The recently updated practice guideline from the American Gastroenterological Association (AGA) on the surveillance of Barrett’s esophagus (BE) is an attempt to strike a balance between desirable and undesirable effects and patient values.

The guideline, published in Gastroenterology, provides eight main evidence-based recommendations and several key implementation statements to help monitor patients after a diagnosis of BE, a condition associated with chronic gastroesophageal reflux disease and the only identifiable risk factor for esophageal adenocarcinoma, a lethal cancer with a dismal five-year survival rate of only about 20%.

“This guideline is timely as the last comprehensive position paper from the AGA on BE screening, surveillance, biomarkers, and endoscopic therapy was published in 2011,” first author Sachin Wani, MD, a professor of medicine and executive director of the Katy O. and Paul M. Rady Esophageal and Gastric Center of Excellence at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, told Medscape Medical News. The guideline is the second instalment in a three-part series on BE, following the 2024 guideline on endoscopic eradication therapy and with a third guideline on screening expected in 2026.

“While endoscopic surveillance of BE is recommended consistently by all international GI [gastrointestinal] society guidelines, several recent studies have evaluated the challenges and limitations associated with our current surveillance practices,” Wani said. Recently, for example, the effectiveness of endoscopic surveillance for overall or cancer-specific survival in patients with BE was challenged in a UK-based randomized controlled trial. It suggested that at-need endoscopy may be a safe alternative for low-risk patients.

“Several recent studies have also described the lack of adherence to established guideline recommendations and quality indicators and the detection of BE-related high- grade dysplasia and cancer after an ostensibly negative exam for these entities,” Wani added.

“What is novel in this guideline is our move away from a one-size-fits-all approach and the need for risk stratification and for performing a high-quality endoscopic examination in patients with suspected and established BE,” he said. “In suitable candidates, endoscopic surveillance is recommended at the present time for patients for early detection of Barrett’s-related high-grade dysplasia and esophageal adenocarcinoma. One of the strongest interventions to improve outcomes is a high-quality endoscopic examination.”

Among the guideline’s key takeaways:

• It recommended using BE length to guide endoscopic surveillance.

• Regular endoscopic surveillance is needed in suitable patients with BE, but no surveillance is recommended for patients with columnar lined esophagus < 1 cm in the absence of any visible lesions or dysplasia.

• This guideline stressed the importance of cessation of surveillance based on age, overall health, and benefit.

• No recommendation was made on the use of enhanced sampling techniques, such as wide-area transepithelial sampling to enhance neoplasia detection and biomarkers such as p53 and the TissueCypher assay to predict BE progression.

• Also recommended is the use of daily proton pump inhibitor therapy as the preferred preventive strategy over anti-reflux surgery.

• The document also provides recommendations on endoscopic surveillance intervals and management in patients with BE-related low-grade dysplasia and indefinite for dysplasia.

• The guideline recognized the importance of several risk-stratification strategies, including biomarkers and advanced sampling techniques but did not make a recommendation for or against these strategies.

“The role of approaches will undoubtedly evolve as results from several ongoing trials become available,” Wani said. He added that these new recommendations are practical and readily implementable into clinical practice and align with most recommendations provided by other US and international GI societies.

Wani cautioned that several knowledge gaps remain to be addressed in future studies. These include clarifying the role of surveillance in study designs that minimize contamination and address the endpoint of esophageal adenocarcinoma mortality. Future studies should also identify risk-stratification tools such as biomarkers to better guide surveillance intervals, risk of progression, and discontinuation of surveillance, he said. “And the role of artificial intelligence in enhancing dysplasia and cancer detection needs to be defined ideally in randomized controlled trials.”

Commenting on the AGA guidance but not involved in its authorship, Amitabh Chak, MD, Younker-Ponsky Chair in Diagnostic Intervention at University Hospitals Cleveland Medical Center in Cleveland, told Medscape Medical News that in a rapidly evolving field the AGA panel rigorously evaluated the most recent evidence to provide measured and clear recommendations on surveillance. “It cleared up some ambiguities and addressed the use of newer methods of risk stratification.” Chak added that further research is needed to determine the clinical utility of newer risk-stratifying approaches.

This guideline was wholly funded by the AGA Institute with no support from industry. Wani was supported by the National Institutes of Health and the Katy O. and Paul M. Rady Endowed Chair in Esophageal Cancer Research.