Early onset Barrettʼs esophagus: new data, new challenges

Barrett's esophagus (BE) is commonly diagnosed in individuals over 50 years of age, with increasing age being a significant risk factor [1]. Owing to its low prevalence in younger populations, most studies and clinical guidelines have focused primarily on older adults; however, the prevalence of BE in younger populations is an area of growing interest and concern, with data indicating an increasing incidence. A large dataset from the USA has shown that, while the proportion of BE patients aged 70 years and older has dropped significantly, younger patient groups have demonstrated the highest increases in BE cases, especially among those aged 30–39 years [2]. Despite extensive research on BE in the general population, data on its incidence and progression in younger individuals remain sparse.

In this issue of Endoscopy, Noordzij et al. present crucial epidemiologic data on the incidence of dysplasia and esophageal adenocarcinoma (EAC) in patients with early onset BE diagnosed before the age of 30 [3]. Data from the Dutch National Pathology Registry identified 231 patients diagnosed with early onset BE between January 1, 1991 and December 31, 2015. Among these patients, 17 developed dysplasia, with a median surveillance time of 5 years, resulting in an incidence rate of 7.3 per 1000 person-years. Additionally, three patients progressed to EAC, diagnosed at ages 28, 35, and 36, with an incidence rate of 1.3 per 1000 person-years. While the observed incidence rate of EAC was not particularly high compared with the general adult population (2.5–3.4 cases per 1000 person-years), the lifetime cumulative incidence of EAC in patients with early onset BE would be higher owing to the longer observation period starting from a younger age.

"Looking to the future, longitudinal studies tracking the progression of BE in young patients over extended periods will provide more definitive data on the lifetime cancer risk."

Although the annual risk of dysplasia/carcinoma in younger individuals is lower compared with previous reports, these findings prompt further discussion on surveillance strategies for young BE patients. The study by Noordzij et al. indicates that early onset BE carries a risk of developing EAC comparable to that of the general adult population. Given the observed risk of progression to dysplasia and EAC, it may be prudent to consider the appropriate surveillance intervals for younger BE patients. Current guidelines from the American Gastroenterological Association (AGA) and the European Society of Gastrointestinal Endoscopy (ESGE) recommend surveillance every 3–5 years [4] [5]. Specifically, ESGE guidelines advise surveillance every 5 years for nondysplastic Barrett's esophagus (NDBE) of 1–3 cm and every 3 years for lengths of 3–10 cm [5]. Based on this study, these intervals seem appropriate for young patients, but discussions should also focus on identifying high risk young patients and consider cost-effectiveness. Risk stratification can help determine appropriate endoscopic surveillance intervals and, as the cancer risk for young people becomes clearer, more specific intervals should be established.

The findings of this study raise several important considerations for clinical management; however, determining which patients should be recommended for endoscopy still remains a topic for discussion. Current guidelines recommend screening for BE or EAC primarily in patients with multiple risk factors, usually setting the age cutoff at 50 years. Early stage EAC in younger patients is however poorly documented. An early onset of GERD symptoms may be linked to BE, with the risk increasing with the duration of GERD symptoms [6]. Wu et al. identified risk factors for BE in adults aged under 50, including male sex, GERD symptoms, and smoking [7]. Iwaya et al. compared young (<50 years) and older patients with stage T1 EAC and high grade dysplasia, finding that young patients were more likely to have ongoing GERD symptoms and obesity [8]. Further research will help to develop more efficient methods for identifying young patients at risk.

It is important to note that this study's definition of early onset BE as occurring in individuals under 30 years is arbitrary and differs from previous publications, which typically categorized young patients as under 50. Given the rising prevalence of BE in individuals under 50, future studies may need to redefine young Barrett's patients. Looking to the future, longitudinal studies tracking the progression of BE in young patients over extended periods will provide more definitive data on the lifetime cancer risk. Research into genetic and molecular markers that can predict the progression of BE to dysplasia or EAC could lead to more personalized and effective surveillance strategies. Randomized controlled trials assessing the efficacy of different surveillance intervals and interventions, such as endoscopic eradication therapy, in young patients with BE are needed to develop evidence-based guidelines.

In conclusion, the study by Noordzij et al. is a significant contribution to our understanding of BE in young patients. It highlights the need for vigilant surveillance and potentially more aggressive management. By identifying and monitoring high risk young patients, we can improve early detection and outcomes. As our understanding of early onset BE evolves, refining our clinical approaches will be crucial to optimizing patient care.

Publication History

Article published online:
22 August 2024

• References

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