The Barrett’s Oesophagus Surveillance Versus Endoscopy At Need Study (BOSS) has provided important new findings. This article underscores the value of standard surveillance for patients with Barrett’s esophagus. This landmark study from 2009-2024 at 109 centers around the UK tracked 3,452 patients diagnosed with Barrett’s esophagus, narrowing in on those whose BE had circumferential length of 1 cm, or a noncircumferential tongue or island of Barrett’s of 2 cm. With about ten years of follow-up guaranteed under protocol, they had a large enough n to drive the analysis.
In this study, patients were randomly assigned to one of two groups: one that underwent upper gastrointestinal endoscopies with biopsy every two years, and another that received endoscopy “at-need,” triggered by the onset of symptoms. This study was supported by the UK’s National Institute for Health and Care Research. First and foremost, it was developed to assess whether regular endoscopic surveillance leads to any survival benefits compared to a more reactive strategy.
Key Findings from the BOSS Study
As you can see, the impact of the BOSS study’s surprising findings has set the medical community abuzz. Our data confirms that patients in the standard surveillance group had an average of only 3.5 total endoscopies during the duration of the study. In comparison, people in the at-need group had an average of only 1.4 procedures. The surveillance group had a mean interval of only 22.9 months between endoscopies. The at-need group had a significantly longer wait time, with an average interval of 31.5 months.
The difference was in how often these two groups were monitored. The findings showed no statistical difference in all-cause mortality risk. In each cohort, about 6.2% of patients died of cancer. In particular, 108 patients in the routine surveillance cohort and 106 in the at-need cohort succumbed to their fight with the disease. Over the entire study period, 333 of 1,733 patients in the surveillance group subsequently died. 356 of 1,719 patients in the at-need group died as well.
“The really low rate of progression to esophageal adenocarcinoma,” – Old
The annual progression rate to esophageal adenocarcinoma (EAC) is very low at 0.23% per patient per year. This low rate brings into question the necessity of such frequent endoscopic surveillance. Serious adverse events were uncommon in both groups. Only 8 patients (0.46%) were found to have serious complications in the surveillance group and 7 patients (0.41%) in the at-need group.
Implications for Clinical Practice
As a result, these findings have led experts to re-evaluate longstanding practices when it comes to Barrett’s esophagus surveillance. Many clinicians feel that despite the study’s important revelations, it will not drastically change current treatment guidelines. Dr. Zhou commented on the study’s implications, stating, “In my opinion, this study does not end the debate and will not change my practice of doing surveillance endoscopy on NDBE, which I typically perform every 3-5 years, based on current guidelines.”
Additionally, Dr. Rubenstein emphasized a more nuanced approach: “It is a reminder that we should be circumspect in who we label as having Barrett’s esophagus, and we should be more proactive in discussing discontinuation of surveillance in patients based on advancing age and comorbidities.” This view moves away from the large scale, one size fits all approach to surveillance that gives priority to increased benefit to patients.
“It’s difficult to conclude from this study that surveillance endoscopy has no impact.” – Zhou
Dr. Zhou acknowledged the limitations of the study. He pointed out that it did not adequately address EAC-related mortality, the most important outcome measure that would help elucidate the role of surveillance endoscopy.
Future Directions in Barrett’s Esophagus Management
As medical professionals continue to study these results, it may prove time to reconsider surveillance guidelines for patients afflicted with Barrett’s esophagus. The authors of the study conclude that surveillance endoscopy every two years improves neither overall survival nor cancer-specific survival. What does this mean for how we spend our money and come up with strategies to care for patients?
Experts suggest that future research should focus on refining criteria for surveillance eligibility and developing individualized approaches based on patient risk factors and overall health status. This new paradigm has great potential to improve the care of Barrett’s esophagus while reducing excess procedures.
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