Many US Patients With Esophageal Cancers Do Not Undergo Screening

By Brandon May

January 05, 2022

NEW YORK (Reuters Health) - A large majority of U.S. patients with esophageal adenocarcinoma (EAC) or esophagogastric-junction adenocarcinoma (EGJAC) have not undergone esophagogastroduodenoscopy (EGD) screening before their diagnosis, despite having several potential opportunities to do so during routine clinical care, a new study shows.

Previous research has shown that fewer than one in five patients with EAC had an EGD before diagnosis, but those studies tended to focus on just a few years leading up to the diagnosis and did not address whether there had been opportunities for screening, researchers write in Gastroenterology.

To investigate, Dr. Joel H. Rubenstein of the LTC Charles S. Kettles VA Medical Center in Ann Arbor, Michigan, and colleagues analyzed data on 3,781 veterans with EAC and 1,427 with EGJAC who were diagnosed between 2010 and 2015. These cases were matched by age with veterans who received Veterans Health Administration (VHA) services during the same period.

The researchers examined the rate of patients who were overdue for surveillance, as defined by a previous diagnosis of Barrett's esophagus (BE) with the most recent EGD done at least five years prior. Patients who had a potential opportunity for screening were defined as those without a previous EGD but with either a diagnosis of gastroesophageal reflux disease (GERD), use of acid-reducing medications, receipt of colonoscopy, or undergoing fecal occult-blood testing (FOBT).

In patients who had continuous care, 18.6% of those with EAC had a prior EGD (odds ratio vs. controls, 1.34; 95% CI, 1.09 to 1.64). Sixty-three percent of EAC patients with a prior EGD had a billing diagnosis of BE between six months and 10 years prior to the cancer diagnosis, while 21.7% of patients had a billing BE diagnosis within six months prior. The researchers say this suggests EGD is sensitive for BE at risk of progression to EAC.

A lower proportion of patients with EGJAC and a prior EGD received a BE diagnosis (32.5%), but 27.5% received a billing BE diagnosis within six months prior.

In the 216 EAC patients with a previous EGD and BE diagnosis, 28.7% were considered overdue for surveillance, and this rate was similar to the control population (30.1%).

Among patients with cancer without a prior EGD, 85.4% of EAC cases and 86.0% of EGJAC cases had one or more opportunities for EGD screening.

Cases of EAC and EGJAC were slightly more likely to receive a GERD diagnosis compared with controls, but no difference was found between groups in terms of the use of acid-reducing medications. The researchers found that the time of FOBT was the most common potential opportunity for offering EGD.

Patients with cancer and a prior PE who were overdue for surveillance comprised 3.3% of EAC cases and 1.3% of EGJAC cases. Missed potential opportunities for screening were the most common mechanism of failure to control cancer in 69.5% and 71.6% of EAC and EGJAC cases, respectively.

"If we could increase the uptake of screening in those at elevated risk, then we could not only diagnose cancers at an earlier stage, but we may even prevent the development of cancer by identifying precancerous lesions, which can be treated very successfully endoscopically," Dr. Rubenstein told Reuters Health by email. "However, this needs to be balanced with risks of over-screening in populations that are at lower risk, which raises costs and can lead to down-stream side effects from over-treatment."

According to the researcher, there are several barriers to patients receiving screening.

"Among those are lack of knowledge among providers and patients of guidelines regarding who should be considered for screening," he said. "Given that these cancers are relatively uncommon, screening for them may not be a priority for providers when they have multiple competing demands on their time with patients." The costs associated with screening represent another consideration, he added.

SOURCE: Gastroenterology, online December 20, 2021.