Recent advances in risk stratification of patients with Barrett's esophagus

Barrett's esophagus (BE) is the only recognized precursor to esophageal adenocarcinoma, but progression risk is highly heterogeneous. While most patients with nondysplastic BE have an annual cancer risk less than 0.5%, a subset with dysplasia or adverse molecular profiles carries markedly higher risk. This variability necessitates precision risk stratification to optimize surveillance and intervention. We review the evolution of BE risk stratification from historical consensus frameworks to contemporary clinical, histologic, and molecular models. Key clinical predictors, validated scoring systems, and recent advances in biomarker-based and imaging-driven surveillance are summarized, with emphasis on their validation and clinical applicability. Established clinical risk factors-age, male sex, smoking, segment length, and dysplasia-remain central to risk prediction. Biomarker assays, including p53 immunohistochemistry, tissue systems pathology and methylation-based assays may provide risk stratification beyond histology. Advances in endoscopic imaging, wide-area transepithelial sampling, and non-endoscopic capsule-based collection platforms could transform surveillance into a risk-adapted paradigm. The management of BE is shifting from a one-size-fits-all surveillance model toward personalized, biomarker-guided care. Integration of clinical, histologic, and molecular data-underpinned by artificial intelligence and real-world validation-promises to refine surveillance, reduce overtreatment, and improve early cancer detection in Barrett's esophagus.