Overall and Cause-Specific Mortality in Patients with Barrett's Esophagus: A Systematic Review and Meta-Analysis of Population-Based Studies.

Abstract

Background: Current guidelines recommend endoscopic surveillance of Barrett's esophagus (BE), but do not account for competing mortality unrelated to esophageal cancer (EC). We conducted a systematic review and meta-analysis to estimate EC and non-EC mortality risk in BE patients.

Method: We searched multiple databases for studies reporting mortality in BE. We included population-based studies providing standardized mortality ratio (SMR). The primary outcome was SMR from all causes, EC and non-EC etiologies. SMR was calculated by dividing the observed mortality over the expected mortality. Logarithmic form of SMRs were pooled using random effects model.

Results: Our search yielded 2826 articles, of which 7 studies (n=34,454) were included. All-cause mortality was elevated in BE patients compared to population controls [pooled SMR 1.24 (95% CI:1.01 - 1.53)] driven in part by increased EC mortality risk [SMR 8.98 (95 CI:5.12-15.77)]. The mortality risk was still increased but attenuated after excluding EC mortality [SMR:1.21 (95% CI:1-1.46)]. There was no increased mortality risk for non-EC malignancies [SMR:1.22 (95% CI:0.82-1.82)] or mortality due to non-cancer etiologies [SMR:1.13 (95% CI:0.90 - 1.43)]. Death due to cardiovascular diseases was higher in BE [SMR:1.16 (95% CI:1.02-1.33)]. BE patients were 10 times more likely to die from non-cancer etiologies than EC [RR: 10.71 (95% CI: 5.98 - 19.16)]. Subgroup analysis of studies that excluded prevalent EC at baseline (3 studies) also showed increased all-cause [SMR: 1.12 (95% CI: 1.07 - 1.18) and EC mortality [SMR 4.7 (95% CI: 3.58 - 6.17)] among BE patients.

Conclusion: BE patients exhibit a higher all-cause mortality, driven in part by risk of EC mortality. A personalized approach to surveillance, mitigating risk of EC while recognizing the broader mortality risks, is warranted.