Impact of radiofrequency ablation for Barrett’s esophagus on quality of life

In a recent study published in Endoscopy, Shaheen et al. compared endoscopic radiofrequency ablation (RFA) with a sham procedure with regard to quality of life (QoL) in patients with Barrett’ esophagus [1]. They concluded that patients receiving RFA had a better QoL compared with patients undergoing the sham procedure. Moreover their study showed significantly lower depression, general worry, stress, worry about esophageal cancer and esophagectomy, dissatisfaction about the condition of their esophagus, and impact on work and family life in the RFA group. However, there are some methodological errors.

In the study, patients in the sham group did not receive intensive treatment to lower the risk of esophageal cancer. However, the RFA group received intensive treatment and repeated endoscopic interventions. At the end of the study period, esophageal cancer had developed in 9.3 % and 1.2 % of the sham and RFA groups, respectively. Nevertheless, each group should be evaluated separately to document the QoL. The generic QoL might be evaluated among subgroups of Barrett’s esophagus patients at the beginning of the study. In a previous study, patients with Barrett’s esophagus had better health-related QoL when compared with patients suffering from erosive reflux disease and nonerosive reflux disease [2]. However, in another study there were no differences in QoL among patients with Barrett’s esophagus and gastroesophageal reflux disease, and both groups scored below average on the subscales of the SF-36 compared with normal controls [3]. It seems to us that QoL should be compared with healthy individuals rather than a sham group. Moreover, it would be better to compare QoL among both sham and RFA groups before and after interventions. In the literature, disease-targeted QoL studies assessed fear of recurrence of cancer, worry about cancer, and levels of anxiety and depression in patients with early neoplasia who were treated with endoscopic therapy compared with surgical treatment [4]. After esophagectomy for high grade dysplasia and intramucosal cancer, patients were able to resume a normal eating pattern, and postoperative QoL became equivalent to that of the general population. Patients with high grade dysplasia, carcinoma in situ and adenocarcinoma showed QoL scores equal to or better than those of healthy individuals.

A second important issue is that several factors may affect QoL as greatly as disease status. The doctor–patient relationship, the number of physician visits, the number and duration of hospitalizations, gender, and marital status may have an effect on the QoL. Although not mentioned explicitly in this report, the authors’ previous study indicated that both ablation and sham group patients with low grade dysplasia underwent biopsy procedures at 6 and 12 months; those with high-grade dysplasia underwent such procedures at 3, 6, 9, and 12 months. In addition, patients in the ablation group had been received up to four ablation sessions at baseline and at 2, 4, and 9 months. The impact of surveillance endoscopy on QoL in the Barrett’s esophagus population has been investigated. Patients reported significantly increased levels of depression, anxiety, and distress during the week prior to their endoscopy compared with the week after. Those who interpreted their risk of esophageal cancer to be high had correspondingly higher levels of procedural discomfort and tended to find endoscopy more burdensome [5]. For all those reasons, numbers of visits and interventions would have an effect on the results of the present study. Moreover, the RFA group had a positive doctor–patient relationship; in contrast, sham group had a negative doctor–patient relationship that suggested a continuing risk of development of esophageal cancer.

References

• 1 Shaheen N J, Peery A F, Hawes R H et al. Quality of life following radiofrequency ablation of dysplastic Barrett’s esophagus.  Endoscopy. 2010;  42 790-799
• 2 Lippmann Q K, Crockett S D, Dellon E S, Shaheen N J. Quality of life in GERD and Barrett’s esophagus is related to gender and manifestation of disease.  Am J Gastroenterol. 2009;  104 2695-2703
• 3 Eloubeidi M A, Provenzale D. Health-related quality of life and severity of symptoms in patients with Barrett’s esophagus and gastroesophageal reflux disease patients without Barrett’s esophagus.  Am J Gastroenterol. 2000;  95 1881-1887
• 4 Rosmolen W D, Boer K R, de Leeuw R J et al. Quality of life and fear of cancer recurrence after endoscopic and surgical treatment for early neoplasia in Barrett’s esophagus.  Endoscopy. 2010;  42 525-531
• 5 Kruijshaar M E, Kerkhof M, Siersema P D et al. The burden of upper gastrointestinal endoscopy in patients with Barrett’s esophagus.  Endoscopy. 2006;  38 873-878