A review of endoscopic records at the Cleveland Clinic Foundation over a 7-yr period yielded 72 cases of Barrett's esophagus. Ten patients had adenocarcinoma at the time of diagnosis of Barrett's esophagus (14%). Sixty-two were followed for a mean of 31 months (range 2-154 months). During this follow-up period, cancer developed in one patient, an incidence of one cancer per 166 patient yr and an annual incidence of 0.6%. Males predominated in the group with both Barrett's esophagus (55 of 72) and adenocarcinoma (10 of 11). Symptoms were similar in those with simple Barrett's esophagus and those complicated by cancer. Our findings on incidence of cancer in Barrett's was applied to a model surveillance program. The cost of yearly endoscopic surveillance is estimated to be +62,000 and 78 lost work days to discover one cancer during the follow-up period. An endoscopic surveillance program requiring every-other-year studies appears justified and would cost only half as much, annually.