# Patient Priorities Brief — Esophageal Adenocarcinoma (EAC) Trajectory
*Stage 2 / PFDD synthesis. People-first framing. Priorities are organized by position on the
Barrett's -> dysplasia -> early EAC -> locally advanced -> metastatic trajectory. These reflect
well-documented themes in the EAC/Barrett's patient experience and FDA patient-focused drug
development principles; individual patient priorities vary and must be confirmed with the community.*

## Cross-trajectory priorities (matter to nearly everyone)
1. **Preserve the ability to eat and swallow.** Dysphagia and the fear of losing normal eating
   are among the most feared and life-defining burdens. Maintaining oral nutrition, avoiding
   feeding tubes, and eating socially rank at or near the top for most people.
2. **Survival with quality, not survival at any cost.** People weigh added months against
   treatment toxicity, hospital time, and functional decline. "Time that feels like living"
   recurs as the real endpoint patients care about.
3. **Minimize treatment burden and toxicity.** Chemo/chemoradiation fatigue, neuropathy,
   nausea, and the cumulative toll of multimodal therapy are major concerns; low-toxicity or
   targeted options are highly valued.
4. **Reduce uncertainty.** Clear prognostic information, knowing whether a treatment is working
   (biomarkers/response signals), and not living in diagnostic limbo.

## By trajectory position
### Barrett's esophagus (no dysplasia) — the at-risk / surveillance population
- **Surveillance fatigue and anxiety.** Repeat endoscopies, biopsy uncertainty, and the
  psychological weight of a "pre-cancer" label. A reliable, less-invasive way to know who will
  progress is a top unmet need.
- **Want interception, not just watching.** Many would accept a well-tolerated preventive
  therapy to lower progression risk rather than waiting for cancer to appear.
- **Reflux symptom control** and confidence that acid suppression is actually protecting them.

### Low-/high-grade dysplasia and early (intramucosal) EAC — the interception window
- **Organ preservation.** Strong preference for endoscopic eradication (EMR/RFA) over
  esophagectomy; avoiding major surgery and its lifelong consequences is paramount.
- **Durable clearance.** Fear of recurrence after ablation; want assurance the dysplasia is
  truly gone and stays gone.
- **Avoid over- and under-treatment.** Anxiety about both missing progression and being pushed
  to surgery unnecessarily.

### Locally advanced / resectable EAC — curative-intent
- **Cure and staying recurrence-free.** Willing to endure intensive therapy for a real shot at
  cure, but want the least that achieves it.
- **Quality of life after esophagectomy.** Eating small meals, dumping syndrome, reflux, weight
  loss, and returning to normal life are enormous post-surgical concerns.
- **Minimal residual disease clarity.** Interest in ctDNA/MRD tools that could personalize
  whether more therapy is needed.

### Metastatic / advanced EAC — treatment
- **Meaningful extension of life with preserved function.** Symptom palliation (swallowing,
  pain, nutrition) is inseparable from any survival goal.
- **Access to targeted/immunotherapy options** and biomarker testing to find them.
- **Support for caregivers and the practical/financial toxicity** of prolonged treatment.

## Implications for target/modality selection (Stage 5 will use these)
- A **well-tolerated, precisely-targeted** agent is valued over broadly cytotoxic approaches at
  every trajectory position.
- An **interception therapy** for Barrett's/dysplasia addresses a top, currently-unmet priority
  (surveillance burden + desire to act) — supports the novelty-first steer.
- **Biomarker-guided** treatment (companion diagnostic) aligns with patients' need to reduce
  uncertainty and avoid ineffective toxicity.
- **Organ/function preservation** should be an explicit design and endpoint consideration, not
  an afterthought.

*Confidence: medium. These are synthesized from established EAC/Barrett's literature and PFDD
principles, not from a fielded EAC-specific survey. A patient-community survey (designable via
patient-centered-market-and-survey) would raise confidence and is recommended as a next step.*