RFA for Barretts

Hello hrpufnstuf!

Insurance (Medicare, especially) companies usually rely on the physician to report whether or not a procedure is elective or medically necessary before they'll consider covering it or reimbursing for it. Given the risks of the procedure, it's not surprising that hospitals won't perform it unless it's absolutely medically necessary (and without dysplasia, it likely wouldn't be considered medically necessary).

I know that there's hope for relieving Barretts. Prior to my fundoplication procedure, I had a 3-4cm ring of Barretts cells right at the GE junction from years of reflux damage. I had a follow-up endoscopy a year after the surgery, and the Barretts cells were gone.

Without dysplasia and family history, it's likely that for now endoscopic monitoring and treating your reflux medically is all that will be done, especially since there haven't been marked changes in the amount of Barretts cells between endoscopies.

Be well and take care!
-TonyG-

Thanks for your responses. Excerpts from a paper I recently read caused me to renew my desire to have RFA now rather than waiting for it to progress, if it ever does.

The recent ASGE guideline recommends endoscopic ablation for BE with HGD; RFA should also be considered and discussed with patients with LGD and for select cases of ND-BE, such as those with a family history of esophageal adenocarcinoma [24]. Given the safety and apparent efficacy of RFA, however, some authorities—including the authors—feel that these guidelines are too restrictive and argue that virtually all patients with BE, irrespective of dysplasia, should be treated with RFA [25].

There are a number of reasons why physicians should consider endoscopic intervention rather than ‘surveillance-only’ for patients with ND-BE or LGD: (a) the inability to predict what patients will progress to HGD or invasive cancer, (b) the inability to predict the time course of such progression, should it occur, (c) the risk for misdiagnosis (under-staging) due to inadequate mucosal sampling, lack of compliance with endoscopic surveillance guidelines and inter-observer disagreement between pathologists, (d) the patients’ anxiety for harboring a premalignant lesion and its impact on quality of life and (e) the availability of endoscopic modalities for completely removing the diseased tissue in a safe, effective and cost-effective manner. Therefore, for patients with ND-BE or LGD, RFA plus surveillance or surveillance-alone could be offered after a thorough discussion of the risks and benefits. The risk-benefit discussion should be tailored to each patient’s needs and underlying medical co-morbidities, with a higher emphasis on enrolling higher-risk patients with long-segment BE, a family history of esophageal adenocarcinoma and significant anxiety associated with the diagnosis of BE. In the real-life clinical settings, RFA is now commonly being performed in patients with both dysplastic and non-dysplastic diseases [29]. In fact, because ND-BE is the most common form of BE (95%), RFA is being performed more often in non-dysplastic than dysplastic BE patients.

Although it is generally assumed that BE progresses in a stepwise fashion from ND to LGD to HGD to intra-mucosal cancer and then eventually to invasive cancer, this is unusual in practice. Sharma et al. reported that EAC incidence in patients with BE was 0.5% per patient per year of follow-up, but also demonstrated that patients may develop invasive cancer despite having ND-BE as their worst histological grade immediately before being diagnosed with cancer [30].

I had hiatal nernia repair and nissen fundoplication in August, 2015. Best thing I ever did. But my follow-up endoscopy in May this year showed low grade dysplasia. Another follow-up in August showed high grade dysplasia. I just had an endoscopic mucosal resection on Friday with RFA scheduled in 3 months. The doctor said this will cure the Barrett's, but... I will be on two a day prilosec for the rest of my life to prevent recurrance. The recovery from the resection and the RFA is like extreme GERD and heartburn. I will have an RFA treatment every three months for the next 2 years. I look forward to being Barrett's and dysplasia free, but the treatment is serious and painful.