Barrett’s esophagus—the only known precancerous condition for esophageal adenocarcinoma—develops when chronic acid reflux damages the esophageal lining. Endoscopies are typically used to monitor such patients for precancerous or cancerous lesions. Now, new research suggests that even this gold-standard procedure can sometimes miss early-stage disease.

The study, conducted at the University of Colorado Cancer Center (Aurora, CO, USA), found that nearly one in four esophageal cancers may go undetected during an initial endoscopy. The findings, which have been accepted for publication in Clinical Gastroenterology and Hepatology, underline the urgent need to improve detection standards and quality metrics for endoscopic examinations.

The study analyzed data from 15,178 individuals newly diagnosed with Barrett’s esophagus between 2006 and 2020 in Finland and Sweden. Researchers found that 22% of cancers were classified as post-endoscopy esophageal cancers (PEECs)—diagnosed 30 days to one year after a negative endoscopy. An additional 18% were detected within 30 days of the initial exam, and 60% appeared more than a year later. Hospitals with higher initial detection rates had significantly fewer missed cancers, indicating that variability in examination quality plays a major role in diagnostic accuracy.

The researchers also identified several reasons for missed cancers, including inconsistent adherence to the Seattle biopsy protocol, inadequate inspection time of the Barrett’s segment, and difficulty recognizing subtle or flat lesions. They note that rapidly progressing cancers may still evade detection, even in high-quality exams.

The study calls for establishing quality benchmarks for upper endoscopy—similar to the “adenoma detection rate” used in colonoscopy—to measure how effectively physicians detect early esophageal changes. The researchers emphasize that high-quality examinations involve using advanced imaging, structured biopsy protocols, and sufficient inspection time for each case.

“Our findings highlight the importance of a high-quality endoscopic examination for patients when they get diagnosed with Barrett’s esophagus, including using the best endoscope available, spending adequate time inspected the Barrett’s segment, and ensuring that we take samples using a structured biopsy protocol,” said Sachin Wani, MD, a University of Colorado Cancer Center member who led the research.

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