How well are patients with Barrett’s esophagus treated in the UK: the gap in management

Barrett’s esophagus (BE) is a known risk factor for esophageal adenocarcinoma (EAC) (1). Several trials have considered possible treatments to delay the conversion of BE to cancer (2). Whilst treatments are being assessed, some studies have shown that good quality surveillance is valuable (3,4), and the large BOSS (5) surveillance study is about to be analysed. The paper in today’s journal looks at the resources available in the UK for good quality surveillance for patients with BE.

Guidelines and measured quality indicators improve outcomes for patients. Exemplars include polyp screening and surveillance guidelines for colorectal cancer (6). In BE, the AspECT trial showed that surveillance outcomes improved once clear protocols were dictated (7). The guidelines for BE (8) were published in 2013.

In the paper by Ratcliffe et al. (9), having a dedicated BE endoscopy service more often gave access to endoscopy diagnosis methods (high resolution white light and acetic acid) and treatment methods (radiofrequency ablation, endoscopic ultrasound, endoscopic dissection/resection). To improve EAC survival, improving detection of early dysplasia and subsequent treatment thereof is required and this paper shows that there is scope to gain access for more patients to cutting edge diagnostic and treatment modalities via dedicated BE endoscopy services. Changes to such services could be done using a stepped wedge design study so that the value of access could be demonstrated.

The biggest hurdle is to formulate agreed national guidelines for the quality outcomes in a good surveillance programme. Once this has been obtained appropriate funding will follow the best programmes thereby driving up quality further.

The authors are to be congratulated for collecting important UK data which provides a steppingstone to improving care for BE patients, not only in Europe but globally.

Acknowledgments

Funding: Sharon B. Love’s salary is supported by MRC grant (MC_UU_00004/08).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Esophagus. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-22-31/coif). SBL’s salary is supported by MRC grant (MC_UU_00004/08). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nowicki-Osuch K, Zhuang L, Jammula S, et al. Molecular phenotyping reveals the identity of Barrett's esophagus and its malignant transition. Science 2021;373:760-7. [Crossref] [PubMed]
2. Jankowski JAZ, de Caestecker J, Love SB, et al. Esomeprazole and aspirin in Barrett's oesophagus (AspECT): a randomised factorial trial. Lancet 2018;392:400-8. Erratum in: Lancet 2018;392:2552. [Crossref] [PubMed]
3. Corley DA, Mehtani K, Quesenberry C, et al. Impact of endoscopic surveillance on mortality from Barrett's esophagus-associated esophageal adenocarcinomas. Gastroenterology 2013;145:312-9.e1. [Crossref] [PubMed]
4. Peters FP, Curvers WL, Rosmolen WD, et al. Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error. Dis Esophagus 2008;21:475-9. [Crossref] [PubMed]
5. Old O, Moayyedi P, Love S, et al. Barrett's Oesophagus Surveillance versus endoscopy at need Study (BOSS): protocol and analysis plan for a multicentre randomized controlled trial. J Med Screen 2015;22:158-64. [Crossref] [PubMed]
6. BSG/ACPGBI/PHE Post-polypectomy and post colorectal cancer resection surveillance guidelines [last accessed 16 Aug 2022]. Available online: https://www.bsg.org.uk/clinical-resource/bsg-acpgbi-phe-post-polypectomy-and-post-colorectal-cancer-resection-surveillance-guidelines/
7. Das D, Ishaq S, Harrison R, et al. Management of Barrett's esophagus in the UK: overtreated and underbiopsied but improved by the introduction of a national randomized trial. Am J Gastroenterol 2008;103:1079-89. [Crossref] [PubMed]
8. BSG guidelines on the diagnosis and management of Barrett’s oesophagus [last accessed 16 Aug 2022]. Available online: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-diagnosis-and-management-of-barretts-oesophagus/
9. Ratcliffe E, Liew Y, Kuan J, et al. Dedicated services for Barrett’s esophagus—a survey and service assessment of provision in United Kingdom hospitals. Ann Esophagus 2022; [Crossref]