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The examine targeted on the comparatively new ideas of post-endoscopy esophageal neoplasia (PEEN) and post-endoscopy esophageal most cancers (PEEC), defined lead investigator Sachin Wani, MD, a professor of gastroenterology on the College of Colorado Anschutz Medical Campus, in Aurora.
CHICAGO—How can you improve esophageal cancer screening for patients with Barrett’s esophagus? A population-based study provides a new framework to determine when neoplasia and cancer in patients with BE represent a screening failure and how providers can conduct better cancer surveillance.
The study focused on the relatively new concepts of post-endoscopy esophageal neoplasia (PEEN) and post-endoscopy esophageal cancer (PEEC), explained lead investigator Sachin Wani, MD, a professor of gastroenterology at the University of Colorado Anschutz Medical Campus, in Aurora.
“The most important reason for PEEN and PEEC is missed lesions. The second reason is rapidly progressing neoplasia and cancer. Understanding the magnitude of PEEN and PEEC is critical for us to standardize the calculation of these entities to reduce the incidence of both,” Dr. Wani reported.
The concepts of PEEN and PEEC are the basis for understanding why screening endoscopy in BE has been associated with “limited effectiveness” despite its promise, according to Dr. Wani. Like reducing the frequency of missed polyps in the colon that are known to limit the efficacy of screening colonoscopy, understanding the steps to minimize PEEN and PEEC has the potential to establish benchmarks to drive improvements of BE surveillance, he said.
PEEN and PEEC were explored in NordBEST (Nordic Barrett’s Esophagus Study), an international population-based collaboration that employed data from the nationalized healthcare systems in Finland, Sweden and Denmark. The data were drawn from follow-up among patients with newly diagnosed BE.
The researchers evaluated 20,588 patients from the three countries with a diagnosis of BE over a 14-year period, excluding those with a history of esophageal or gastric cardia cancer. New lesions were considered PEEN or PEEC if they were identified 30 to 365 days after the index diagnosis of BE, and lesions detected fewer than 30 days after diagnosis were designated as the neoplasia detection rate (NDR). The mean age in the study population was 64.6 years, and it mostly consisted of men (67%).
The analysis of PEEN was restricted to records from Sweden, because data on high-grade dysplasia (HGD) were not captured in the health systems from the other countries. Of 279 cases of new lesions, 48 (17.2%) were considered to be PEEN, 41 (14.6%) NDR, and 190 (68.1%) incident neoplasia, defined as HGD or esophageal adenocarcinoma (EAC) diagnosed a year or more after initial detection of BE.
In the analysis of PEEC, which included 20,588 patients from all participating countries, 279 were diagnosed with EAC. Of these, the majority was incident EAC (62%), while PEEC represented 23.2% and NDR 14.6% of the cases. The incidence rates calculated for 100,000 person-years are shown in the Table.
| Table. Lesion Incidence Rates Per 100,000 Person-Years | ||||
| Swedish population | Full study population | |||
|---|---|---|---|---|
| Lesion | Incidence rate | 95% CI | Incidence rate | 95% CI |
| NDR | 3,906 | 2,876-5,305 | 2,521 | 1,857-3,425 |
| PEEN | 421 | 317-558 | NA | NA |
| PEEC | NA | NA | 369 | 289-470 |
| Incident HGD/EAC | 285 | 247-328 | 199 | 172-231 |
| EAC, esophageal adenocarcinoma; HGD, high-grade dysplasia; NA, not applicable; NDR, neoplasia detection rate; PEEC, post-endoscopy esophageal cancer; PEEN, post-endoscopy esophageal neoplasia. Based on Digestive Disease Week 2023 (abstract 857). | ||||
Several sensitivity analyses “did not change the message,” Dr. Wani said. For example, when the period of interest was expanded to include neoplasia or cancer 30 days to three years after a BE diagnosis, 39% of cases of HGD were classified as PEEN and 45.8% of cases of EAC were classified as PEEC.
Missed or Rapidly Progressing Lesions
Of next steps to determine the root cause of PEEN and PEEC, one will be to go back to the baseline biopsy to determine whether the neoplasia or EAC was the result of a pathology error, inadequate examination of the BE or was not present at the time of biopsy, suggesting a rapidly progressing lesion.
Overall, nearly 25% of all cancers that develop before the next scheduled surveillance exam after an index endoscopy can be characterized as PEEC, according to Dr. Wani. “Most likely, a large proportion of these represent missed neoplasia,” Dr. Wani said. As these missed lesions “are undermining our current screening and surveillance strategies,” the goal of this work is to understand why the lesions are missed.
The rates of PEEN and PEEC could not be analyzed at the level of the endoscopist in this study, but Dr. Wani said he believes analyses based on PEEN and PEEC have the potential to be used as quality indicators like those that have been used to boost polyp detection rates in colonoscopy.
One approach is a “consensus-based categorization construct” to uncover patient and physician variables that predict PEEN and PEEC. If standardized calculations of PEEN and PEEC can be derived from modifiable predictors, these could provide “minimal acceptable performance standards to operationalize PEEN and PEEC as quality indicators,” Dr. Wani said.
Given that “most EAC is still being diagnosed at advanced stages when the prognosis is dismal,” Dr. Wani said new strategies are needed to understand and prevent PEEN and PEEC.
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