Published in Cancer Detection and Prevention 1999; 23(2):177-178.

Commentary: Barrett's Esophagus: Are Caucasians the Only Ethnic Group At Risk?

Ronnie Fass, M.D.

Dept. of Internal Medicine, Section of Gastroenterology, Arizona Health Sciences Center and Tucson VA Medical Center, Tucson, AZ 85723

Address all correspondence and reprint requests to: Ronnie Fass, M.D., Dept. of Internal Medicine, Section of Gastroenterology, Arizona Health Sciences Center and Tucson VA Medical Center, Tucson, AZ 85723

Intestinal metaplasia that replaces the normal stratified squamous epithelium of the esophagus is the currently accepted definition of Barrett's esophagus (1). Barrett's esophagus is recognized as a complication of chronic gastroesophageal reflux disease (GERD) and a lesion with malignant potential for the development of adenocarcinoma of the esophagus (2). The incidence of adenocarcinoma of the esophagus is among the most rapidly rising in the United States (3, 4). However, despite the plethora of literature about the pathogenesis and management, there is little data about the ethnic predilection of Barrett's esophagus. Although the premalignant lesion is considered to afflict primarily Caucasian males in the United States, prevalence studies in other ethnic groups are sparse or unavailable (1). The importance in identifying the true ethnic distribution of the disease has been increasing as the debate about population screening intensifies. If Barrett's epithelium mainly affects Caucasians, then this population should be the target of a screening program. Presently there is no consensus at what point GERD patients should be screened and whether this approach is cost effective. Equally important is to first determine the ethnic distribution of the disease. African Americans have been shown to have a prevalence which is 10-20 times lower than Caucasians (5). This significant difference has been related to the relatively low prevalence of GERD in this ethnic group. A higher concentration of epidermal growth factor (EGF) in the saliva of African Americans has been suggested as one of the possible explanations. Further population based studies that specifically target the African American population are needed. GERD has been traditionally considered less common in the Far East, where prevalence as low as 2.4% in the general population has been reported (6). Although studies assessing the prevalence of Barrett's esophagus in the Orient are lacking, the currently accepted assumption is that the lesion is less common in Asians. In a collaborative project that we conducted with a group in Taiwan, 464 consecutive endoscopies were prospectively evaluated (7). Erosive esophagitis was detected in 14.5% and Barrett's esophagus in 1.98% of the overall patients undergoing endoscopy for any reason. The reported frequency of Barrett's esophagus and erosive esophagitis is similar to previous literature reports from Western countries (2, 8). Thus, this new information suggests that both Barrett's esophagus and GERD are more common in the Chinese population in Taiwan than previously reported. It is unclear if this new trend encompasses other countries in the far East. The causes for higher frequency of Barrett's esophagus than expected in Taiwan remain speculative. A significant increase in consumption of alcohol and cigarettes is a possible contributing factor (9). Other possibilities include aging of the population and significant increase in dietary fat (245%) over the last half century (10). The frequency of Barrett's esophagus in Hispanic patients has been recently evaluated by our group as well (11). The study was carried out at the Tucson VA Medical Center and included all patients that underwent upper endoscopy over a 3 year period. There was no difference in the prevalence of Barrett's esophagus between Caucasians and Hispanics. However, the Hispanic patients tended to be younger and 83% of them had a Barrett's mucosa tongue which was less than 3cm in length (short segment) compared to only 38% of the Caucasian patients. One Hispanic patient had low grade dysplasia on histopathology. Although this study is limited to a VA patient population, it should serve as the impetus for further population based studies in Barrett's esophagus in Hispanics. Epidemiological studies assessing other ethnic groups (Native Americans, etc.) are lacking. These types of studies require screening of large populations from various ethnic groups even if GERD symptoms are not present. Normal, healthy people may be reluctant to undergo upper endoscopy for screening purposes, but this may not be the only obstacle. Recruiting the number of subjects needed to accurately assess the risk for Barrett's esophagus requires dedicated personnel and is associated with a significant cost. A possible solution for this dilemma is the use of trans-nasal or small caliber per oral endoscopy that does not require conscious sedation and the involvement of several centers concomitantly in the project. Funding sources should be available in the future for these important projects. In conclusion, recent reports from our group suggest that Barrett's esophagus may not be limited to Caucasians. These early reports may actually point out epidemiological trends where Barrett's esophagus is becoming increasingly more common in other ethnic populations. Dramatic lifestyle changes which result in increase in risk factors for GERD may be part of the answer. Thus far, the ethnic distribution of Barrett's esophagus has been neglected and should become an important focus for future research. References:
(1) Spechier S, Goyal R. Barrett's esophagus. N Engl J Med 1986;315:362-371.
(2) Naef A, Savary M, Ozzello L, Pearson F. Columnar-lined lower esophagus: an acquired lesion with malignant predisposition. J Thorac Cardio Surg 1975;70:826-835.
(3) Pera M, Cameron AJ, Trastek, VJ, Carpenter HA, et al. Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction. Gastroenterology 1993; 104:510-513.
(4) McArdle JE, Lewin KJ, Randall G, Weinstein W. Distribution of dysplasias and early invasive carcinoma in Barrett's esophagus. Hum Pathol 1992;23:479-482.
(5) Jam S, Parker R, Spechier S. Racial differences in the frequency of GERD complications. Gastroenterology 1997;112(4):A20.
(6) Chen P, Wu C, Chang-Chien 5, Liaw Y. Comparison of Olympus GJF-P2 and GTE-K pandoscopy. Taiwan I Hsueh Hui Tsa Chihi J Formosan Med Assoc. 1979;78: 136-140.
(7) Yeh C, Hsu C, Ho A, Sampliner R, Fass R. Erosive esophagitis and Barrett's esophagus in Taiwan. A higher frequency than expected. Dig Dis Sci 1997;42(4):702-706.
(8) Burbige E, Radigan J. Characteristics of the columnar-cell lined (Barrett's) esophagus. Gastrointest Endosc 1979;25:133-136.
(9) Department of Statistics. (Ministry of Interior, Republic of China.). Handbook of statistics of internal affairs. 1993.
(10) Department of Health. (Executive Yuan, Republic of China.). Directory of nutrition for people of the Republic of China. 1991.
(11) Bersentes K, Fass R, Padda 5, Johnson C, Sampliner R. Prevalence of Barrett's esophagus in Hispanics is similar to Caucasians. Dig Dis Sci 1998;43(5):1038-1041.

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