Barrett’s Esophagus Surveillance & TissueCypher®

Barrett’s esophagus is a change in the lining of the lower esophagus that is associated with long-standing acid reflux (GERD). It is the only known precursor to esophageal adenocarcinoma, a type of esophageal cancer, but most people with Barrett’s esophagus never develop cancer. Dr. Campbell performs upper endoscopy (EGD) with biopsies to watch for early changes, and the TissueCypher® Barrett’s Esophagus Test may be recommended to help personalize your follow-up.

What is Barrett’s esophagus?

With Barrett’s esophagus, the normal lining at the lower end of the esophagus is replaced by a different type of lining, a change linked to repeated exposure to stomach acid. Barrett’s itself usually does not cause symptoms beyond the reflux that led to it. It is found during an EGD and confirmed when biopsies of the changed lining are examined by a pathologist.

Why surveillance endoscopy matters

The pathologist grades each set of biopsies for dysplasia (precancerous change): no dysplasia, indefinite for dysplasia, low-grade dysplasia or high-grade dysplasia. Surveillance endoscopy, a scheduled EGD with biopsies, aims to find dysplasia or early cancer at a stage when it can still be treated, often through the endoscope.

• The American Gastroenterological Association (AGA) advises careful inspection with high-definition endoscopy and biopsies taken using the Seattle protocol: biopsies from four quadrants every 1–2 cm of the Barrett’s segment, plus targeted biopsies of any visible lesion.
• Because pathologists can disagree on dysplasia, both AGA and the American College of Gastroenterology (ACG) call for a diagnosis of dysplasia to be confirmed by a second or expert pathologist.
• AGA advises that all patients with Barrett’s esophagus take at least daily proton pump inhibitor (PPI) acid-suppressing medicine.

How often is surveillance done? What the guidelines say

Your surveillance schedule depends mainly on the dysplasia grade on your biopsies and the length of the Barrett’s segment. The 2022 ACG guideline suggests:

• No dysplasia, segment shorter than 3 cm: EGD every 5 years.
• No dysplasia, segment 3 cm or longer: EGD every 3 years.
• Indefinite for dysplasia (confirmed by a second pathologist): repeat EGD within 6 months after increasing PPI medicine to twice daily (if not already on a high dose); if it stays indefinite, EGD every year.
• Low-grade dysplasia (confirmed by a second pathologist), if you choose surveillance instead of treatment: EGD at 6 months and 12 months after diagnosis, then every year.

ACG notes these intervals assume a high-quality first exam with adequate biopsies. The 2022 AGA Clinical Practice Update advises surveillance endoscopy every 3 to 5 years for Barrett’s without dysplasia. For high-grade dysplasia, and for low-grade dysplasia, the guidelines favor endoscopic treatment rather than surveillance alone (see below). Dr. Campbell will set a schedule that fits your biopsy results and overall health.

TissueCypher® Barrett’s Esophagus Test: personal risk stratification

Two people with the same pathology report can carry different risks. The TissueCypher® Barrett’s Esophagus Test, made by Castle Biosciences, is a laboratory test run on biopsy tissue already taken during your EGD, so it does not require another procedure. Castle Biosciences works with the pathology laboratory to obtain tissue from your original biopsy, analyzes it, and sends the report to your doctor.

• What it estimates: your individual risk of progression to high-grade dysplasia or esophageal cancer within five years of the biopsy. The test uses an AI-driven analysis of cancer-associated protein biomarkers and tissue features.
• What the report shows: a risk class (low, intermediate or high), a risk score from 0 to 10, and a five-year probability of progression.
• Who it is for: people whose Barrett’s biopsies are read as non-dysplastic, indefinite for dysplasia, or low-grade dysplasia.
• How results are used: according to Castle Biosciences, a low-risk result can support standard or longer surveillance intervals for selected patients, while a high-risk result can lead to closer surveillance or treatment. The result is used together with your pathology grade and other risk factors, not in place of them.

What the guidelines say: the 2022 AGA Clinical Practice Update states that a tissue systems pathology-based prediction assay (the panel discussed TissueCypher) may be used for risk stratification of patients with non-dysplastic Barrett’s esophagus. The 2022 ACG guideline did not make a recommendation on using biomarkers in routine practice, citing insufficient data at the time. Dr. Campbell can talk with you about whether the test makes sense for you.

If dysplasia or high risk is found

ACG and AGA favor endoscopic eradication therapy (removing or ablating the Barrett’s lining through the endoscope) for high-grade dysplasia, and also for low-grade dysplasia, although AGA notes some patients with low-grade dysplasia may reasonably choose surveillance. AGA suggests against routine treatment of Barrett’s without dysplasia. Dr. Campbell offers endoscopic eradication therapy, including endoscopic resection and ablation, for Barrett’s esophagus with dysplasia and for selected high-risk Barrett’s, and will recommend the right approach for you.

When to call

Make an appointment if you have been told you have Barrett’s esophagus and are not sure when your next EGD is due, if heartburn or reflux continues despite medicine, or if you would like to discuss TissueCypher testing. Trouble swallowing, food sticking, vomiting blood or black stools should be checked promptly. For an emergency, call 911.

Related

• Upper endoscopy (EGD)
• Acid reflux (GERD) & hiatal hernia
• Barrett’s esophagus ablation (endoscopic eradication therapy)
• MiVu™ reflux testing during EGD

Sources

1. Shaheen NJ, et al. Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117(4).
2. AGA Clinical Practice Update on New Technology and Innovation for Surveillance and Screening in Barrett’s Esophagus: Expert Review (2022).
3. Castle Biosciences: TissueCypher® Barrett’s Esophagus Test, patient information.
4. Castle Biosciences: TissueCypher® “Our Test” (patient information).
5. TissueCypher® overview (tissuecypher.com).

Where surgery is performed

Dr. Campbell operates at AdventHealth Port Charlotte and Murdock Surgery Center. Consultations and follow-up visits take place at the Charlotte Harbor Surgical office in Port Charlotte.