Exploring the COVID-19 Pandemic’s Effect on Barrett’s Esophagus and Esophageal Cancer Screening

The COVID-19 pandemic had dramatic effects on all types of cancer screenings, from mammograms to colonoscopies. In the early days of the health crisis in spring 2020, screening numbers dropped dramatically as health care providers shifted their attention to caring for the seriously ill and fears of contracting the virus kept the general public away from hospitals, clinics, and other facilities.

New research by University of Colorado Cancer Center member Sachin Wani, MD, director of the Katy O. and Paul M. Rady Esophageal and Gastric Center of Excellence, details the effects of the pandemic on esophageal cancer screening, looking in particular at diagnoses of Barrett’s esophagus (BE), a condition in which the lining of the esophagus becomes damaged by acid reflux, which causes the lining to appear pink with abnormal cells on biopsies. BE is the only identifiable premalignant condition for esophageal adenocarcinoma and increases the risk of developing esophageal cancer compared to the general population. Wani’s study was published October 2 in the American Journal of Gastroenterology and led by Kusuma Pokala, MD, a trainee in the Division of Gastroenterology and Hepatology and Interventional Endoscopy Section

Wani and his team analyzed data from January 2018 to December 2022, finding a significant decline in the number of BE and BE-related dysplasia (abnormal cells) diagnoses during the COVID-19 pandemic, with an almost 50% reduction in the amount of dysplasia diagnosed in the early days of the pandemic. The decrease, Wani writes, “may result in deleterious downstream effects on esophageal adenocarcinoma morbidity and mortality.”

We spoke with Wani about his research and its findings.

You looked at a lot of data regarding a decline in esophageal cancer screening during the COVID-19 pandemic; is this something you were seeing in your clinic as well?

Absolutely. And we’re very interested in the impact of that. We are interested in the impact of the pandemic on the number of patients that get diagnosed with Barrett’s esophagus and Barrett’s-related dysplasia. We already had data showing that upper endoscopy volume declined during the pandemic, and as a result of this decline, the number of patients who were diagnosed with colorectal cancer declined as well. We know the incidence has not dropped to such an extent — these patients were there, but they weren’t getting the diagnosis that they needed.

Was there anything unique about the Barrett’s esophagus numbers that that stood out to you, or were these numbers in line with what we’re seeing about the pandemic’s effect on screening for other cancers?

It’s in line with what we’ve seen with other screening programs, specifically colorectal cancer. What’s unique about our study is that this is the first comprehensive analysis using a national benchmarking registry to address this question. What’s interesting, but at the same time troublesome, is the fact that even though we’re seeing an increase in the number of endoscopies as the pandemic is beginning to wane, we’re still not seeing an appropriate compensatory increase in the number of Barrett’s diagnosis and dysplasia, especially at stage 2 and 3. We feel this will have an overall impact on the epidemiology of esophageal adenocarcinoma and its associated morbidity and mortality.

What’s the ideal time to catch Barrett’s esophagus before it can potentially become cancerous?

We want to diagnose Barrett’s esophagus when someone only has Barrett’s esophagus or Barrett’s esophagus-related dysplasia or early cancer. We can put Barrett’s esophagus patients in surveillance programs so we can catch early cancer. We can manage these patients with endoscopic eradication therapies, as opposed to when they present with advanced stage disease where they need to go through chemotherapy, radiation, or esophagectomy. Or even worse, when they present with metastatic disease.

What symptoms or risk factors prompt a recommendation that someone be tested for BE?

Screening for Barrett’s esophagus is recommended in individuals who are at risk, as opposed to screening for colorectal cancer, which is recommended in the general population. Recommendation for screening for BE and esophageal cancer uses a risk-stratified approach. We test individuals who have chronic reflux disease along with a host of other risk factors — age greater than 50, male gender, Caucasian, history of smoking, obesity, family history of Barrett’s and esophageal cancer. We use a combination of these risk factors to determine their candidacy for screening for BE and esophageal cancer.

What is the screening process for BE?

The screening involves doing an upper endoscopy to see if they have a change in the lining of the esophagus. We take biopsies, and if they have what’s called intestinal metaplasia — a change in the cells that line the esophagus — that’s how we make the diagnosis of Barrett’s. It’s interesting to note that we’re in the midst of a paradigm shift in the way we may be able to screen for Barrett’s and esophageal cancer using cell-collection devices. Patients who are at risk can potentially swallow this device, then the device collects cells from the lower part of the esophagus. Only if that test is positive do they need to undergo an upper endoscopy.

Is the drop in screening numbers for BE at all attributable to an awareness issue, where people maybe aren’t aware that this is something they need to get screened for?

It is 100% an awareness issue, not just among our patients, but among our providers as well. Educating our patients and our physician community is critical, and it is an important mission of our Rady Esophageal and Gastric Center of Excellence. Several studies have demonstrated that the overall adherence rates to BE screening recommendations among physicians and patients are suboptimal. We need to aspire to a higher benchmark.