Professor El-Omar has selected Dr Massimiliano di Pietro from the Department of Oncology, University of Cambridge, Cambridge, UK to do the next #GUTBlog. Dr Massimiliano di Pietro is the first author.

The #GUTBlog focusses on the Guideline paper “National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett’s oesophagus and stage I oesophageal adenocarcinoma” which was published in paper copy in GUT in June 2024.

Dr di Pietro writes:

“The aims of this guideline were:

1. To update and replace the NICE guideline on ablative therapy for Barrett’s oesophagus (BO) with high grade dysplasia (CG106 – 2010)
2. Include comprehensive guidance on general pharmacological, endoscopic and surgical management of patients with confirmed diagnosis of BO
3. Provide an update on treatment options for all stages of early Barrett’s-related neoplasia

The diagnostic criteria for BO and management of oesophageal adenocarcinoma (OAC) stage II or higher  were excluded from the remit of this guideline. The committee included 3 gastroenterologists, 2 upper GI surgeons, a radiologist, a pathologist, an oncologist, a nurse endoscopist, a general practitioner, a dietician and two lay members.  This was an evidence-based guideline with focus on the best available clinical and health economic evidence. The quality of the evidence from quantitative studies was assessed using the GRADE methodology and meta-analyses were conducted using Cochrane Review Manager. Below is a summary of the main recommendations included in the guideline.

The working group recommend all patients with a new diagnosis of BO should be offered a clinic consultation with the aim to discuss the implication of this diagnosis in terms of cancer risk and the available treatments. The committee also recommend that the endoscopists should include in the report of surveillance procedures a lay summary, as well as a reference to ongoing symptoms and pharmacological control to inform the managing physician.

The evidence on pharmacological chemoprevention is currently not sufficient to formulate a positive recommendation on use of drugs to prevent cancer. The aim of acid suppression should be symptoms control following NICE guideline on management of gastro-oesophageal reflux disease (GORD)

https://www.nice.org.uk/guidance/cg184/chapter/Recommendations#interventions-for-gord

Extensive analysis of the AspECT trial  (1) data led to the conclusion that there is no evidence of cancer chemoprevention efficacy for Aspirin, which is therefore not recommended for treatment of BO. Likewise, there is no evidence that antireflux surgery has chemopreventive effect and the offer of surgery should be based on existing recommendation for the management of GORD.

Endoscopic surveillance should be carried out using high-resolution white light endoscopy with targeted and random biopsies as per Seattle protocol. There is lack of evidence that in unselected population of BO patients use of dye or electronic chromoendoscopy increases detection rate for early neoplasia and that chromoendoscopy aided targeted biopsies can replace 4-quadrant biopsies. The committee noted that Cytosponge with biomarkers (2) is a promising technology for surveillance and welcomed the ongoing BEST4 surveillance study to clarify the role of minimally invasive technology to relieve the burden of endoscopic surveillance on the health care system. There lack of evidence on the best surveillance intervals required for non-dysplastic BO; therefore the recommendations are in line with previous British Society of Gastroenterology guidelines, whereby  patients with long segment BO (3cm or longer) should be followed up every 2-3 years, whereas an endoscopy every 3-5 years is sufficient for short segments BO (<3cm) (3) . The interval can be tailored by the managing physician based on known risk factors for progression such as older age, male sex, positive family history of oesophageal cancer and history of smoking. Indefinite for dysplasia should be followed up in 6 months with optimisation of acid suppressing medications.

Patients referred with BO-related early neoplasia should be primarily staged with endoscopic resection (ER), which is the best technique to assess the T-stage of early OAC. CT and PET have no role in staging of suspected stage I OAC, whereas EUS should only be used for suspected T1b OAC prior to ER and completion of staging in patients with T1b OAC diagnosed on ER specimen.

NICE recommends use of radiofrequency ablation for patients with low-grade dysplasia confirmed by expert pathologists on at least two separate endoscopies. NICE also recommends endoscopic ablation of patients with flat high-grade dysplasia with no endoscopically visible lesions and for those who received a curative ER for stage I adenocarcinoma.

Based on carefully assessment of risks and benefits of endoscopic vs surgical therapies, NICE recommends ER as primary treatment for stage T1a OAC. People with T1b OAC with high-risk features, such as lymph-vascular invasion or poor differentiation or invasion deeper than 500 micron, should be offered an oesophagectomy. The committee noted that there remains uncertainty about the safest and most effective treatment of T1b OAC with low-risk features, therefore the decision between ER and oesophagectomy should be based on perceived risks and benefits for each individual patient.

Finally, the committee noted the lack of evidence for non-surgical options for patients with T1b and high-risk features. The committee agreed that radiotherapy alone or in combination with chemotherapy could be offered in patients who are unfit for surgery to reduce the risk of recurrence.

References:

1. Jankowski JAZ, de Caestecker J, Love SB, Reilly G, Watson P, Sanders S, et al. Esomeprazole and aspirin in Barrett’s oesophagus (AspECT): a randomised factorial trial. Lancet. 2018;392(10145):400-8.
2. Pilonis ND, Killcoyne S, Tan WK, O’Donovan M, Malhotra S, Tripathi M, et al. Use of a Cytosponge biomarker panel to prioritise endoscopic Barrett’s oesophagus surveillance: a cross-sectional study followed by a real-world prospective pilot. Lancet Oncol. 2022;23(2):270-8.
3. Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang JY, Watson P, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut. 2014;63(1):7-42.

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