of surveillance often renders RFA for nondysplastic BE cost-prohibitive and cost-ineffective.
• Patient age and comorbidities must be considered in managing long-segment BE, which carries an elevated cancer risk; RFA may be an alternative to surveillance, particularly if the patient has a family history of BE and EAC.

Citation(s):

Ganz RA et al. The case for ablating nondysplastic Barrett's esophagus. Gastrointest Endosc 2014 Nov; 80:866.

Lightdale CJ.Radiofrequency ablation for nondysplastic Barrett's esophagus: Certainly not for all. Gastrointest Endosc 2014 Nov; 80:873.