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The Problem With Medical Specialty Recommendations: Barrett's Esophagus

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The recommendations of specialty medical organizations are generally accepted as standards for care. Certainly, doctors with greater training and experience should be the most knowledgeable about their own particular field of expertise, and their advice should represent the best and most up-to-date medical practice. When cardiology groups issue suggestions about the treatment of cardiac problems or oncology groups about cancer, their advice, understandably, is believed by medical consumers as being true state-of-the-art. Often these recommendations deserve this degree of trust, but sometimes that trust is not warranted.

Specialty organizations, for example, typically propose a greater role in medical care by their members than might be justified by scientific evidence. Even well-meaning specialists can convince themselves of the exaggerated importance of their services and propose their performing more procedures, tests and interventions than are really needed. Adhering to such recommendations necessarily increases the workload and the income of those specialty physicians who made the recommendations in the first place. Such obvious conflicts of interests taint these types of guidelines.

The recommendations of the American College of Gastroenterology (ACG) concerning screening endoscopy for Barrett's esophagus illustrates how a professional society's recommendations can be self-serving and contrary to best care. The aggressive approach advised by the ACG and widely practiced by American gastroenterologists appears excessive when the natural history of the disease is carefully considered.

Barrett's esophagus is identified by abnormal cells in the distal esophagus. The normal lining cells of the esophagus appear under the microscope as a flat layer of cells called squamous epithelium. Uncommonly, some cells at the end of the esophagus change, losing their flat appearance and looking like tall columns, so-called metaplastic columnar epithelium. At times these cells become progressively more abnormal, or dysplastic. This series of changes in the lining cells is accompanied by an increased risk of cancer with a particularly lethal form of cancer, adenocarcinoma of the esophagus, occasionally developing. Attempts at finding metaplastic or dysplastic changes in the esophagus early and intervening before cancer develops prompted the ACG to come up with their recommendations. According to this group, endoscopic screening is done in older people with heartburn, a high-risk group for finding Barrett's, and surveillance screening is done in those already identified with the abnormality.

The recommendations, however, are problematic. Screening the estimated 7.3 million adults over 45 who have frequent heartburn would yield a 10 percent incidence of Barrett's; but it would entirely miss about 40 percent of those who develop esophageal adenocarcinoma without any prior history of heartburn.[1][2][3]

Once the metaplastic change of Barrett's esophagus is identified, a policy of surveillance endoscopy is initiated with two endoscopies and biopsies done the the first year, and additional endoscopies done every three years for life. If any minimally abnormal dysplastic cells are seen, the endoscopy is done yearly and if those abnormalities become more high-grade, endoscopy is performed every three months. The uncertainty is whether this invasive screening policy, performed on millions of Americans yearly, is worth the cost and effort and actually saves lives.

A study from Denmark published in the Oct. 13, 2011 issue of the New England Journal of Medicine has shed some light on the ACG recommendations.[4] The entire 5.4 million people of Denmark were the study group since all Danish medical reports are recorded in central registries. Data from the Danish Cancer Registry and the Danish Pathology Registry were analyzed by the authors of this article to determine the incidence of high-grade dysplasia and cancer among patients with Barrett's esophagus. Using this enormous information bank, the authors found that 860 people with Barrett's esophagus needed to undergo an endoscopy in order to find one cancer. In those with just metaplastic change without dysplasia, the yield was even lower. The authors further cited previous studies which showed a normal life expectancy in people with Barrett's esophagus and no survival benefit in those who undergo surveillance screening. Armed with facts, the authors questioned the value of routine screening and the rationale for our present recommendations.

Although science does not support the current American policy as proposed by the ACG, it is unlikely anything will change. The doctors who perform the endoscopy are well paid for the procedure and will continue to encourage it. When patients are presented with the possibility of cancer, they will eagerly opt for any screening-even if the screening is not justified by science. And failure to comply with recommendations, even those not scientifically based, exposes practitioners to possible malpractice suit. In Barrett's screening -- as in all of health care -- money, consumer demand and malpractice fear serve only to increase costs and compromise quality.

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References:

[1] Camilleri, et al, Prevalence and Socioeconomi Impact of Upper Gastrointestinal Disorders, Clin Gastroent Hepatol, 2005:3:543-552

[2] Wang, et al, Updated Guidelines for the Diagnosis, Surveillance, and Therapy of Barrett's Esophagus, American Journal of Gastroenterology 2008, 103, 788-797

[3] Sharma, et al, A critical review of the diagnosis and management of Barrett's Esophagus, Gastroenterology,2004,127;310-3

[4] Hvid-Jensen, et al, Incidence of Adenocarcinoma among patients with Barrett's Esophagus, NEJM, 365;15, 10/13/11 1375-1383

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