A recently validated homegrown model may help physicians and patients determine a personalized follow-up strategy after treatment of Barrett’s esophagus. Following a recent publication in Gastroenterology Dr. Sanne van Munster tells about the background, results and the low-threshold use of this prediction model.
The combination of endoscopic resection and radiofrequency ablation (RFA) is the preferred treatment worldwide, including in the Netherlands, for eradication of Barrett’s esophagus with dysplasia and/or early cancer.
Recidiephrisico
Endoscopic follow-up is performed after complete eradication of Barrett’s esophagus to identify and treat recurrences at an early stage and thus prevent progression to advanced cancer. The reported recurrence risks vary widely, from 1% to 20% per person-year. These differences can be partly explained by heterogeneous definitions for complete eradication of Barrett’s esophagus and for recurrences. Centralization of Barrett care, as is the case in the Netherlands, can also play a role. In addition, lower recurrence percentages have been reported for patients treated in a center of expertise. Most studies published to date are limited by small size and short follow-up.
There is an increasing amount of data indicating that the current treatment is very effective in the long term. The risk of recurrence after such treatment is very low. “We have no evidence-based advice on how to follow up patients after this treatment,” says Van Munster, who is now training as an MDL doctor at St. Antonius Hospital and also works as a post-doc at Amsterdam UMC. “The guideline recommendations differ and are based on expert opinion. They were drawn up during the period when we had just had this treatment and we did not yet know whether it was effective. That’s why we check these patients very often. Now we do that every three months during the first year and every three months after that. No one knows how long that will take. Because data is now coming in that this combination treatment is also so effective in the long term, we wonder whether we should adjust the advice, and if so how.”
Register of all patients
In the Netherlands, care for patients with Barrett’s esophagus is centralized in nine centers of expertise. “There is a homogeneous treatment,” says Van Munster. “The centers have a common treatment protocol, the endoscopists and pathologists are jointly trained and we organize semi-annual meetings to discuss difficult patients. All patients with Barrett’s esophagus in the Netherlands who require endoscopic treatment are treated in one of these centers of expertise. This infrastructure means that we can register data of all patients treated in the Netherlands with good quality.”
The data is kept in the Dutch Barrett Expert Center (BEC) registry. The 1154 patients included in our study are almost all patients who have undergone this intervention since the introduction of the endoscopic treatment. During a mean follow-up of 4 years, 38 patients developed a recurrence, representing an incidence of 0.8% per person-year.
The following features were independently associated with recurrence (strongest to weakest predictor): a new visible lesion during the RFA treatment period, greater number of endoscopic resection treatments, male gender, longer barrett height before treatment, high-grade dysplasia or cancer at baseline, and younger age. “These are all factors that are readily available,” adds Van Munster. “These factors have been included in the prediction model. We then validated our model externally in a dataset from Belgium and Switzerland.”
Online tool
Because the built model is quite complicated in terms of calculations, Van Munster and co-researchers have created an online tool in which all variables that are important can be entered. “You can indicate all the variables that are important predictors,” she explains. “Then you get an insightful graph for the next seven years of how great the risk of recurrence is. The tool is available online and MDL doctors can fill out their own patients for their patients.”
The model can be used to determine together with the patient how (often) the follow-up checks should take place. If the risk of recurrence is very low and the patient is a bit older and has comorbidity, then Van Munster can imagine that the doctor agrees with the patient to do fewer check-ups or even no more check-ups, because these have few benefits, but there are risks and benefits. generate tax. “In patients with a high risk, you can decide not to do less than follow the guideline,” she says about the other end of the spectrum. “We cannot give firm advice on the basis of this study, but in the vast majority of these patients we can check much less frequently. That saves a lot of scopes every year. It is also a completely different message for the patient if we tell them that he or she needs regular check-ups because the cancer may come back, or if we tell them that we are almost certain that nothing will come back and we don’t need it anymore. to check.”
Conclusion and follow-up projects
This is the first externally validated model predicting visible dysplastic recurrence after successful endoscopic eradication treatment of Barrett’s esophagus with dysplasia or early cancer. With external validation, this model has good distinctiveness and good calibration.
Van Munster and colleagues are working on follow-up projects to advise evidence-based intervals, based on this model and its cost-effectiveness. In the meantime, this model is available that is easy to use and interpret. It can serve as a kind of handle in the doctor’s office to determine the desired follow-up frequency.
Bron:
Van Munster S, Nieuwenhuis E, Bisschops R, et al. Dysplastic Recurrence After Successful Treatment for Early Barrett’s Neoplasia: Development and Validation of a Prediction Model. Gastroenterology. 2022:S0016-5085(22)00271-2.