1. The Role of Secondary Versus Tertiary Prevention in Decreasing the Incidence of Esophageal Adenocarcinoma in Patients with Barrett’s Esophagus Lindsay West, PA-S, John Carter, PhD Department of Physician Assistant College of Health Professions, Wichita, KansasINTRODUCTION Esophageal Adenocarcinoma (EA) is a predominate and deadly malignancy of the esophagus. The incidence of EA has risen dramatically in the last three decades making it the most rapidly increasing malignancy in the United States. 1 The unexplained increase in incidence of EA along with its dismal 5-year survival rate of less than 10% has made it a topic of great and recent interest. 2 Gastroesophageal reflux disease (GERD) and Barrett’s Esophagus (BE) have been identified as the strongest risk factors for EA. BE is a premalignant condition of EA in which normal squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium due to repeated insult by gastric acid. The objective of this study is to determine if secondary or tertiary prevention is more effective in decreasing the incidence and mortality in BE and EA. METHODS This study was a systematic review of the literature using an evidence based technique. Research was conducted beginning September 2004 and continued through December 2005. Literature searches were performed using Pubmed and Medline with no consideration of literature published prior to 1990. The search was conducted using the key words esophageal neoplasm, gastroesophageal reflux, Barrett’s esophagus, and treatment. Articles obtained were reviewed for relevant information regarding the epidemiology of esophageal adenocarcinoma and methods of primary, secondary and tertiary prevention and their success or failure in preventing EA. Selected articles were further reviewed and categorized according to type of study and topics covered by the study. All literature was reviewed with the intent of discerning the most effective way of preventing esophageal adenocarcinoma. RESULTS The literature revealed that the main method of secondary prevention is through screening and surveillance which have been recommended in patients with GERD and BE. Screening and surveillance have been shown to detect cancers at earlier stages and increase the five-year survival rate, but there is still controversy regarding guidelines, the cost-effectiveness and if it actually decreases the incidence or mortality of EA. Forms of tertiary prevention include proton pump inhibitors (PPIs), COX II inhibitors, endoscopic procedures and open antireflux surgeries. There is clear evidence for the effectiveness of PPIs in symptom control in GERD and BE and in treatment of esophagitis. There is evidence that PPIs may promote mild regression of BE, but there is not enough evidence to support this claim or to conclude that PPIs reduce the incidence or mortality of EA. Endoscopic therapies and COX II inhibitors have a promising future in the prevention of EA, but there is not yet enough evidence to support these methods. DISCUSSION The literature regarding Barrett’s Esophagus and esophageal adenocarcinoma is controversial. The current recommendation guidelines for screening and surveillance in GERD and BE are highly debated. Screening is widely practiced and proven to improve the outcome of EA, but many believe the benefits do not outweigh the drawbacks. Research on the effectiveness of tertiary prevention techniques in BE and EA also showed varied results. There is little evidence confirming the role of PPIs in inducing course changing results in BE and EA. There is optimism regarding the future role of COX II inhibitors in the treatment and prevention of BE and EA, but more research is warranted on this topic before it can be a widely used option. A significant consideration in reviewing the literature on esophageal adenocarcinoma and BE is the limited reliability due to an overall lack of prospective randomized studies. CONCLUSIONS Secondary and tertiary prevention both have a promising future in EA, but with an overall lack of research in some areas and lack of prospective randomized studies, no conclusion can be made regarding the superiority of either secondary or tertiary prevention in decreasing the incidence or mortality of EA. However, with the dismal outcome of EA, it is necessary to utilize any treatment option with evidence of success. At this time this includes a combination of primary and tertiary prevention with PPIs and surveillance. REFERENCES 1. Savarion V, Dulbecco P. Optimizing symptom relief and preventin complications in adults with gastro-oesphageal reflux disease. Digestion. 2004;69:9-16. 2. Jager E, Heintz A, Junginger T. Synchronous bilateral endoscopic adrenalectomy. Surg Endosc. 2004;18:314-318.