Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management

Why the committee made the recommendations

Qualitative evidence highlighted knowledge gaps and uncertainties at the time of diagnosis of Barrett's oesophagus. The committee emphasised this reflected their experience with people they see in clinical practice. They agreed a clinical consultation should be offered following diagnosis to provide information and support on the risk of progression to cancer and symptom control, and general information about endoscopic surveillance.

Providing information both verbally and in written form is helpful as information can be difficult to grasp at a single consultation and written information will enable people to revisit the information when needed. This should include general information about the diagnosis of Barrett's oesophagus, available treatments and any patient support groups.

The use of complex medical terminology limits people's ability to understand information. The committee agreed it was important that each endoscopy report includes a lay summary of the findings and that this is given to the person.

How the recommendations might affect practice

The recommendations are in line with current practice and therefore are unlikely to have a substantial resource impact.

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Why the committee made the recommendations

Limited evidence showed that proton pump inhibitors (PPIs) had no clinically important effect on outcomes (including all-cause mortality, progression to any grade of dysplasia or cancer, and serious adverse events). The committee agreed there was insufficient evidence to recommend PPIs to prevent progression to oesophageal dysplasia and cancer and decided not to make a recommendation on this.

The committee agreed there was insufficient evidence to recommend aspirin to prevent progression to oesophageal dysplasia and cancer and decided to make a do not offer recommendation. Evidence showed that participants taking aspirin were more likely to get adverse events than those who did not, but the difference was small and not conclusive. The committee noted this was in line with their clinical experience and knowledge that bleeding is more likely to be seen in people treated with aspirin. They agreed that the inconclusive results could be attributed to a protective effect from PPIs taken by people in both the aspirin and no aspirin study groups.

Although the committee did not look for evidence on medication use for symptom control, they agreed that acid-suppressant medication such as PPIs are highly effective and widely used in current practice to control symptoms of gastro-oesophageal reflux disease in people with Barrett's oesophagus. They decided it was useful to provide a link to the relevant section of the NICE guideline on gastro-oesophageal reflux disease.

How the recommendations might affect practice

Aspirin is not currently used to prevent progression to oesophageal dysplasia and cancer. Therefore, the recommendations are not expected to result in a change in current practice or to have a resource impact.

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Why the committee made the recommendations

Evidence showed there was a 30% reduction in mortality for people who received endoscopic surveillance compared to those that did not. Based on this and their clinical experience, the committee agreed it should be offered to people with Barrett's oesophagus provided the person's general health is adequate, and the benefits of surveillance outweigh the risks. The committee noted this is the current standard of care for endoscopic surveillance for Barrett's oesophagus.

The committee agreed that the risk of complications of endoscopic surveillance should be considered on an individual basis because the frequency and consequences of complications will vary depending on a range of factors, including age, fraility and medical comorbidities. It was agreed that possible complications should be discussed with the person with Barrett's oesophagus.

Evidence for electronic and conventional chromoendoscopy techniques (including narrow band imaging, acetic acid, methylene blue) as well as endoscopic brushing was obtained from people with dysplasia and early-stage cancer. This means that these techniques have not been validated in an unselected population with Barrett's oesophagus undergoing standard endoscopic surveillance and therefore could not be recommended. A recommendation for research was made to assess the effectiveness of these techniques for surveillance of Barrett's oesophagus.

How the recommendations might affect practice

Endoscopic surveillance is widely used for monitoring people with Barrett's oesophagus. Adherence to the biopsy protocols requires additional procedure time beyond that of a standard endoscopy, but many services have already increased the time allocation for Barrett's surveillance and overall resource impact is not expected to be significant.

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Why the committee made the recommendations

In the absence of evidence on endoscopic staging techniques, the committee drew upon their clinical experience to inform decision making. They agreed that endoscopic resection should be offered to people with suspected stage 1 oesophageal adenocarcinoma as it is the most accurate staging technique and is the gold standard in current practice as recommended by the British Society of Gastroenterology (BSG) guidelines.

There are 2 techniques for resection of suspected stage 1 oesophageal adenocarcinoma: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The evidence did not show superiority of 1 technique over the other so the recommendation does not specify which to use.

The committee noted, based on their clinical experience, that ESD may offer an advantage in individuals with Barrett's oesophagus-related neoplasia (lesions larger than 15 mm, poorly lifting tumours and lesions at risk for submucosal invasion) but there was no reason to select it routinely over EMR for small slightly elevated lesions because ESD is a complex procedure and is associated with more complications.

Limited evidence indicated poor diagnostic accuracy of CT as a staging technique for early stage oesophageal adenocarcinoma because the resolution of CT is inadequate in detecting very small tumours and small volume lymph node metastasis. Therefore, there was consensus that CT should not be used before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma.

Limited evidence on the mini-probe endoscopic ultrasonograph (mini-probe EUS) and the conventional radial endoscopic ultrasonograph (crEUS) showed they cannot distinguish well between T1a and T1b tumours but can detect lymph node metastasis with greater accuracy. Based on the evidence and their clinical experience, the committee agreed that EUS should not be used before endoscopic resection for staging suspected T1a oesophageal adenocarcinoma, as this carries a negligible risk of lymph node metastasis.

EUS should be considered when an oesophageal lesion is suspected to be T1b cancer based on endoscopic appearances, for example sessile lesions with significant luminal component (Paris 0-Is) or depressed lesions (Paris 0-IIc). It should also be considered for people with confirmed T1b oesophageal adenocarcinoma, who have a significant risk of lymph node metastasis and may benefit from additional oncological treatment, such as radiotherapy alone or in combination with chemotherapy.

How the recommendations might affect practice

These recommendations are in line with current practice and therefore will not have a resource impact.

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Why the committee made the recommendations

The evidence showed that endoscopic treatment using a combination of endoscopic resection and endoscopic ablation or endoscopic ablation alone is effective to treat people with high-grade dysplasia and prevent progression to adenocarcinoma. Based on clinical experience the committee recommended that high-grade dysplasia be endoscopically resected, when oesophageal lesions are visible at endoscopy, and the residual Barrett's oesophagus be treated with endoscopic ablation.

There are 2 techniques for resection of dysplastic lesions in Barrett's oesophagus: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). There is no evidence of superiority of 1 technique over the other so the recommendation does not specify which to use.

The evidence indicated that both radiofrequency ablation (RFA) and argon plasma coagulation (APC) are effective in reducing the risk of recurring oesophageal lesions in people who have received an endoscopic resection for high-grade dysplasia. However, the committee noted that for very long segment Barrett's oesophagus RFA might be more practical than APC, which has a significantly smaller ablation catheter than RFA. Given that there is no evidence of superiority of one ablation technique over the other, the committee agreed further research was needed to determine the most effective endoscopic ablation technique to use and made a recommendation for research.

Evidence showed that RFA in people with confirmed low-grade oesophageal dysplasia protects from progression to high-grade dysplasia or cancer. The committee noted this was in line with their experience and that low-grade dysplasia is primarily managed by RFA in current practice.

Based on their clinical experience, the committee emphasised that for RFA to be offered, evidence of low-grade dysplasia from biopsies from 2 separate endoscopies and confirmation of the diagnosis by 2 gastrointestinal pathologists should be present. They noted this was in line with current practice where RFA takes place in specialist centres by endoscopists with appropriate experience and would not be considered in cases where there is evidence of low-grade oesophageal dysplasia from biopsies from only 1 endoscopy or where there is no confirmation by a second gastrointestinal pathologist.

There was no evidence to support use of other ablation techniques for treating low-grade dysplasia.

In the absence of clinical evidence on people with indefinite dysplasia of the oesophagus, the committee drew on their clinical experience to make a recommendation for this population. They emphasised that the risk of progression to high-grade oesophageal dysplasia or cancer is around 3 to 5 times higher than the risk in the non-dysplastic population and therefore endoscopic surveillance every 6 months would be appropriate. The committee also noted, based on their clinical experience, that indefinite dysplasia is often linked to excessive inflammation of the oesophagus, therefore optimisation of acid-suppressant medication is appropriate.

How the recommendations might affect practice

These recommendations are in line with current practice and therefore will not have a resource impact.

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Why the committee made the recommendations

The quality of the evidence was limited but reflected the committee's clinical experience that endoscopic resection and oesophagectomy are equally effective for treating stage 1 adenocarcinoma, and oesophagectomy is associated with a higher incidence of serious adverse events. There was a lack of evidence on how the 2 treatments affect quality of life so the committee drew on their own experience to consider this. As part of standard practice a clinical consultation would be offered to the person to discuss the treatment options and the advantages and disadvantages of both approaches.

Endoscopic resection is less invasive and has fewer complications than oesophagectomy. The committee agreed that even after successful endoscopic treatment there remains a risk of recurrence of Barrett's oesophagus and oesophageal neoplasia. Therefore, endoscopic treatment comes with a greater need for ongoing endoscopic surveillance, which could lead to anxiety about recurrence and possibly impacts on quality of life. This was reinforced by a patient committee member. Despite this, the committee agreed endoscopic resection is still more likely to result in better quality of life post-treatment than oesophagectomy. Therefore, it should be offered as first-line treatment to people with T1a adenocarcinoma.

There was evidence supporting the effectiveness of using endoscopic resection followed by endoscopic ablation to treat people with T1a adenocarcinoma of the oesophagus.

The evidence indicated that both radiofrequency ablation (RFA) and argon plasma coagulation (APC) are effective in reducing the risk of recurring oesophageal lesions in people who have received an endoscopic resection for T1a adenocarcinoma. However, the committee noted that for very long segment of Barrett's oesophagus RFA might be more practical than APC, which has a significantly smaller ablation catheter than RFA. Given that there is no evidence of superiority of one technique over the other, the committee agreed further research was needed to determine the most effective endoscopic ablation technique to use and made a recommendation for research.

The lack of specific evidence for people with T1b oesophageal adenocarcinoma was a concern for the committee who agreed this is where there is the most uncertainty over appropriate treatment. In the absence of evidence, the committee decided to make a recommendation to offer oesophagectomy rather than endoscopic resection for people with T1b oesophageal adenocarcinoma at high risk of cancer progression. This was based on their clinical experience that there is a greater risk of local recurrence in cases of incomplete endoscopic resection and a high risk of lymph node metastasis in cases with deep submucosal invasion (more than 500 micron) and lymphovascular invasion. They decided not to make a recommendation for people with T1b at low risk of cancer progression as it was less clear which treatment option would be best but made a recommendation for research to determine the effectiveness of endoscopic resection with or without adjuvant chemoradiotherapy and oesophagectomy for adults with T1b oesophageal adenocarcinoma.

How the recommendations might affect practice

The current recommendations are in line with current practice and therefore will not have a resource impact.

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Why the committee made the recommendations

In the absence of evidence to guide decision making, the committee drew upon their clinical experience to make a recommendation on non-surgical treatment for T1b oesophageal adenocarcinoma.

Using radiotherapy alone or in combination with chemotherapy to treat oesophageal adenocarcinoma is current practice.

The committee agreed that radiotherapy alone or in combination with chemotherapy would be appropriate for people with T1b oesophageal adenocarcinoma at high risk of cancer progression as it is likely to reduce the risk of recurrence. They noted that chemotherapy alone is not a definitive treatment.

How the recommendations might affect practice

The current recommendations are in line with current practice and therefore are unlikely to have a significant resource impact.

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Why the committee made the recommendations

In the absence of evidence of a clinical benefit of anti-reflux surgery to reduce progression to dysplasia or cancer, the committee agreed it should not be recommended for this reason.

Although the committee did not look for evidence on medication use for symptom control, they agreed that anti-reflux surgery can provide an alternative option for people who are intolerant to or unwilling to take acid-suppressant medication such as proton pump inhibitors (PPIs) and should be considered for this population. They decided it was useful to provide a link to the relevant recommendation in the NICE guideline on gastro-oesophageal reflux disease. In the absence of evidence, the committee agreed not to make a recommendation for anti-reflux surgery to induce remission or prevent recurrence in people with stage 1 adenocarcinoma. People who fail to respond to radiofrequency ablation (RFA) are sometimes referred for anti-reflux surgery. However, the committee noted that in such cases other ablation therapies such as argon plasma coagulation (APC) could be considered instead of anti-reflux surgery.

How the recommendations might affect practice

The current recommendations are in line with current practice and therefore will not have a resource impact.

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