A multi-national team of researchers has found in the world’s largest review on the best methods to manage and treat common pre-cancerous and cancerous conditions of the esophagus that good endoscopy equipment, more endoscopic surgery and more tissue sampling is needed to improve patient care.
Around 2% of the world’s population suffers from Barrett’s esophagus. Men over the age of 50 living in developed countries are in the highest risk group. It is estimated that the risk of developing esophageal adenocarcinoma amongst people with Barrett’s esophagus is around 0.5 to 1% per year. Each year in the UK almost 482,000 new cases of esophageal cancer are diagnosed, with a mortality rate of 406,500 people annually. This type of cancer is the 5th most common cancer in the UK and the 8th most common cancer worldwide.
The study, published online in the August issue of the medical journal Gastroenterology, was led by Professor Janusz Jankowski from London University’s Blizard Institute of Cell and Molecular Science at Queen Mary in England. Jankowski and his team reviewed almost 12,000 papers on the care and treatment of Barrett’s Dysplasia and early-stage esophageal adenocarcinoma and analyzed the findings by using the Delphi process.
The Delphi process is a novel analyzing method that enables researchers to attain an agreement on all reviewed papers’ strengths of evidence so that the conclusion of the findings can be used as recommendations to manage patients suffering from these conditions. The study is a first in attempting to review all available research in this field.
Professor Jankowski, Sir James Black Professor of Gastrointestinal Biology and Trials explained: “In the absence of top grade evidence from large randomized clinical trials, this large systematic review, using a global consensus achieved by the Delphi voting method, allows real clarity about the best ways to treat this disease.”
Barrett’s esophagus is characterized by abnormal changes within the cells that line the lower end of the gullet, and is usually caused by acid reflux. Over the last few years, the incidence rate for the condition has risen steadily, with 10-20% of patients suffering from acid reflux developing Barrett’s esophagus. The condition can progress to develop into Barrett’s dysplasia, in which the cells become pre-cancerous and can subsequently develop into esophageal adenocarcinoma (cancer).
Given that the adenocarcinoma diagnosis has a poor 5-year survival rate of less than 15%, early detection and treatment in the early states of the disease are absolutely crucial, although one of the problems has been a lack of agreement on the best way to manage and treat the disease.
Professor Jankowski and his team drafted statements on the diagnosis, epidemiology, methods of surveillance, treatment approaches and prevention of high-grade dysplasia and early adenocarcinoma in patients with Barrett’s esophagus after reviewing all available studies. In what is known as the Delphi process, they subsequently performed four rounds of anonymous voting on the statements until they reached a consensus in 81 of the 91 statements. A consensus of 80% or more was defined as agreeing strongly or agreed with reservation on a statement.
Professor Jankowski explained:
“The key messages to emerge from this process are that the endoscopic equipment needs to be good (vital in times of cutbacks) and that endoscopic surgery can be better than the more risky open surgery. In addition, there needs to be more and larger samples of tissues taken so that the pathologist can make sure that no early cancers are missed. At present, there are no reliable biomarkers (molecular changes) that can replace good equipment, a well-trained endoscopist and a methodical pathologist.”
During an endoscopy, the surgeon inserts a thin tube into the patient’s throat in those suffering from Barrett’s esophagus, dysplasia and esophageal cancer, which contains a light source, a video camera and, if needed, instruments to perform surgery or obtaining tissue samples. An endoscopy can be performed in many areas of the body to avoid open surgery, like opening the chest to access the esophagus for instance.
Professor Jankowski remarked:
“This huge systematic review using the Delphi process with 92 international experts really does underline that hospitals need good equipment, doctors need the best training in both diagnostic and endoscopic techniques and a good expert pathologist to process the samples. In times of cutbacks it is likely that some units will refer patients to larger centers nearby. Although some patients will be inconvenienced, it does mean they will get the best of local expertise.”
“We have used novel methods and a huge team to come up with simple ways to improve care in one of the commonest pre-cancerous conditions, which, if left unmonitored or untreated, can develop into a cancer that is usually fatal. Most of our findings are relevant to clinical practice and should be used immediately to guide clinical activity. In addition, areas where we were not able to reach agreement indicate where future clinical research is likely to most productive. We often talk about increasing cancer rates in the UK; while we strive to find better cures for cancer, it is still the case that prevention is even better. This paper provides a solid basis for better esophageal cancer prevention.”
Written by Grace Rattue