Risk Factors for Barrett Esophagus
Objectives Esophageal adenocarcinoma is more common among non-Hispanic Whites (NHWs) than African Americans (AAs). It is unclear whether its precursor, Barrett's esophagus (BE), is also less common among AAs, and whether differences in risk factor profiles explain the racial disparity.
Methods Data were from a case–control study among eligible Veterans Affairs patients scheduled for an upper endoscopy, and a sample identified from primary care clinics. Participants completed a questionnaire on sociodemographic and clinical factors and underwent a study esophagogastroduodenoscopy. We calculated race-specific BE prevalence rates and used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for BE.
Results There were 301 BE cases and 1,651 controls. BE prevalence was significantly higher among NHWs than AAs (21.3 vs. 5.0%; P<0.001). NHWs were more likely than AAs to be male, have a high waist-to-hip ratio (WHR), hiatal hernia, and use proton-pump inhibitors (PPIs), but less likely to have Helicobacter pylori (P<0.001). Among cases, NHWs were more likely to have long-segment BE and dysplasia than AAs. Independent BE risk factors for AAs included a hiatus hernia ≥3 cm (OR 4.12; 95% CI, 1.57–10.81) and a history of gastroesophageal reflux disease or PPI use (OR, 3.70; 95% CI, 1.40–9.78), whereas high WHR (OR, 2.82; 95% CI, 1.41–5.63), hiatus hernia ≥3 cm (OR, 4.95; 95% CI, 3.05–8.03), PPI use (OR, 1.88; 95% CI, 1.33–2.66), and H. pylori (OR, 0.64; 95% CI, 0.41–0.99) were statistically significantly associated with BE risk for NHWs. Among all cases and controls, race was a risk factor for BE, independent of other BE risk factors (OR for AAs, 0.26; 95% CI, 0.17–0.38).
Conclusions Among veterans, the prevalence of BE was lower in AAs compared with NHWs. This disparity was not accounted for by differences in risk estimates or prevalence of risk factors between NHWs and AAs.
The incidence of esophageal adenocarcinoma and its precursor, Barrett's esophagus (BE), has increased rapidly over the past four decades among non-Hispanic Whites (NHWs) in the United States, Europe, and Australia. On the other hand, the incidence of esophageal adenocarcinoma is much lower among African Americans (AAs) and, although the incidence of esophageal adenocarcinoma is increasing among AAs, the rate of increase is less than that for NHWs. It is unclear whether the incidence of BE is also less among AAs compared with NHWs.
Some, but not all, existing data indicate lower prevalence of BE in AAs compared with NHWs. Several single-center and multicenter studies from the United States have reported a lower prevalence of BE among patients undergoing upper endoscopy. On the other hand, a retrospective, single-center, cross-sectional study in the United States of 4,457 patients (107 with BE and 4,350 without BE) found that BE prevalence was not significantly different among racial groups including NHWs, AAs, or Hispanics regardless of reflux history. In addition, a retrospective, multicenter, case–control study in the United Kingdom of 20,310 patients (1,005 BE patients) revealed that there was no statistical difference in the prevalence of BE in Afro-Caribbeans compared with whites.
It is unclear whether racial differences in the incidence of esophageal adenocarcinoma and BE are due to differences in the risk factor profiles for the formation of BE or for the progression of BE to esophageal adenocarcinoma, differences in prevalence of risk factors common to AAs and NHWs, or differences in genetic predisposition between AAs and NHWs. A cross-sectional, single-center study of Department of Veterans Affairs (VA) employees reported no significant differences in the prevalence of gastroesophageal reflux disease (GERD), the primary risk factor for BE, between AAs and NHWs, but it reported a lower prevalence of erosive esophagitis in AAs. Another single-center study of 259 patients with esophagitis found that heartburn was a more frequent indication for endoscopy for NHWs with erosive esophagitis, whereas nausea and vomiting were more frequent indications for AAs. A single-center study of 7,193 controls and 95 NHW BE cases, but only 16 AA BE cases, found that AAs trended toward having a lower prevalence of long-segment BE (LSBE) and were less likely to have dysplastic BE compared with NHWs. As most studies have been essentially limited to NHWs, it remains unclear whether known or suspected factors that increase (smoking and abdominal obesity) or decrease (H. pylori infection, gastritis and medication BE risk in NHWs also influence the risk for BE in AAs and account for the difference in BE risk between AAs and NHWs.
We therefore analyzed data from a large, single-center cross-sectional study to assess the prevalence of BE in NHWs and AAs separately, and to identify the sociodemographic and clinical risk factors associated with BE risk in these two groups. We hypothesized that BE would be more common in NHWs than in AAs, and that differences in patterns of fat distribution (i.e., abdominal obesity in terms of waist-to-hip ratio (WHR)) and H. pylori prevalence among AAs and NHWs would explain the higher prevalence of BE in NHWs.
Abstract and Introduction
Abstract
Objectives Esophageal adenocarcinoma is more common among non-Hispanic Whites (NHWs) than African Americans (AAs). It is unclear whether its precursor, Barrett's esophagus (BE), is also less common among AAs, and whether differences in risk factor profiles explain the racial disparity.
Methods Data were from a case–control study among eligible Veterans Affairs patients scheduled for an upper endoscopy, and a sample identified from primary care clinics. Participants completed a questionnaire on sociodemographic and clinical factors and underwent a study esophagogastroduodenoscopy. We calculated race-specific BE prevalence rates and used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for BE.
Results There were 301 BE cases and 1,651 controls. BE prevalence was significantly higher among NHWs than AAs (21.3 vs. 5.0%; P<0.001). NHWs were more likely than AAs to be male, have a high waist-to-hip ratio (WHR), hiatal hernia, and use proton-pump inhibitors (PPIs), but less likely to have Helicobacter pylori (P<0.001). Among cases, NHWs were more likely to have long-segment BE and dysplasia than AAs. Independent BE risk factors for AAs included a hiatus hernia ≥3 cm (OR 4.12; 95% CI, 1.57–10.81) and a history of gastroesophageal reflux disease or PPI use (OR, 3.70; 95% CI, 1.40–9.78), whereas high WHR (OR, 2.82; 95% CI, 1.41–5.63), hiatus hernia ≥3 cm (OR, 4.95; 95% CI, 3.05–8.03), PPI use (OR, 1.88; 95% CI, 1.33–2.66), and H. pylori (OR, 0.64; 95% CI, 0.41–0.99) were statistically significantly associated with BE risk for NHWs. Among all cases and controls, race was a risk factor for BE, independent of other BE risk factors (OR for AAs, 0.26; 95% CI, 0.17–0.38).
Conclusions Among veterans, the prevalence of BE was lower in AAs compared with NHWs. This disparity was not accounted for by differences in risk estimates or prevalence of risk factors between NHWs and AAs.
Introduction
The incidence of esophageal adenocarcinoma and its precursor, Barrett's esophagus (BE), has increased rapidly over the past four decades among non-Hispanic Whites (NHWs) in the United States, Europe, and Australia. On the other hand, the incidence of esophageal adenocarcinoma is much lower among African Americans (AAs) and, although the incidence of esophageal adenocarcinoma is increasing among AAs, the rate of increase is less than that for NHWs. It is unclear whether the incidence of BE is also less among AAs compared with NHWs.
Some, but not all, existing data indicate lower prevalence of BE in AAs compared with NHWs. Several single-center and multicenter studies from the United States have reported a lower prevalence of BE among patients undergoing upper endoscopy. On the other hand, a retrospective, single-center, cross-sectional study in the United States of 4,457 patients (107 with BE and 4,350 without BE) found that BE prevalence was not significantly different among racial groups including NHWs, AAs, or Hispanics regardless of reflux history. In addition, a retrospective, multicenter, case–control study in the United Kingdom of 20,310 patients (1,005 BE patients) revealed that there was no statistical difference in the prevalence of BE in Afro-Caribbeans compared with whites.
It is unclear whether racial differences in the incidence of esophageal adenocarcinoma and BE are due to differences in the risk factor profiles for the formation of BE or for the progression of BE to esophageal adenocarcinoma, differences in prevalence of risk factors common to AAs and NHWs, or differences in genetic predisposition between AAs and NHWs. A cross-sectional, single-center study of Department of Veterans Affairs (VA) employees reported no significant differences in the prevalence of gastroesophageal reflux disease (GERD), the primary risk factor for BE, between AAs and NHWs, but it reported a lower prevalence of erosive esophagitis in AAs. Another single-center study of 259 patients with esophagitis found that heartburn was a more frequent indication for endoscopy for NHWs with erosive esophagitis, whereas nausea and vomiting were more frequent indications for AAs. A single-center study of 7,193 controls and 95 NHW BE cases, but only 16 AA BE cases, found that AAs trended toward having a lower prevalence of long-segment BE (LSBE) and were less likely to have dysplastic BE compared with NHWs. As most studies have been essentially limited to NHWs, it remains unclear whether known or suspected factors that increase (smoking and abdominal obesity) or decrease (H. pylori infection, gastritis and medication BE risk in NHWs also influence the risk for BE in AAs and account for the difference in BE risk between AAs and NHWs.
We therefore analyzed data from a large, single-center cross-sectional study to assess the prevalence of BE in NHWs and AAs separately, and to identify the sociodemographic and clinical risk factors associated with BE risk in these two groups. We hypothesized that BE would be more common in NHWs than in AAs, and that differences in patterns of fat distribution (i.e., abdominal obesity in terms of waist-to-hip ratio (WHR)) and H. pylori prevalence among AAs and NHWs would explain the higher prevalence of BE in NHWs.