title: The Impact of a Prior Diagnosis of Barrett's Esophagus on Esophageal Adenocarcinoma Survival.
abstract: OBJECTIVE
  Endoscopic surveillance of patients with Barrett's Esophagus (BE) is recommended to detect esophageal adenocarcinoma (EAC) and its dysplasia precursors, but survival benefits are unclear. Using Surveillance, Epidemiology, and End Results (SEER) and linked Medicare data, we sought to determine the impact of a prior BE diagnosis on survival in patients with EAC.
  
  
  METHODS
  Our analysis focused on patients over age 65 with primary EAC diagnosed in a SEER region from 2000-2011 and enrolled in Medicare. We identified patients with preexisting BE prior to EAC diagnosis and compared this group to EAC patients without a prior BE diagnosis. A Cox Proportional Hazards model compared survival and included variables such as age, sex, cancer stage, treatment, and medical comorbidities.
  
  
  RESULTS
  Among 4,978 SEER-Medicare patients identified with EAC, 577 (12%) had preexisting BE; 4,401 (88%) did not. BE patients had overall lower stage (28.5% stage I vs. 12.8% stage IV) than those without preexisting BE (16.4% stage I vs. 30.6% stage IV). Overall survival was better among patients in the BE group (hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.50-0.61); this benefit persisted in the adjusted model (HR, 0.72; 95%, 0.65-0.80). After adjusting for lead-time bias, the HRs attenuated to the null, with an unadjusted HR of 0.96 (95% CI: 0.86-1.05, P=0.39) and adjusted HR of 0.99 (CI: 0.89-1.10, P=0.92).
  
  
  CONCLUSIONS
  Survival outcomes in patients with a BE diagnosis prior to EAC were statistically better in both the unadjusted and adjusted Cox proportional hazards model. However, this benefit appears to be predominantly lead-time and length-time bias.
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Angela C
authors.initials: AC
authors.lastname: Tramontano
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Deirdre F
authors.initials: DF
authors.lastname: Sheehan
authors.affiliation: Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Yeh
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Chung Yin
authors.initials: CY
authors.lastname: Kong
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Emily C
authors.initials: EC
authors.lastname: Dowling
authors.affiliation: Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA.|Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors.forename: Joel H
authors.initials: JH
authors.lastname: Rubenstein
authors.affiliation: Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, New York, USA.
authors.forename: Julian A
authors.initials: JA
authors.lastname: Abrams
authors.affiliation: University of Washington School of Medicine, Seattle, Washington, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Inadomi
authors.affiliation: Harvard Medical School, Boston, Massachusetts, USA.|Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Schrag
authors.affiliation: Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Boston, Massachusetts, USA.|Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Chin
authors.initials: C
authors.lastname: Hur
mesh_terms: D000230:Adenocarcinoma / Q000150:complications / Q000401:mortality* / Q000473:pathology; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000150:complications* / Q000473:pathology; D004938:Esophageal Neoplasms / Q000150:complications / Q000401:mortality* / Q000473:pathology; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D018426:SEER Program; D015996:Survival Rate; D014481:United States