nature publishing group ORIGINAL CONTRIBUTIONS ESOPHAGUS 1215 © 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY see related editorial on page x INTRODUCTION Over the past decades, esophageal adenocarcinoma (EAC) has been shown to have the most rapidly rising incidence of all malignancies in the Western world (1). Despite improving diag- nostic modalities, EAC is frequently detected at an advanced stage, making treatment with a curative intention no longer possible (1–3). he incidence of Barrett’ s esophagus (BE), the premalignant precursor lesion of EAC, is also rising (4,5). As the risk of progression to EAC is increased in BE, guide- lines recommend participation in an endoscopic surveillance program once a diagnosis of BE is established (6–9). Surveillance participation for BE has been shown to be asso- ciated with a lower tumor stage at the time of EAC detection (10–13). However, results regarding better survival in surveilled Surveillance of Barrett’ s Esophagus and Mortality from Esophageal Adenocarcinoma: A Population-Based Cohort Study Romy E. Verbeek, MD 1 , Max Leenders, PhD 1 , Fiebo J.W. ten Kate, MD, PhD 2 , Richard van Hillegersberg, MD, PhD 3 , Frank P. Vleggaar, MD, PhD 1 , Jantine W.P.M. van Baal, PhD 1 , Martijn G.H. van Oijen, PhD 1 and Peter D. Siersema, MD, PhD 1 OBJECTIVES: Barrett’ s esophagus (BE) is associated with an increased risk of developing esophageal adenocarci- noma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endo- scopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC. METHODS: All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautom- atiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up. RESULTS: In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients under- going adequate surveillance (adjusted hazard ratio (HR) = 0.79, 95% confidence interval (CI) = 0.64–0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR = 0.19, 95% CI = 0.16–0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR = 0.66, 95% CI = 0.58–0.76). CONCLUSIONS: Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis. SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg Am J Gastroenterol 2014; 109:1215–1222; doi:10.1038/ajg.2014.156; published online 1 July 2014 1 Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands; 2 Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands; 3 Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. Correspondence: Romy E. Verbeek, MD, Department of Gastroenterology and Hepatology (F02.618), University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: R.E.Verbeek-2@umcutrecht.nl Received 29 January 2014; accepted 11 May 2014