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Better to be looked over than be overlooked
- Shaji Sebastian, Colm O`Morain (8 June 2006)
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Improving surveillance for Barrett’s oesophagus: the AspECT and Boss trials provide an evidence base!
- Janusz Jankowski, Hugh Barr (12 June 2006)
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Shaji Sebastian, Consultant Gastroenterologist Hull HU3 2JZ, Colm O`Morain
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The audit by Bampton et al(1) once again highlights the practical problems encountered in the area of Barrett`s oesophagus surveillance.The relative benefits of a surveillance strategy in Barrett`s oesophagus continues to be an area of constant debate in the gastroenterology community. Despite recommendations based on rigorous review of the available evidence by national societies like the British Society of Gastroenterology the compliance regarding both the number of biopsies and interval between endoscopies remain suboptimal. Our retrospective audit of 441 patients with Barrett`s oesophagus in a university teaching hospital setting showed an alarmingly low compliance rate of 8.6%(2). The main area of concern was that quadrantic biopsies were not taken in a large proportion of patients. Similar figures were seen in an audit in United States where the compliance rates varied from 14% to 38% in a patient population from both teaching hospitals and community centres(3). As seen by Bamton et al, the prospective audit in our centre following dissemination of guidelines among endoscopists showed improved compliance only to a modest 61%. The main reasons for lack of compliance continues to be the lack of dedicated endoscopy lists with extended time allocation and the ongoing debate between `believers` and `non believers` of a surveillance strategy in Barrett`s. A survey by of Irish Gastroenterologists showed that, while majority believed in some form of surveillance, quadrantic biopsies were taken by only one third of respondents(Moss et al personal communication). A recent United Kingdom audit drew similar conclusions(4). In these circumstances, the use of a dedicated practitioner to flag up patients with Barrett`s oesophagus in conjunction with an adequate mechanism to evaluate usefulness of surveillance in individual patients as shown by the authors appear to be the way forward. Although the cost implications of this approach is to be fully evaluated in the study,we agree with the authors that the costs may be offset by the potential savings from the reduction in the number of endoscopies done at inappropriate intervals. The value of chromoendoscopy and magnifying endoscopy in Barrett`s esophagus is still evolving. For the moment four quadrant biopsies remain key to a useful surveillance programme. The endoscopy governance meetings should focus on the much needed attention to the quality of Barrett`s surveillance in individual centres. The words of May West (1892-1980) who said ` it is better to be looked over than overlooked` seems very pertinant in a high quality Barrett`s surveillance programme. 1. Bampton PA, Schloithe A, Bull J, Fraser RJ, Padbury RTA, Watson DI. Improving surveillance for Barrett`s oesophagus. BMJ 2006;332:1320- 1323(3 June) 2. Sebastian S, Qasim A, McLoughlin R, Rathore O, Crotty P et al An audit of the biopsy protocol for Barrett`s oesophagus- need to improve compliance to guidelines. Endoscopy 2004;36(5):A254 3. Chand N, Miller C, Cassara J, Ruffin K, Cattau EL et al. Barrett`s surveillance per the ACG guidelines, do we really do what they say? Am J Gastroenterol 2003;98(9):S20 4.Mandal A, Plyford RJ, Wicks C. Current practice in surveillance strategy for patients with Barrett`s oesophagus in the UK. Aliment Pharmacol Ther 2003;17:1319-24. Competing interests: Part of the data presented and published as an abstract at the UEGW 2004 |
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Janusz Jankowski, professor University of Oxford, Hugh Barr
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Dear Editor, We read with interest the quality improvement report for improving surveillance for Barrett’s oesophagus by Bampton et al (1). This group is one of the best exponents of research in this area and their findings are helpful. However, improving adherence to guidelines which are themselves lacking a sufficient evidence base may not actually improve hard clinical outcomes such as ‘all causes of mortality’ or even ‘cancer progression’. The major problem with a surveillance only approach is that only an estimated 5-10% of patients with Barrett’s oesophagus will benefit as the rest are either not referred for endoscopy or default the surveillance programme (2). If we assume for a moment that surveillance is beneficial on the basis that we more commonly find early grade 1 oesophageal cancers in surveillance (which have an 80% survival) compared with the norm of grade 3 or 4 oesophageal cancers in non surveillance endoscopies (15% survival). Even these generalisations cannot outweigh the lack of cost effectiveness of surveillance of Barrett’s oesophagus surveillance and indeed the additional cost of coordinators to mange the process as described by Bampton and colleagues may make it less so (3). The real value of surveillance needs to be tested in a randomised trial so that all confounding issues associated with surveillance such as compliance to medication, improved optimisation of therapy, reinforcement of health life style practices, management of co-morbid lesions by agents which could chemoprevent oesophageal cancer e.g. aspirin for cardiac disease and putting the patient on an alert status for changing symptoms can be independently assessed. The Barrett’s Oesophagus Surveillance Study (BOSS) aims to randomise 2,500 patients with proven Barrett’s oesophagus to either surveillance endoscopy as recommended in the guidelines recommended by Bampton et al (1, 4) and no surveillance for patients. In this trial full written informed consent of all the relevant issues will take place and although the trial is about to start at the very least we will be able to address whether patients in the non surveillance arms will violate the BOSS protocol by withdrawal from the study due to anxiety over existing and new ‘reflux’ symptoms. There could be other outcomes however as we already have provisional evidence to indicate that chemoprevention of Barrett’s oesophagus may decrease cancer incidence by up to 45% (5). It is possible therefore that once cancer incidence is stratified by aspirin use in the surveillance and non surveillance arms the value of surveillance will be modest and perhaps even neutral when taking into account other issues such as endoscopic and multiple biopsy induced mortality, morbidity and anxiety. The role of chemoprevention is itself already being tested is another large randomised study involving 5000 patients with Barrett’s oesophagus and is already underway, the Aspirin Esomeprazole Chemoprevention Trial (AspECT). In conclusion we applaud this study but wonder whether in the fullness of time resources might perhaps be proven to be better spent in mass chemoprevention of patients with reflux disease (> 35 years) for 10 or more years. Prof Janusz Jankowski, University of Oxford, Chief Investigator to AspECT trial Prof Hugh Barr, Gloucestershire Royal Hospital, Chief Investigator to BOSS trial, 1. Bampton PA, Schloithe A, Bull J, Fraser RJ, Padbury RTA, Watson DI. Improving surveillance for Barrett’s oesophagus. BMJ;332:1390-1323. 2. Jankowski J, Hawk E. A methodological analysis of chemoprevention in the Gastrointestinal tract. Nature Clin Pract Gastro 2006:3;101-111. 3. Shaheen NJ, Provenzale D, Sandler RS.Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence.Am J Gastroenterol. 2002 Jun;97(6):1319-27. 4. Sampliner RE; Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol. 2002 Aug;97(8):1888-95. 5. Jankowski J, Moayyedi P. Aspirin as chemoprevention for Barrett’s esophagus: a large RCT underway in the UK (extended original research correspondence). J Natl Cancer Inst 2004;96:885-7. Competing interests: None declared |
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