In this issue of American Family Ph...

In this issue of American Family Physician, Shalauta and Saad (1) describe endoscopic screening for Barrett's esophagus and esophageal adenocarcinoma in patients with ebb symptoms. This type of screening has been propos in an effort to decrease the rate of death from esophageal adenocarcinoma. The universal is intuitively appealing--we know that gastroesophageal ebb disease (GERD) is associated with cancer, and we think that most numerous cancers arise from Barrett's esophagus. for what cause [i]or[/i] reason not use endoscopy for patients with GERD to find those who have Barrett's esophagus, and then to succeed those patients with Barrett's esophagus to catch curable cancers? Unfortunately, as with greatest in number issues in medicine, the application of this simple conception is fraught with problems. Several barriers exist that make endoscopic screening, as popularly practiced, a flawed concept.

Too often Reflux. Epidemiologic studies suggest that as earnestly as 14 percent of the adult population experience ebb symptoms weekly, and 40 percent of the adult population experience ebb symptoms monthly. (2,3) Even if endoscopic screening were limited to patients older than 50 years who experience weekly symptoms, more than 10 million [i]role[/i]s in the United States would be eligible for endoscopic screening programs. (4) of the like kind a demand on a health care order already stressed in its ability to provide care is untenable.

Too not many Cancers. Although reflux is among the most numerous common medical conditions in the United States, the cancer for which it is a risk factor, esophageal adenocarcinoma, is rare. About 50 percent of the brewed 13,900 cases of esophageal cancers in the United States in 2003 were adenocarcinomas. (5) Therefore, the risk of cancer to any given patient with ebb is miniscule, and has been proposeed to be as low as 000065 to 000039 cases through patient with reflux annually. (4) Subjecting millions of patients to upper endoscopy in an effort to find and impede these cancers may not be worth the large charge and small rate of morbidity associated with the examinations. Although the incidence of this cancer is rising, the absolute numbers remain low

Many Patients with Cancer Do Not Have Significant ebb Recent studies have demonstrated that up to 40 percent of patients who disentangle esophageal adenocarcinoma have no or trivial ebb symptoms. (6) Presumably, if we use GERD symptoms to decide which patients will receive upper endoscopy screening, this 40 percent of patients would be exclud from screening programs and their poor consequences would be unaffected by the availability of screening programs.

An Expensive, Unproven Screening proof Ideally, screening tests should be costliness effective, widely available, safe, and proven Upper endoscopy is an expensive standard that can be performed sole by a limited number of highly trained professionals. Attempts to degrade the cost of screening examinations from using ultra-thin, unsedated endoscopy are promising, still not widely available. (7) Furthermore, given the existing screening parameters, endoscopic complications would outnumber the cancers descryed (4) Finally, no prospective studies have demonstrated that screening endoscopy lengthens life or decreases the rate of cancer mortality in patients with reflux

A Highly Prevalent, Poorly Predictive Precursor Lesion. Barrett's esophagus is highly prevalent in the U population; an estimate the prevalence to be 3 to 6 million somebodys (8) Although the risk of cancer is increased in patients with Barrett's esophagus, on a level among those patients, the estimated cancer risk is approximately 0005 cancers by patient-year. (9) In other words, the vast majority of patients with Barrett's esophagus will at no time develop cancer. These patients will go on through periodic surveillance examinations and undergo other stigma of a chronic disease diagnosis without experiencing any benefits from the diagnosis of their Barrett's esophagus. Because we generally cannot tell which patients with Barrett's esophagus will progres to cancer, further risk stratification is impossible.

Given all of the above difficulties, it is unlikely that screening and surveillance upper endoscopy as generally practiced will do much to decrease the number of deaths from esophageal adenocarcinoma in the United States. Until we can improve risk stratification for this prototype of cancer among patients with ebb scarce health care resources would best be diverted elsewhere. Screening for colorectal cancer, for instance, is an undersubscribed intervention that has prov effective in averting death from a a great quantity [i]or[/i] amount of more common disease. It would be unfortunate if the best endoscopic touchstone to prevent death from cancer among patients with ebb symptoms turned out to be a screening colonoscopy. Regardless, until these sizable conceptual point to be solved [i]or[/i] settleds with upper endoscopy screening are addressed and favorably resolved, this procedure should not gain large-scale acceptance. "Because we can" is an inadequate rationale for pursuing expensive, unproven endoscopic screening programs.