Barrett’s esophagus as a marker for increased risk for esophageal cancer and cardiorespiratory disease

We read with interest the article by Caygill et al. [1], titled “Mortality in Barrett’s esophagus: three decades of experience at a single center,” published in a recent issue of Endoscopy. Barrett’s esophagus results from gastroesophageal reflux and is predisposed to progress to esophageal adenocarcinoma via a sequence involving low grade and high grade dysplasia [2]. Caygill et al. [1] compared mortality, from 1978 to 2009, among persons with Barrett’s esophagus against that of the general population. Most importantly, the authors found that esophageal adenocarcinoma-related mortality of those with Barrett’s esophagus was 25-fold greater (annual cancer risk 0.43 %), compared with that of the general population and showed a male predominance. Furthermore, the majority of those with Barrett’s esophagus died from noncancer causes (cardiorespiratory). There was no difference regarding deaths due to nonesophageal cancers (colorectal etc.). The question remains of whether the data from the study contribute to more adequately characterize those who would profit from removal of Barrett’s esophagus before the development of dysplasia and cancer.

Conceptually, those who died due to esophageal adenocarcinoma would have benefited from early removal of Barrett’s esophagus, before the development of malignancy [1]. Based on the study by Caygill et al. [1], males positive for Barrett’s esophagus, without co-morbidities (cardiorespiratory), would have fallen into this category. Radiofrequency ablation (RFA) represents a novel effective therapy for durable elimination of Barrett’s [3] [4] [5]. Recently Sikkema et al. [6] defined a subgroup of persons with nondysplastic Barrett’s esophagus (NDBE) who share an increased cancer risk, comparable to that of low grade dysplasia, which represents an accepted indication for RFA [5]. The studies by Caygill et al. [1] and Sikkema et al. [6] taken together justify the consideration of RFA within clinical studies in NDBE-positive individuals (males) without co-morbidities [1], and with a history of gastroesophageal reflux disease of > 10 years, presence of hiatal hernia, endoscopically visible columnar-lined esophagus (> 2.0 cm), esophagitis, and a positive family history for gastrointestinal cancer [6].

The finding that the majority of persons with Barrett’s did not die from esophageal adenocarcinoma justifies asking whether Barrett’s esophagus and cardiorespiratory diseases share a common pathophysiology [1] [2] [7]. Since both conditions are associated with abnormal eating behavior and with lifestyle it seems reasonable that both Barrett’s esophagus and cardiorespiratory diseases might be different manifestations of a metabolic imbalance [1] [2] [7]. Furthermore the risk for cardiorespiratory disease seems to be increased among those with Barrett’s. Thus, from a holistic point of view, Barrett’s esophagus may serve as a marker for increased risk of development of a cardiorespiratory disease [1] [7]. This needs to be elucidated, inasmuch as these correlations may help in developing disease prevention strategies aimed at decreasing mortality due to cardiorespiratory disorders and esophageal adenocarcinoma.

We would be grateful if Caygill et al. might address the abovementioned considerations.

• References

• 1 Caygill CPJ, Charlett A, Wall CM et al. Mortality in Barrett’s esophagus: three decades at a single center. Endoscopy 2012; 44: 892-898
• 2 Forte JG. The gastric parietal cell: at home and abroad. Eur Surg 2010; 42: 134-148
• 3 Fleischer DE, Overholt BF, Sharma VK et al. Endoscopic radiofrequency ablation for Barrett’s esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy 2010; 42: 781-789
• 4 Lyday WD, Corbett FS, Kuperman DA et al. Radiofrequency ablation of Barrett’s esophagus: outcomes of 429 patients from a multicenter community practice registry. Endoscopy 2010; 42: 272-278
• 5 Shaheen NJ, Peery F, Hawes RH et al. Quality of life following radiofrequency ablation of dysplastic Barrett’s esophagus. Endoscopy 2010; 42: 790-799
• 6 Sikkema M, Looman CWN, Steyerberg EW et al. Predictors for neoplastic progression in patients with Barrett’s esophagus: a prospective cohort study. Am J Gastroenterol 2011; 106: 1231-1238
• 7 Tsesmeli N, Coumaros D. The future of bariatrics: endoscopy, endoluminal surgery, and natural orifice transluminal endoscopic surgery. Endoscopy 2010; 42: 155-162