Evidence review for frequency and duration of endoscopic surveillance

1.1.4.1. Included studies

No relevant clinical studies were identified comparing lower frequencies and duration of endoscopic surveillance or no surveillance with surveillance according to current guideline recommendations.

See also the study selection flow chart in Appendix C.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix E.

1.1.6.1. Included studies

No health economic studies were included.

1.1.6.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix D.

1.1.10.1. The outcomes that matter most

The outcomes considered for this review were health related quality of life, progression to high grade dysplasia or cancer, mortality, adverse events / complications, physician and patient adherence to surveillance. For purposes of decision making, all outcomes are considered equally important and were therefore rated as critical by the committee. No evidence was identified for any of the outcomes.

1.1.10.2. The quality of the evidence

No relevant clinical studies were identified comparing a different frequency and duration of endoscopic surveillance to the recommended ranges for surveillance given in current guidelines. Studies were commonly excluded because they were for a population not specified within the review protocol such as people with dysplasia, or they compared surveillance that did not match current guidelines as specified in the protocol to no surveillance.

1.1.10.3. Benefits and harms

The committee noted there was no evidence to recommend endoscopic surveillance that is of lower frequency compared to the current frequency recommended in guidelines or to support a definitive optimal frequency and duration. Based on their clinical experience and in line with the British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus, the committee agreed the frequency and duration of surveillance should be determined according to the individual patient’s risk factors. The committee noted the frequency of endoscopic surveillance as recommended in the BSG guidelines would be appropriate as the risk of disease progression may vary between individuals. Currently the frequency of surveillance is 2-3 years for people with Barrett’s oesophagus segment 3cm or longer, and 3-5 years for people with Barrett’s oesophagus shorter than 3cm with intestinal metaplasia. The committee agreed the main risk factors included Barrett’s segment size, age, gender, smoking status, and family history. In contrast to the BSG guideline, the European and US guidelines recommend a lower frequency of surveillance that is, 5 years for short segment and 3 years for long segment. The committee noted that surveillance according to the BSG guidelines is current practice across the UK and it would not be appropriate to recommend a lower frequency of surveillance given the lack of evidence to support such a change. In line with the BSG guidelines, the committee agreed that people with short-segment (less than 3 cm) Barrett’s oesophagus and no intestinal metaplasia (confirmed at 2 endoscopies), should not be offered surveillance as the risk of disease progression is low and the any potential benefit of surveillance does not outweigh the risks involved.

The committee considered the various factors that can influence the decision to recommend different frequencies of surveillance for each patient, which include age, co-morbidities, and the fitness of the patient for repeated invasive procedures.

The committee discussed age as a risk factor for disease progression which was hence considered a factor determining the appropriate duration of surveillance. The committee noted that the European guidelines advise against surveillance for people above the age of 75 whereas the BSG guidelines do not include an age cut-off but suggest ongoing surveillance based on an individual’s clinical assessment. When discussing the duration of endoscopic surveillance, the committee agreed with the view of the BSG, arguing that an age-related threshold failed to recognise the heterogeneity of the population and the multitude of other factors that determine fitness for endoscopy. The committee agreed that surveillance should continue for as long as it was in the patient’s interests, the benefits of surveillance outweigh any potential risks, and that this decision should be part of the ongoing patient/clinician discussion. They agreed that an important factor to consider would be the suitability of treatments involved in the entire endoscopic care pathway, which include endoscopy and intensive endoscopic treatment. Suitability should be based on a clinical assessment of the individual’s general health that will determine the trade-off between the benefits and risks of undergoing the endoscopic pathway.

1.1.10.4. Cost effectiveness and resource use

In general, more frequent surveillance will be more costly but would potentially provide more health gain if more cancers are detected and treated early.

There were no published economic evaluations found. In the absence of suitable clinical evidence, cost-effectiveness modelling was not feasible.

The committee’s decision to recommend offering:

• endoscopic surveillance every 2-3 years to people with long-segment Barrett’s oesophagus and
• every 3-5 years to people with short-segment Barrett’s oesophagus with intestinal metaplasia

Reflects current practice and is therefore unlikely to have a substantial impact on resource.

The committee also made a research recommendation to assess clinical and molecular biomarkers that can inform the optimal interval of and time for discharge from endoscopic surveillance. The cost associated with such biomarkers would lead to an increase in NHS resource use: the costs of the new technologies and associated staff time to conduct the tests. However, it would allow surveillance to be targeted on those patients that would most benefit, which could lead to more efficient use of resources. The impact of such technologies should be subject to cost effectiveness analysis.

1.1.10.5. Other factors the committee took into account

The committee emphasised they were aware of ongoing studies looking at clinical and molecular biomarkers for risk stratification of Barrett’s oesophagus. They noted that evidence of biomarkers associated with a greater risk of progression of dysplasia or cancer could inform the appropriate frequency and duration of endoscopic surveillance and decided to make a recommendation for research in this area.

Why this is important

Barrett’s surveillance is currently performed at 2–5-year intervals in patients who are deemed to potentially benefit from surveillance. This interval is based on consensus opinion rather than evidence, although it is to some extent tailored according to known clinical determinants of progression. The length of Barrett’s oesophagus appears to be the strongest risk factor for progression (<3cm, lower risk vs 3cm or longer, higher risk), but other clinical risk factors for oesophageal cancer have been described, including male gender, increasing age, positive family history and smoking status. If further factors associated with a greater risk of progression of non-dysplastic Barrett’s are identified and a stronger association between already identified factors and risk of progression is established through research, this would allow more precise individual tailoring of follow-up intervals, reducing frequency in those at low risk and intensifying it in those at high risk.

Rationale for research recommendation

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Modified PICO table

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