Improving surveillance for Barrett's oesophagus: AspECT and BOSS trials provide an evidence baseBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7556.1512 (Published 22 June 2006) Cite this as: BMJ 2006;332:1512
- Janusz Jankowski, chief investigator, AspECT trial (, )
- Hugh Barr, chief investigator, BOSS trial
- Department of Clinical Pharmacology, University of Oxford, Oxford OX2 6HE
- Department of Surgery, Gloucestershire Royal Hospital, Gloucester GL1 3NN
EDITOR—We read with interest the quality improvement report for improving surveillance for Barrett's oesophagus by Bampton et al.1 Improving adherence to guidelines that are themselves lacking a sufficient evidence base may not actually improve hard clinical outcomes such as all causes of mortality or even cancer progression.
The major problem with a surveillance only approach is that only an estimated 5-10% of patients with Barrett's oesophagus will benefit as the rest are either not referred for endoscopy or default the surveillance programme.2 The real value of surveillance needs to be tested in a randomised trial so that all confounding issues associated with surveillance can be independently assessed. The Barrett's oesophagus surveillance study (BOSS) aims to randomise 2500 patients with proved Barrett's oesophagus to either surveillance endoscopy as recommended in the guidelines recommended by Bampton et al and no surveillance for patients.1 3
In this trial, full written informed consent of all the relevant issues will take place and, although the trial is about to start, we will be able to address whether patients in the non-surveillance arms will violate the BOSS protocol by withdrawal from the study owing to anxiety over existing and new “reflux” symptoms. There could be other outcomes, however, as we already have provisional evidence to indicate that chemoprevention of Barrett's oesophagus may decrease cancer incidence by up to 45%.3 It is possible, therefore, that once cancer incidence is stratified by aspirin use in the surveillance and non-surveillance arms the value of surveillance will be modest and perhaps even neutral when taking into account other issues such as endoscopic and multiple biopsy induced mortality, morbidity, and anxiety. The role of chemoprevention is itself already being tested in another large randomised study involving 5000 patients with Barrett's oesophagus, the aspirin esomeprazole chemoprevention trial (AspECT).
We wonder whether in the fullness of time resources may perhaps be proved to be better spent in mass chemoprevention for patients with reflux disease (> 35 years) for 10 or more years.
Competing interests None declared.