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No benefit of routine screening for EAC and in chronic GERD patients

Tue, 07/07/2020 - 10:58
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A new guideline from the Canadian Task Force on Preventive Health Care, based on a rigorous systematic review of the latest evidence, found no benefit of routine screening for oesophageal adenocarcinoma (EAC) and precursor conditions (Barrett oesophagus and dysplasia) in patients with chronic gastroesophageal reflux disease (GERD).

The guideline, ‘Guideline on screening for esophageal adenocarcinoma in patients with chronic gastroesophageal reflux disease’, published in CMAJ (Canadian Medical Association Journal), recommends not screening adults because there is an absence of evidence for benefit, and there are uncertain harms, important resource implications and variable patient values and preferences.

"Given the many needs facing the health system, it is important to use services where we know there is benefit," said Dr Stephane Groulx, assistant clinical professor, Department of Community Health Sciences, Université de Sherbrooke and Chair of the Task Force EAC working group. "We did not find sufficient data to recommend routine screening by upper endoscopy of people with chronic GERD for EAC and precursor conditions, such as Barrett oesophagus."

This recommendation does not apply to people with alarm symptoms for oesophageal cancer, such as difficulty or pain swallowing, recurrent vomiting, unexplained weight loss, anaemia, loss of appetite or gastrointestinal bleeding, or to those who have already been diagnosed with Barrett oesophagus.

Current practice in Canada does not involve organized screening programs for EAC among patients diagnosed with chronic GERD, although some family physicians do refer these patients for EGD.

"Clinicians should be aware of alarm symptoms in patients and conduct appropriate investigation, referral and management of these patients," explained Dr Scott Klarenbach, a member of the working group and professor in the Department of Medicine, University of Alberta. "Physicians who routinely refer patients without alarm symptoms for screening may want to stop, given the lack of evidence showing benefit."

It was hoped that early detection could save lives; unfortunately, the Task Force's rigorous review of available evidence did not identify any benefit from screening.

Although age 50 years or older, male gender, having a family history, white race, abdominal obesity and smoking are factors that may increase the risk of EAC, relevant trials and cohort studies did not provide sufficient data to recommend screening for individuals with one or more of these risk factors.

As the evidence underpinning the guideline was of low- or very-low-certainty, and because screening by endoscopy is costly and may cause harm, the Task Force calls for more research to help understand which patients with chronic GERD are most likely to develop EAC and whether screening of specific high-risk groups provides benefit that outweighs the known harms.

During the development of the guideline, the task force engaged patients to understand values and preferences around screening.

The College of Family Physicians of Canada and the Nurse Practitioner Association of Canada have endorsed the guideline. The Canadian Partnership Against Cancer has provided a statement of support for the guideline.

In a related commentary, Dr Sander Veldhuyzen van Zanten, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, writes "The Task Force's strong recommendation against gastroscopy screening for patients with chronic GERD without alarm symptoms depended in part on the assumption that scarce health resources would need to be expended to implement screening."

He agrees that routine screening of patients younger than 50 who have chronic GERD is unnecessary. However, because gastroscopy is generally a safe and straightforward procedure, he suggests it may be considered in patients older than 50 who have chronic GERD and risk factors such as obesity and smoking.

To access this paper, please click here