Probability-based screening for BE, esophageal cancer could reduce screening needs by 45%
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Key takeaways:
- Age, male sex and family history were positive predictors of BE/EAC.
- Targeted screening of patients with a 5% probability of disease reduced the screening population by 45.2% but still detected 71% of cases.
Targeted screening of older adults with GERD and a 5% probability of Barrett’s esophagus or esophageal adenocarcinoma could “substantially decrease” the population to screen, while still detecting more than 70% of disease, data showed.
“Esophageal adenocarcinoma (EAC) has a 5-year survival of less than 20%, but a previous diagnosis of Barrett’s esophagus is associated with earlier-stage cancer and improved survival,” W. Keith Tan, a clinical PhD fellow at the Early Cancer Institute at University of Cambridge, and colleagues wrote in Gastroenterology. “The capsule sponge trefoil factor 3 (TFF3) test is a minimally invasive test that can be used to detect BE and early EAC.”
The Barrett’s Esophagus Screening Trial 3 (BEST3) was a multicenter, randomized controlled trial that compared the offer of the capsule sponge TFF3 vs. usual care in a primary care population of 6,388 patients aged 50 years or older with GERD. Researchers aimed to identify the optimal target population to screen for BE and stage 1 EAC to maximize diagnostic yield and minimize overdiagnosis.
After estimating the number of missed BE/EACs in usual care, Tan and colleagues used data from TFF3-negative patients invited at random for a poststudy endoscopy and diagnosed with BE/EAC. Researchers then calculated the expected number of diagnoses in usual care using the expected BE/EAC proportion in the intervention arm.
According to study results, the number of BE/EACs detected (0.3%) in usual care fell short of the expected 10.6%, which suggested that 98% go undiagnosed. Researchers projected that, assuming all participants accepted screening with the capsule sponge TFF3, they could detect 506 cases of BE/EAC and up to 74% undiagnosed by current screening standards could be screen-detected.
Among 1,654 patients in the intention-to-treat population who successfully swallowed the sponge capsule, age (OR = 1.05; 95% CI, 1.03-1.07), male sex (OR = 2.46; 95% CI, 1.67-3.64) and family history (OR = 1.81; 95% CI, 1.04-3.15) positively predicted BE/EAC. Researchers then used age and sex to model the probability of a BE/EAC diagnosis and found that women aged 60 years and older and men aged 50 years and older could be screened to target individuals with a 3% probability of BE/EAC. Similarly, for a 5% probability, women aged 65 years and older and men aged 55 years and older should be screened, and for a 10% probability, men aged 65 years and older.
Tan and colleagues then used an estimated screening population of 3.98 million individuals aged 50 to 74 years with GERD and deduced that increasing the screening threshold from 3% to 5% probability reduced the number needed to screen by 45.2% while still detecting 71% of cases. Increasing the threshold to 10% among men reduced the screening proportion screen by 84% but missed 72.3% of cases.
“Overall, this study shows that the current referral strategies identify only a fraction (13 of 680; 2%) of the projected BE and stage 1 EACs expected among a reflux population aged 50 years and older,” Tan and colleagues wrote. “Further, targeted screening of individuals with a 5% probability of having BE/EAC could substantially decrease the population to screen while still detecting more than 70% of BE/EACs.”
They continued: “A large, randomized screening trial (BEST4) in the identified target population will determine whether a non-endoscopic screening approach can reduce morbidity and mortality from EAC.”
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