Strategies to prevent Barrett's esophagus associated esophageal adenocarcinoma

There has been a rise in the incidence of esophageal adenocarcinoma (EAC) over the past five decades in the United States, and it remains a highly lethal malignancy due to frequent late-stage diagnosis. Barrett's esophagus (BE), a well-established precursor to EAC, presents a critical window for early intervention through screening, surveillance, and endoscopic eradication therapy. Despite gastrointestinal society guideline recommendations for screening, the majority of patients with BE or early EAC remain undiagnosed until symptoms of late-stage cancer emerge. This review outlines current challenges and evolving strategies in the United States in BE detection and management, including risk stratification models, non-endoscopic screening tools, high-quality endoscopic techniques, tissue-based biomarkers, and artificial intelligence-enhanced imaging. We highlight best practices for surveillance, emphasizing the importance of thorough inspection of high-risk anatomic zones and the integration of advanced imaging. Endoscopic eradication therapy, including endoscopic mucosal resection and ablation, achieves high rates of complete eradication when performed with meticulous technique, especially with comprehensive treatment of the gastroesophageal junction and gastric cardia. Long-term surveillance remains essential due to the risk of recurrence. As new technologies continue to emerge, integrating precision tools into routine practice will be key to improving outcomes and reducing EAC mortality.