588 Correspondence Gastroenterology Vol. 146, No. 2

Ineffective Surveillance Does NotImprove Survival in Patients With Bar-rett’sWhoProgresstoAdenocarcinoma

Dear Sir:The study by Corley et al1 concluded that surveillance

endoscopy for Barrett’s esophagus was not associated withan overall reduced risk of death from esophageal adeno-carcinoma despite the fact that it detected earlier stagedisease. This conclusion suggests that even early stageesophageal cancer is lethal in most patients. Data fromsurgical and endoscopic series disprove this conclusion;both esophagectomy and endoscopic resection and ablationare associated with nearly universal survival in patientswith intramucosal adenocarcinoma.2–4 What then are thealternative explanations for their findings?

First, only 4 surveillance patients (11%) in the Corley et alstudy had curable intramucosal cancer. A disturbing 89% ofthe surveillance patients had more advanced disease,including 22% with systemic metastases. Although the au-thors included as “early stage” disease the 4 patients withintramucosal cancer and the 15 patients without lymph nodeinvolvement, they gave no information on the depth of tumorinvasion in those 15 patients or howmany lymph nodes wereresected. Removal of only a few negative lymph nodes wouldhardly be reassuring that an adenocarcinoma invasivebeyond themucosa was truly “early stage.” Instead, it is likelythat very few surveillance patients actually had curableadenocarcinoma at the time of diagnosis. If surveillance doesnot detect cancer at a curable stage, it is ineffective surveil-lance. The major reason why the surveillance was ineffectivein this study was likely the surveillance intervals. Among thesurveillance cases almost one-half had not had an endoscopyin the 3 years before the cancer diagnosis, and nearly 40%didnot have an endoscopy within the prior 5 years, despite thefact that surveillance cases were more likely than controls tohave dysplasia (both low and high grade) and had longerlengths of Barrett’s esophagus. These long surveillance in-tervals explain why the cancer was found on an endoscopydone to evaluate symptoms rather than for surveillance in onehalf of the patients. Further evidence pointing toward inef-fective surveillance was the lack of a significant difference inthe stage of disease between patients in surveillance andthose not in surveillance.

Second, if the treatment for disease detected by surveil-lance is lethal, it will eliminate any benefit of surveillance.Endoscopic therapy for early stage adenocarcinoma has anexcellent cure rate with minimal morbidity and mortality, yetno patient received this therapy. Instead, an esophagectomywas done, and assuming that the 8 surveillance patients whohad distant metastatic disease and the 2 with an unknownstage did not undergo esophagectomy, the treatment-relatedmortality rate for esophagectomy in the surveillance patientswas 14% (4/28). This is little different from the 20%mortalityrate for esophagectomy in patients with surveillance-detectedcancers reported by Corley et al in 2002.5 This remains amongthe highest esophagectomymortality rates everpublished, and

is well outside the 1%–5%mortality rate reported from mosthigh-volume, tertiary centers.6,7 Importantly, 80% of themortalities related to esophagectomy in the current seriesby Corley et al occurred in surveillance patients. Further,one-half of the patients who were unable or unwilling toundergo esophagectomy were in the surveillance group.

The authors summarized that, although surveillance wasassociated with finding disease at an earlier stage, thetreatment was ineffective, harmful, or declined by many pa-tients. An alternative conclusion is that protracted surveil-lance intervals for patients with Barrett’s esophagus leads tofew patients being found with curable disease. What mighthave been a cost-effective surveillance strategy was clearlynot a cancer-effective surveillance strategy. Further, treat-ment for surveillance-detected cancer associated with highmorbidity and mortality rates negates any benefit of sur-veillance and encourages patients to decline therapy. Instead,if the surveillance had been done at an interval that detecteddisease at the curable stage of high-grade dysplasia orintramucosal cancer, and the treatment was with an effectiveprocedure with low morbidity and mortality such as endo-scopic resection and ablation or a laparoscopic vagal sparingesophagectomy at a high-volume tertiary center, the outcomeof this study likely would have been dramatically different.

STEVEN R. DEMEESTERTOM R. DEMEESTERDepartment of SurgeryThe University of Southern CaliforniaKeck School of MedicineLos Angeles, California

References

1. Corley D, et al. Gastroenterology 2013;145:312–319.2. Peyre C, et al. Ann Surg 2007;246:665–674.3. Pech O, et al. Gut 2008;57:1200–1206.4. Zehetner J, et al. J Thorac Cardiovasc Surg 2011;

141:39–47.5. Corley D, et al. Gastroenterology 2002;122:633–640.6. Portale G, et al. J Am Coll Surg 2006;202:588–596.7. Luketich JD, et al. Ann Surg 2003;238:486–494.

Conflicts of interestThe authors disclose no conflicts.

http://dx.doi.org/10.1053/j.gastro.2013.10.069

Reply. We thank the authors for their thoughtfulcomments regarding our study. Ms. Kolb, Dr Kaltenbach,and Dr Soetikno raise the interesting question of whetherenhanced detection techniques may improve the potentialeffectiveness of Barrett’s esophagus surveillance forprecancerous changes/dysplasia, particularly for “flat”dysplasia/neoplasia. We agree that the development of newtechniques for identifying these lesions is a promising areaof research. They also emphasize that variation in training