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Management of high-grade dysplasia in patients with Barrett’s esophagus varies significantly in England
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A national population-based study in England showed that management of high-grade dysplasia in Barrett’s esophagus varied significantly across the country; about one-third of patients did not receive active treatment.
Although prior studies found wide variation in the reported management of BE patients with high-grade dysplasia (HGD), the results were not based on patient-level data, and endoscopic treatment techniques have since become more widely available, the researchers wrote. Therefore, they sought to evaluate the management of HGD in England by comparing patient-level data to current practice guidelines.
As part of the National Oesophago-Gastric Cancer Audit, the National Health Service trusts in England prospectively collected data on patient characteristics, diagnosis and endoscopic findings, treatment planning and treatment details, corresponding to patients who were newly diagnosed with HGD from April 2012 through March 2013. During this time, 465 cases of HGD were reported (mean age, 71.3 ± 10.5 years; 71.6% men).
A second pathologist confirmed the diagnosis in 79.4% of cases. Eighty-six percent of patients had their treatment planned at a multidisciplinary team meeting. Overall, 62.4% of patients were managed endoscopically (most often with endoscopic resection or radiofrequency ablation), 32% of patients were planned to receive no active treatment or undergo only surveillance, and 5.6% of patients underwent esophagectomy.
Older patients were more likely to be managed by surveillance (P < .001), ranging from 19.5% in patients aged younger than 65 years to 63.8% in patients aged 85 years and older. Patients whose cases were discussed at a multidisciplinary meeting were more likely to receive active treatment (73.5% vs. 44.3%; P < .001), as were patients who were managed at higher-volume trusts treating 15 or more cases per year (87.8% vs. 55.4%; P < .001), those who had their HGD diagnosis confirmed by a second biopsy (76.8% vs. 56.4%; P < .001) and those who were referred to a specialist center (83% vs. 59.7%; P < .001).
“There is significant variation in the management of esophageal HGD across English NHS trusts, with a third of patients managed by surveillance alone,” the researchers concluded. “This is despite current [British Society of Gastroenterology] guidelines clearly supporting the endoscopic treatment of HGD in preference to either esophagectomy or surveillance alone. Our results support the BSG recommendation that all cases of HGD should be discussed at a specialist [multidisciplinary team] meeting and that treatment should be centralized to high-volume centers.”
In a related editorial, Sravanthi Parasa, MD, and Prateek Sharma, MD, of the division of gastroenterology and hepatology, VA Medical Center, University of Kansas School of Medicine, Kansas City, Missouri, discuss ways to accurately measure quality of care in BE patients with HGD, and how to determine the indicators of best practices. To improve outcomes, they called for a “standardized, noncommercialized approach to disseminating new technical skills” to endoscopists, and higher procedural volumes.
“Overall, changing physician practice requires complex, sustained, multifaceted interventions, and most hospitals may not have the individual expertise or resources to launch these effective quality improvement interventions,” they wrote. “Therefore, development of standard clear reporting of quality measures is needed, which will minimize variability in reporting and misinterpretation and enhance the accuracy and reliability of quality indicators.” Resources like the GI Quality Improvement Consortium “could address such an issue.” – by Adam Leitenberger
Disclosure: The researchers report no relevant financial disclosures. Parasa and Sharma report they have received research support from Cook Medical, CDx Labs, Cosmo Pharmaceuticals and Olympus.
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