Use of the Cytosponge to screen for Barrett's esophagus is feasible in primary care settings

Reference

Fitzgerald RC, di Pietro M, O'Donovan M, et al. Cytosponge-trefoil factor 3 versus usual care to identify Barrett's oesophagus in a primary care setting: a multicentre, pragmatic, randomised controlled trial. Lancet 2020;396(10247):333-344.

Synopsis

These researchers enrolled patients older than 50 years who had received prescriptions of histamine-2 receptor antagonists or proton pump inhibitors for at least 6 months in the previous year. They excluded patients who were concomitantly treated with nonsteroidal anti-inflammatory agents, those who had a known history of Barrett's esophagus, and those who had an upper endoscopy in the previous 5 years. The researchers randomized the patients to receive usual care (n = 6388) or office-based screening by a trained nurse (n = 6834). Usual care consisted of continued acid-suppression treatment and lifestyle advice or endoscopy referral according to the clinician's whims. The intervention consisted of swallowing a capsule containing a polyester mesh sphere (the Cytosponge) attached to a thread. After the patient swallows the capsule, the nurse yanks on the thread and pulls out the sponge and sends it for processing. In this case, the lab used a specific biomarker, trefoil factor 3 (TFF3), to identify the presence of intestinal metaplasia, and offered a referral for endoscopy if TFF3 was present. Of the 6834 patients invited to screening, only 2679 expressed interest: 1750 patients underwent the procedure, 96 (5.5%) were unable to swallow the capsule, and 231 had a positive TFF3 test result (10 of whom declined the endoscopy referral). A total of 311 (nearly 20%) of the patients had an equivocal negative result and were invited for a repeat procedure. Among the patients receiving usual care, 13 (< 1%) were given a diagnosis of Barrett's esophagus in the following year compared with 140 (2%) of the screened group. The absolute difference was 18.3 cases per 1000 person years. Four of the screened patients were found to have dysplasia and 5 had stage I esophageal cancer. One patient had to undergo endoscopy to rescue a sponge that separated from its thread; 89% of the patients felt the procedure was tolerable. Although the authors correctly identify Barrett's esophagus as a precancerous condition, they fail to report the incidence of cancer is low. So, more work is needed to see if patients who are screened for Barrett's esophagus in this manner are better off as a result.