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Risk Stratification in Predicting Esophageal Cancer: A New Paradigm for Managing Barrett’s Esophagus

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1.0 AMA PRA Category 1 Credit™

Release Date: July 1, 2024

Expiration Date: December 31, 2025

Faculty

Seth A. Gross, MD, FACG, FASGE, AGAF

Professor of Medicine
Clinical Chief, Division of Gastroenterology and Hepatology
NYU Langone Health
New York, NY

Raman Muthusamy, MD, MAS, FACG, FASGE, AGAF

Leon J. Tiber, MD, and David S. Alpert, MD, Chair in Medicine
Medical Director of Endoscopy, UCLA Health System
Professor of Clinical Medicine
David Geffen School of Medicine at UCLA
Los Angeles, CA

J. George Sun, MD

Gastroenterologist
Medical Director of Endoscopy, Memorial Endoscopy Center
Digestive Health Associates
Houston, TX

Goal

The goal of this activity is to educate health care providers about a novel precision medicine prognostic test that objectively and independently predicts the development of esophageal cancer in patients with Barrett’s esophagus (BE).

Intended Audiences

The intended audience for this activity comprises gastroenterologists; foregut surgeons; gastroenterology physician assistants, nurse practitioners, and nurses; as well as other clinicians involved in managing patients with BE.

Educational Objectives

Summarize the increasing health system burden of esophageal cancer.
Recognize patients at high risk for developing esophageal cancer.
Describe diagnostic and prognostic tests that provide actionable information for identifying and managing BE.
Explain methods to avoid unnecessary surveillance endoscopies.

Physician Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Applied Clinical Education (ACE). Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation

Global designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Contact Information

For information about the accreditation of this program, please contact Global at 303-395-1782 or cme@globaleducationgroup.com.

Instructions for Obtaining Credit

To receive credit, participants must participate in the activity and complete and pass the post-test, at www.cmezone.com/CU241, with a minimum score of 70%. Additionally, participants will need to complete the evaluation. CME certificates will be sent via email to those successfully completing the activity.

System Requirements

1.4 GHz Intel Pentium 4 or faster processor (or equivalent)
Windows 10, 8.1 (32-bit/64-bit); Windows 7 (32-bit/64-bit) 512 MB of RAM (1 GB recommended)
Microsoft Internet Explorer 11 or later, Windows Edge browser, Mozilla Firefox, and Google Chrome
For HTML Client – Google Chrome (v70.0 and above), Mozilla Firefox (v65.0 and above), and Edge (v42.0 and above)

Mac

1.83 GHz Intel Core Duo or faster processor 512 MB of RAM (1 GB recommended)
MAC OS X 10.12, 10.13, and 10.14
Mozilla Firefox, Apple Safari, Google Chrome
For HTML Client – Google Chrome (v70.0 and above), Apple Safari (v12.0 and above), and Mozilla Firefox (v65.0 and above)

Fee Information and Refund/Cancellation Policy

There is no fee for this educational activity.

Disclosures of Relevant Financial Relationships

Global adheres to the policies and guidelines, including the Standards for Integrity and Independence in Accredited CE, set forth to providers by the Accreditation Council for Continuing Medical Education (ACCME) and all other professional organizations, as applicable, stating those activities where continuing education credits are awarded must be balanced, independent, objective, and scientifically rigorous. All persons in a position to control the content of an accredited continuing education program provided by Global are required to disclose all financial relationships with any ineligible company within the past 24 months to Global. All financial relationships reported are identified as relevant and mitigated by Global in accordance with the Standards for Integrity and Independence in Accredited CE in advance of delivery of the activity to learners. The content of this activity was vetted by Global to assure objectivity and that the activity is free of commercial bias. All relevant financial relationships have been mitigated.

The faculty have the following relevant financial relationships with ineligible companies:

Seth A. Gross, MD, FACG, FASGE, AGAF

Consulting fees (eg, advisory boards): Castle Biosciences, Cook, Medtronic, Microtech, Olympus

Raman Muthusamy, MD, MAS

Consulting fees (eg, advisory boards): Boston Scientific, Endogastric Solutions, Medtronic, Motus GI, Pentax
Contracted research (principal investigators must provide information, even if received by the institution): Boston Scientific (now ended)
Honoraria: Castle Biosciences, Pentax
Speakers’ bureau: Castle Biosciences
Stock option holder (individual stocks/stock options; diversified mutual funds do not need to be disclosed): Capsovision

J. George Sun, MD

Speakers' bureau: Castle Biosciences

The planners and managers have the following relevant financial relationships with ineligible companies:

The planners and managers at Global Education Group have no relevant financial relationships to disclose.
The planners and managers at ACE have no relevant financial relationships to disclose.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents not indicated by the FDA. Global and ACE do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

This activity is jointly provided by Global Education Group and Applied Clinical Education.

This activity is supported by an educational grant from Castle Biosciences.

This activity is distributed by Gastroenterology & Endoscopy News, CMEZone.com, and General Surgery News.

* Required

1. Which of the following is true of esophageal adenocarcinoma (EAC)?*

It arises from small polypoid excrescences, denuded epithelium, and plaques commonly located in the cervical esophagus or upper and middle thoracic esophagus.
The main risk factors are alcohol consumption and tobacco use.
Other factors include hot beverage consumption, nitrosamine exposure, and inhaled or ingested polycyclic aromatic hydrocarbons.
It is the fastest-growing cancer in the United States by incidence.

2. Which of the following is not true of Barrett’s esophagus (BE)?*

It is the only identifiable precursor to EAC.
Risk factors include male sex, white race, cigarette smoking, and central adiposity.
It can be reliably predicted by the presence of gastroesophageal reflux disease (GERD) symptoms such as heartburn, regurgitation, dysphagia, or chest pain.
Diagnosis requires the presence of columnar epithelium at least 3 cm above the proximal margin of the gastric folds, according to the universally accepted Prague criteria.

3. According to current guidelines, which of the following BE patients should undergo screening for EAC with upper endoscopy + biopsy?*

All patients with GERD
Older, male, white patients
Younger, female, Black patients
Patients who have been on proton pump inhibitor treatment for at least 5 years

4. True or false: The rate of progression from BE to EAC can be reliably determined by histologic findings of dysplasia on biopsy.*

True
False

5. Sampling during screening and surveillance for EAC should be performed using the ___ biopsy protocol.*

Seattle
Z line
American Gastroenterological Association (AGA)
Prague

6. Which of the following is true of The TissueCypher (TC) Barrett’s Esophagus Assay? *

It uses brush sampling to obtain transepithelial specimens circumferentially.
It involves cell collection using a 30-mm polyurethane sponge in a capsule attached to a string.
It assesses clinical factors, such as patient age, sex, body mass index (BMI), abdominal obesity, ethnicity, tobacco use, education level, family history, and GERD symptoms.
It takes a systems biology approach to computational anatomic pathology based on spatialomics, which incorporates the spatial context of cell populations and tissue systems while investigating morphology and expression of 9 biomarkers.

7. Your patient scores a 7 on the TC assay. You can tell him that this suggests ___ risk for progression to high-grade dysplasia (HGD) or EAC within ___ years. *

low, 10
intermediate, 5
high, 5
high, 10

8. In a pooled analysis of 5 published studies of TC in 699 individuals with BE, ___. *

the sensitivity for detecting disease progression was 62.3% for TC vs 28.3% for expert pathologist-confirmed low-grade dysplasia (LGD)
patients with nondysplastic BE who scored high risk on TC progressed at a similar rate (3.2% per year) as those with expert pathologist-confirmed LGD (3.7% per year)
TC results had stronger predictive power than clinicopathologic features, including segment length, hiatal hernia, age, sex, and pathology diagnosis
All of the above are true

9. Endoscopic eradication therapy (EET) is the mainstay of treatment for BE with dysplasia because ___.*

it modulates prostaglandin E2 (PGE2), a hormone associated with resistance to apoptosis, increased angiogenesis, and enhanced invasion in Barrett’s mucosa and other gastrointestinal neoplasias
it combines resection (endoscopic mucosal resection and/or endoscopic submucosal dissection) of visible lesions in the affected segment and ablative techniques, such as radiofrequency ablation and cryotherapy, to eradicate any residual, flat, nondysplastic BE (NDBE)
it creates an effective barrier to reflux at the gastroesophageal junction and thus improves physiologic and mechanical issues that may be involved in the pathogenesis of GERD
it uses a thin, sheathed endoscope that typically triggers the pharyngeal reflex significantly less than the oral passage of a standard endoscope

10. Your patient is a 45-year-old white man with a BMI of 35 kg/m² a 20-pack-year cigarette smoking history, and a family history of EAC. His Barrett’s segment is 3 cm, and he has had BE for 3 years. His TC score is 2. What is the next most appropriate step for this patient? *

EET
Surveillance in <1 year
Surveillance in 3-5 years
Repeat biopsy

false

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Demographics

1. I am a: ___

MD
DO
RN
NP
PharmD
PA
Other (please specify): ___

2. What is your specialty?

Primary care physician
Family practice
Internal medicine
Gastroenterologist
Foregut surgeon
Other (please specify): ___

3. What is your practice setting?

Outpatient
Hospital
Medical school
Group private practice
Solo private practice
Other (please specify): ___