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## Complete Summary

#### GUIDELINE TITLE

American Gastroenterological Association medical position statement:
role of the gastroenterologist in the management of esophageal
carcinoma.

#### BIBLIOGRAPHIC SOURCE(S)

Wang KK, Wongkeesong LM, Buttar NS. American Gastroenterological
Association medical position statement: role of the gastroenterologist
in the management of esophageal carcinoma. Gastroenterology 2005
May;128(5):1468-70.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15887128)

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, the Clinical Practice Committee
meets three times a year to review all American Gastroenterological
Association Institute (AGAI) guidelines. This review includes new
literature searches of electronic databases followed by expert committee
review of new evidence that has emerged since the original publication
date.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Esophageal carcinoma, including squamous cell cancer and adenocarcinoma

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Internal Medicine\
Oncology\
Radiation Oncology\
Radiology\
Surgery\
Thoracic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To examine the clinical practice of the gastroenterologist in the
management of the patient with esophageal carcinoma

#### TARGET POPULATION

Adult patients at risk of or with esophageal carcinoma

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening and Surveillance**

1.  Risk assessment

2.  Surveillance endoscopy

3.  Biopsy

4.  Endoscopic mucosal resection

5.  Endoscopic ultrasonography

6.  Brush cytology

**Prevention**

1.  Acid inhibition

2.  Chemoprevention

3.  Lifestyle modifications including

    -   Weight loss

    -   Stopping tobacco use

    -   Eating fresh fruits and vegetables

**Diagnosis and Staging**

1.  Flexible endoscopy

2.  Brush cytology

3.  Biopsy

4.  Fine needle aspiration of lymph nodes

5.  Computed tomography

6.  Endoscopic ultrasonography

7.  Endoscopic mucosal resection

8.  Positron emission tomography

**Treatment**

*Early Esophageal Cancer T1 N0 M0*

1.  Surgery

2.  Endoscopic mucosal resection

3.  Photodynamic therapy

*Advanced Esophageal Cancer*

1.  Surgery

    -   Esophagectomy

    -   Lymph node dissection

2.  Chemotherapy (palliative or neoadjuvant)

    -   Cis-platinum

    -   5-fluorouracil

3.  Radiation therapy

4.  Palliation

    -   Esophageal stenting

    -   Endoscopic tumor ablation with photodynamic therapy, alcohol
        injection, or laser therapy

5.  Supportive measures

    -   Nutritional support

    -   Emotional and social support

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of esophageal cancer

-   Morbidity and mortality

-   Adverse effects of treatment

-   Cost-effectiveness of surveillance

-   False positive and false negative diagnostic test results

-   Survival time

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A search and review of the literature available on MEDLINE and
PREMEDLINE was performed on the topics of esophageal neoplasm,
esophageal cancer, and Barrett\'s esophagus from 1968 to 2004.
Bibliographies of significant reports were also reviewed to ensure that
the pertinent literature was reviewed.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I** evidence is the presence of at least one prospective,
randomized, controlled trial.

**Level II** evidence is based on well-designed cohort or
case-controlled studies.

**Level III** evidence is based on case series or flawed clinical
trials.

**Level IV** evidence is based on opinions of respected authorities or
expert committees.

**Level V** evidence is insufficient evidence to form any opinions.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

Guideline developer reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Screening and Surveillance for Esophageal Cancer**

Early detection is the key to the treatment of any gastrointestinal
malignancy, and this is particularly true of esophageal adenocarcinoma.
Intramucosal carcinomas have virtually no risk of metastasis, while
cancers that penetrate into the deep mucosa or submucosa can have
significant risks of dissemination. At the current time, screening and
surveillance for esophageal cancer is still controversial. Screening
asymptomatic populations for adenocarcinoma cannot be recommended
because current studies suggest that cancers and predisposing conditions
such as long-segment Barrett\'s esophagus are uncommon without symptoms.
Screening patients with symptoms of heartburn who are older than 50
years of age may be of value because this is a higher-risk group, but
this has not been proven in a prospective study. Squamous cell cancers
of the esophagus are less common in the United States, and screening is
not recommended except for very select subgroups such as patients with
tylosis, Fanconi\'s anemia, and lye-induced strictures. The presence of
risk factors such as long-term tobacco or alcohol use, achalasia, or
squamous head and neck cancers may identify selected groups for
screening.

Surveillance endoscopy has been used the most in the setting of
Barrett\'s esophagus. Surveillance endoscopy is complicated by 2 major
problems: sampling error (missing significant neoplastic lesions) and
interpretation errors (histologic uncertainty regarding the presence of
dysplasia). Sampling errors will be hopefully reduced in the future by
the development of novel technologies that allow the endoscopist to
visualize neoplastic lesions at the time of endoscopy, such as optical
biopsy techniques or magnification techniques. Most have not been proven
to be effective in trials, and some techniques such as methylene
blue--assisted chromoendoscopy have been suggested to be potentially
deleterious to the mucosa. The use of molecular markers to predict the
occurrence of cancer has promise to improve the yield of surveillance
biopsies and potentially augment histology.

At this time, surveillance endoscopy should be performed with random
biopsies with 4 biopsy specimens taken at least every 1-2 cm of
esophageal mucosa with additional biopsy specimens taken of any mucosal
abnormality. Patients without dysplasia or mucosal abnormalities on
their initial evaluation should be examined again in 1 year with
surveillance biopsies to decrease the chances of sampling error. If no
dysplasia is found again, surveillance can reasonably be deferred for
another 5 years until the patient reaches a point at which cancer
therapy is not possible or life expectancy is limited. Surveillance
should be practiced only if the patient is anticipated to have a
reasonable life expectancy and can tolerate treatment for esophageal
cancer. In patients in whom low-grade dysplasia is found without mucosal
abnormalities, it is recommended that endoscopy be repeated again in 1
year to be certain that there is no evidence of high-grade dysplasia or
cancer. If low-grade dysplasia is confirmed by 2 pathologists, then the
patient should be reexamined on a yearly basis because this group tends
to have an increased risk of cancer. If there is disagreement about the
presence of any dysplasia, surveillance can be deferred for 2 years. If
high-grade dysplasia is detected and confirmed by 2 experienced
pathologists, treatment with either surgical resection or endoscopic
therapy can be recommended depending on the presence and nature of any
mucosal abnormalities. The presence of multifocal high-grade dysplasia
appears to be associated with an increased risk of development of
cancer, and these patients might be more suitable for more aggressive
treatment. Surveillance can be offered if both the patient and the
physician are willing to follow a careful regimen of endoscopy every 3
months with at least 8 random biopsy specimens taken every 2 cm of
involved esophagus. All mucosal abnormalities should be investigated
with endoscopic ultrasonography and mucosal resection if these
techniques are available to be certain that there is no underlying
cancer. If ablative therapy has been performed, surveillance is still
needed in the same area of involvement at least as frequently as if
ablation had not been performed. Efforts should be made to examine the
new squamous mucosa to determine if submucosal lesions might be present.

**Chemoprevention for Esophageal Cancer**

Chemoprevention would seem to be ideally suited to the problem of
esophageal cancer, but studies have not proven that there is a specific
treatment that would decrease cancer risk. There is strong epidemiologic
and preclinical data that cyclooxygenase-2 inhibition might be of value
as a chemoprevention agent, but no prospective clinical studies have
been performed to prove that there is a reduction in risk for cancer.
Control of acid or gastroesophageal refluxate should decrease
inflammation and therefore decrease cancer formation; however,
epidemiologic studies do not support the use of fundoplication for
prevention of cancer. Similarly, there is no clear rationale for the use
of high-dose proton pump inhibitors solely as a chemoprevention agent.
Lifestyle modifications such as weight loss, stopping tobacco use, and
eating fresh fruits and vegetables can be recommended based on
epidemiologic evidence to decrease cancer risk.

**Diagnosis and Staging of Esophageal Cancer**

The diagnosis of esophageal cancer is established by flexible endoscopy
with biopsy to confirm histologic evidence of disease. Computed
tomography is recommended as the first staging study because detection
of metastasis would clearly alter therapy. Endoscopic ultrasonography
can also be recommended if available to evaluate esophageal cancer if
computed tomography does not find any evidence of distant metastasis or
unresectable cancer. Fine needle aspirates should be performed on
regional lymph nodes if present and suspicious on endoscopic
ultrasonography. If the cancer was diagnosed as mucosal based on
ultrasonography, endoscopic mucosal resection could then be performed to
stage and potentially treat early-stage cancer if it is available. In
localities where endoscopic ultrasonography and endoscopic mucosal
resection are unavailable, surgical resection should be performed for
early-stage cancers. Positron emission tomography scans can be performed
if all of the previous studies do not show evidence of metastatic
disease because it may be more sensitive for distant metastasis, which
would alter the therapeutic approach.

**Treatment of Esophageal Cancer**

Treatment of cancer is dependent on the stage of the cancer. Early
cancers T1, N0, M0 by the American Joint Commission on Cancer are the
most likely to be potentially curable. If the cancer is confined to the
mucosa, these cancers are usually treated with esophagectomy, although
endoscopic therapy has been shown to be effective in early squamous cell
cancers of the esophagus treated in Japan using endoscopic mucosal
resection. There is also some evidence that this approach may be
successful in early adenocarcinoma. The risk of metastasis is very low
if the cancer is confined to the mucosal layers. If there is penetration
into the submucosa, the risk of metastasis becomes significant and
esophagectomy would be recommended if there were no signs of distant
metastasis or invasion of adjacent structures. If there is definite
evidence of metastasis to regional lymph nodes, neoadjuvant chemotherapy
in combination with radiation therapy administered before surgical
resection may improve survival. Esophagectomy can be practiced by
transhiatal or transthoracic routes. Minimally invasive esophagectomy
has been advocated but is still associated with substantial morbidity
and mortality. More advanced disease with metastasis to other organs or
distant lymph node groups should be considered for palliative therapy
with chemotherapy. Most commonly, combined therapy consists of
chemotherapy with multiple courses of cis-platinum and 5-fluorouracil
concomitantly given with ionizing radiation.

Palliation of advanced cancer can be achieved endoscopically with
dilation, although relief is short-lived. Esophageal stenting is
recommended for long-term palliation of cancers that are long and
located at least 2 cm from the cricopharyngeal muscle. Expandable metal
stents are preferred to plastic semirigid stents and are available in a
coated form to decrease tumor ingrowth. Expandable plastic stents are
reasonable for intermediate-term use when removal of stents is planned.
Endoscopic tumor ablation for palliation of dysphagia can be performed
with photodynamic therapy, alcohol injection, or laser therapy with
similar efficacy in appropriate patients, although stents are clearly
the preferred method of palliation. Nutritional support should be
considered before chemotherapy or radiation therapy with enteral
nutrition being the preferred method. Physicians must also keep in mind
the emotional support required of these patients because esophageal
cancer tends to be socially isolating as well as physically disabling.

#### CLINICAL ALGORITHM(S)

Clinical algorithms are provided in the Technical Review that
accompanies the guideline for:

-   Staging of Advanced Cancers

-   Staging of Early Cancers

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The strength of the evidence upon which the statements are based is
noted in the technical review paper accompanying the original guideline
document, with prospective, randomized, controlled trials being the
strongest. When adequate data are absent, expert consensus is used and
is identified as such.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Esophageal cancer is increasing in incidence and is associated with a
high mortality rate. The ability of gastroenterologists to increase
survival in this disease will depend on earlier detection through
screening and surveillance strategies.

#### POTENTIAL HARMS

-   Adverse effects from surgical intervention, chemotherapy, and
    radiation therapy

-   Surveillance endoscopy is complicated by sampling error (missing
    significant neoplastic lesions) and interpretation errors
    (histologic uncertainty).

-   Biopsy is associated with risk of complications.

-   Stent related morbidity

-   Intratumoral injection of absolute alcohol may result in chest pain.
    Serious complications, including mediastinitis and tracheoesophageal
    fistulas, occur in up to 5% of cases.

-   Endoscopic mucosal resection is associated with risk of
    complications.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guideline has been developed under the aegis of the American
Gastroenterological Association (AGA) and its Clinical Practice and
Economics Committee (CPEC) and was approved by the AGA Governing Board.
The data used to formulate these recommendations are derived from the
data available at the time of their creation and may be supplemented and
updated as new information is assimilated. These recommendations are
intended for adult patients, with the intent of suggesting preferred
approaches to specific medical issues or problems. They are based upon
the interpretation and assimilation of scientifically valid research,
derived from a comprehensive review of published literature. Ideally,
the intent is to provide evidence based on prospective, randomized
placebo-controlled trials; however, when this is not possible the use of
experts\' consensus may occur. The recommendations are intended to apply
to healthcare providers of all specialties. It is important to stress
that these recommendations should not be construed as a standard of
care. The AGA stresses that the final decision regarding the care of the
patient should be made by the physician with a focus on all aspects of
the patient\'s current medical situation.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wang KK, Wongkeesong LM, Buttar NS. American Gastroenterological
Association medical position statement: role of the gastroenterologist
in the management of esophageal carcinoma. Gastroenterology 2005
May;128(5):1468-70.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15887128)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 May

#### GUIDELINE DEVELOPER(S)

American Gastroenterological Association Institute - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Gastroenterological Association Institute

#### GUIDELINE COMMITTEE

American Gastroenterological Association Clinical Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Kenneth K. Wang; Loius Michel Wongkeesong; Navtej S. Buttar

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, the Clinical Practice Committee
meets three times a year to review all American Gastroenterological
Association Institute (AGAI) guidelines. This review includes new
literature searches of electronic databases followed by expert committee
review of new evidence that has emerged since the original publication
date.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Gastroenterological
Association Institute (AGAI) *[Gastroenterology]{.underline}* journal
Web
site](http://www.gastrojournal.org/article/PIIS0016508505006050/fulltext).

Print copies: Available from the American Gastroenterological
Association Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   American Gastroenterological Association technical review on the
    role of the gastroenterologist in the management of esophageal
    carcinoma. Gastroenterology 2005 May;128(5);1471-1505.

Electronic copies: Available from the [American Gastroenterological
Association Institute (AGAI) *[Gastroenterology]{.underline}* journal
Web
site](http://www.gastrojournal.org/article/PIIS0016508505006062/fulltext).

Print copies: Available from American Gastroenterological Association
Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on June 14, 2005. The information was
verified by the guideline developer on June 30 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008