Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The stages of cancer/oesophageal adenocarcinoma referred to in this guideline are based on the 8th edition of the Union for International Cancer Control (UICC) tumour node metastasis (TNM) classification of malignant tumours.

1.1 Information and support

1.1.1 Offer a clinical consultation to people with newly diagnosed Barrett's oesophagus to discuss risk of cancer, endoscopic surveillance plans and symptom control.

1.1.2 Give the person verbal and written information about their diagnosis, available treatments and patient support groups. Give them time to consider this information when making decisions about their care.

1.1.3 After each surveillance procedure, provide the person with an endoscopy report that includes a lay summary of the findings and a reference to ongoing symptom control.

1.1.4 Follow the recommendations on communication and information in the NICE guidelines on patient experience in adult NHS services and shared decision making.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support.

Full details of the evidence and the committee's discussion are in evidence review A: patient information and support.

1.2 Pharmacological interventions

Preventing disease progression

1.2.2 Do not offer aspirin to people with Barrett's oesophagus to prevent progression to oesophageal dysplasia and cancer.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pharmacological interventions.

Full details of the evidence and the committee's discussion are in evidence review B: pharmacological interventions to reduce progression to dysplasia or cancer.

1.3 Endoscopic surveillance

1.3.1 Discuss the benefits and risks of endoscopic surveillance with the person diagnosed with Barrett's oesophagus.

1.3.2 Offer high resolution white light endoscopy with Seattle biopsy protocol for surveillance of Barrett's oesophagus. Take into account the health of the person and ensure the benefits of surveillance outweigh the risks.

Frequency of endoscopic surveillance

1.3.3 Offer high resolution white light endoscopic surveillance with Seattle protocol biopsies:

  • every 2 to 3 years to people with long-segment (3 cm or longer) Barrett's oesophagus

  • every 3 to 5 years to people with short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia.

1.3.4 Assess a person's risk of cancer based on their age, sex, family history of oesophageal cancer and smoking history and tailor the frequency of endoscopic surveillance accordingly, within the intervals given in recommendation 1.3.3.

1.3.5 Do not offer endoscopic surveillance to people with short-segment (less than 3 cm) Barrett's oesophagus without intestinal metaplasia provided the diagnosis has been confirmed at 2 endoscopies.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on endoscopic surveillance.

Full details of the evidence and the committee's discussion are in:

evidence reviews C: endoscopic surveillance using white light endoscopy, D: diagnostic accuracy of endoscopic surveillance techniques, E: non-endoscopic surveillance techniques and F: frequency and duration of endoscopic surveillance.

1.4 Staging for suspected stage 1 oesophageal adenocarcinoma

1.4.1 Offer endoscopic resection for staging, to people with suspected stage 1 oesophageal adenocarcinoma.

1.4.2 Do not use CT before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma.

1.4.3 Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a oesophageal adenocarcinoma.

1.4.4 Consider EUS for nodal staging, for people with suspected T1b oesophageal adenocarcinoma based on endoscopic appearances or diagnosed with T1b oesophageal adenocarcinoma based on histological examination of endoscopic resection specimens.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on staging for suspected stage 1 oesophageal adenocarcinoma.

Full details of the evidence and the committee's discussion are in evidence review G: endoscopic and radiological staging techniques.

1.5 Managing Barrett's oesophagus with dysplasia

1.5.1 Offer endoscopic resection of visible oesophageal lesions as first-line treatment to people with high-grade dysplasia.

1.5.2 Offer endoscopic ablation of any residual Barrett's oesophagus to people with high-grade dysplasia after treatment with endoscopic resection.

1.5.3 Offer radiofrequency ablation to people with low-grade oesophageal dysplasia diagnosed from biopsies taken at 2 separate endoscopies. Two gastrointestinal pathologists should confirm the histological diagnosis.

1.5.4 Consider endoscopic surveillance at 6 monthly intervals with dose optimisation of acid-suppressant medication for people diagnosed with indefinite dysplasia of the oesophagus.

1.5.5 Offer endoscopic follow-up to people who have received endoscopic treatment for Barrett's oesophagus with dysplasia.

1.5.6 Follow the NICE interventional procedures guidance on endoscopic radiofrequency ablation for Barrett's oesophagus with low-grade dysplasia or no dysplasia and epithelial radiofrequency ablation for Barrett's oesophagus.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing Barrett's oesophagus with dysplasia.

Full details of the evidence and the committee's discussion are in evidence reviews H: endoscopic treatment (high-grade dysplasia and stage 1 adenocarcinoma), I: endoscopic treatment (low-grade dysplasia and indefinite dysplasia) and J: endoscopic and radiological follow-up after treatment.

1.6 Managing stage 1 oesophageal adenocarcinoma

1.6.1 Offer a clinical consultation to people with stage 1 oesophageal adenocarcinoma to discuss and evaluate the suitability of treatment options, including endoscopic resection or oesophagectomy.

1.6.2 Offer endoscopic resection as first-line treatment to people with T1a oesophageal adenocarcinoma.

1.6.3 Offer endoscopic ablation of any residual Barrett's oesophagus to people with T1a oesophageal adenocarcinoma after treatment with endoscopic resection.

1.6.4 Offer endoscopic follow-up to people who have received endoscopic treatment for stage 1 oesophageal adenocarcinoma.

1.6.5 Offer oesophagectomy to people with T1b oesophageal adenocarcinoma who are fit for surgery and at high risk of cancer progression. For example, where there is:

  • incomplete endoscopic resection

  • evidence of lymphovascular invasion or deep submucosal invasion (more than 500 micron) on histological examination of endoscopic resection specimens.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing stage 1 oesophageal adenocarcinoma.

Full details of the evidence and the committee's discussion are in evidence reviews J: endoscopic and radiological follow-up after treatment and K: oesophagectomy versus endoscopic treatment.

1.7 Non-surgical treatment for T1b oesophageal adenocarcinoma

1.7.1 Consider radiotherapy (alone or in combination with chemotherapy) for people with T1b oesophageal adenocarcinoma at high risk of cancer progression (for example, incomplete endoscopic resection, or evidence of lymphovascular invasion or deep submucosal invasion (more than 500 micron) on histological examination of endoscopic resection specimens) and who are unfit for oesophagectomy.

1.7.2 Offer endoscopic follow-up to people who have received radiotherapy for T1b oesophageal adenocarcinoma.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on non-surgical treatment for T1b oesophageal adenocarcinoma.

Full details of the evidence and the committee's discussion are in evidence reviews L: non-surgical treatment for T1b oesophageal adenocarcinoma and J: endoscopic and radiological follow-up after treatment.

1.8 Anti-reflux surgery

1.8.1 Do not offer anti-reflux surgery to people with Barrett's oesophagus to prevent progression to dysplasia or cancer.

1.8.2 Follow the recommendations on laparoscopic fundoplication for gastro-oesophageal reflux disease in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on anti-reflux surgery.

Full details of the evidence and the committee's discussion are in evidence reviews M: anti-reflux surgery to induce remission of disease or prevent recurrence and N: anti-reflux surgery to reduce progression to dysplasia or cancer.

Terms used in this guideline

This section defines terms that have been used in this guideline.

Barrett's oesophagus

An oesophagus in which any portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, which is clearly visible endoscopically (≥1 cm) above the gastro-oesophageal junction and confirmed histopathologically from oesophageal biopsies.

Seattle biopsy protocol

Entails four-quadrant random biopsies for every 2 cm of Barrett's oesophagus in addition to targeted biopsies on macroscopically visible lesions.

Stage 1 adenocarcinoma

Any oesophageal adenocarcinoma with T1 stage and no lymph node (N0) or distant metastasis (M0).