Barrett's Esophagus Treatment: Integrating Novel Strategies Into Practice
Barrett's Esophagus Treatment: Integrating Novel Strategies Into Practice
In the next 5 years the use of endoluminal therapy for early Barrett's neoplasia will spread more widely now that oncological safety of this treatment has been proven. The indication for ER will probably be extended to superficial submucosal lesions with favorable characteristics (well-to-moderately differentiated, no blood or lymph vessel infiltration and not excavated). The introduction of RFA with its good efficacy and safety profile will lower the threshold for treating and ablating Barrett's esophagus once the long-term follow-up data of recent trials become available. Intensive investigation is currently ongoing to identify molecular and clinical markers to select patients with LGIN or intestinal metaplasia who are at high risk for developing cancer. If these predictive markers become available, the treatment indication will probably shift to this at-risk group before patients develop cancer or HGIN. By assessing the risk at an earlier stage, RFA ablation is likely to become even safer, since most complications are currently associated with a previous ER. This will probably lead to a decrease in the use of the ER technique and surgery, and hopefully eventually to a decrease in the incidence of esophageal adenocarcinoma in the long term. It needs to be emphasized, however, that training in endoluminal therapy is crucial to maintain the excellent safety features of ER and RFA. One possible downside of RFA is, indeed, that it is so simple to apply that it may be applied without proper endoscopic work-up. Therefore, training in detecting early neoplastic lesions that need resection prior to RFA will probably be the most challenging task in the next 5 years.
Five-year View
In the next 5 years the use of endoluminal therapy for early Barrett's neoplasia will spread more widely now that oncological safety of this treatment has been proven. The indication for ER will probably be extended to superficial submucosal lesions with favorable characteristics (well-to-moderately differentiated, no blood or lymph vessel infiltration and not excavated). The introduction of RFA with its good efficacy and safety profile will lower the threshold for treating and ablating Barrett's esophagus once the long-term follow-up data of recent trials become available. Intensive investigation is currently ongoing to identify molecular and clinical markers to select patients with LGIN or intestinal metaplasia who are at high risk for developing cancer. If these predictive markers become available, the treatment indication will probably shift to this at-risk group before patients develop cancer or HGIN. By assessing the risk at an earlier stage, RFA ablation is likely to become even safer, since most complications are currently associated with a previous ER. This will probably lead to a decrease in the use of the ER technique and surgery, and hopefully eventually to a decrease in the incidence of esophageal adenocarcinoma in the long term. It needs to be emphasized, however, that training in endoluminal therapy is crucial to maintain the excellent safety features of ER and RFA. One possible downside of RFA is, indeed, that it is so simple to apply that it may be applied without proper endoscopic work-up. Therefore, training in detecting early neoplastic lesions that need resection prior to RFA will probably be the most challenging task in the next 5 years.
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