Surveillance decision

Surveillance decision

We will update the guideline on Barrett's oesophagus.

The scope will be extended to incorporate management of low-grade dysplasia.

We considered this guideline alongside the following related guidelines that will not be updated:

See the webpages for each guideline for the surveillance decisions for these guidelines.

The following table gives an overview of how evidence identified in surveillance might affect each area of the guideline, including any proposed new areas.

Section of the guideline

New evidence identified

Impact

Confirming diagnosis of high-grade dysplasia or intramucosal cancer

Yes

No

Key principles of care

No

No

Offering endoscopic therapy

Yes

Yes

Endoscopic therapies

Yes

Yes

Radiofrequency ablation after endoscopic resection

Yes

Yes

Radiofrequency ablation and cryotherapy

Yes

Yes

Patient and carer support and information

No

No

Areas not currently covered in the guideline – low-grade dysplasia

Yes

Yes

Reasons for the decision

This section provides a summary of the areas that will be updated and the reasons for the decision to update.

Offering endoscopic therapy

The guideline recommends considering endoscopic therapy, particularly for those in whom surgery is unsuitable or who do not wish to undergo surgery. Clinical practice has progressed since the publication of the guideline, with evidence suggesting that most people who have treatment have endoscopic therapy, with surgery used only in a minority of patients.

Rates of complete eradication in the UK have increased in the years after the guideline published. However, there appears to be inconsistency in the management of Barrett's oesophagus across the UK. The evidence mainly consists of observational studies and small randomised controlled trials, which is similar to the limited evidence available when developing the current guideline. Nevertheless, there is a need to update the guideline so that it remains relevant to clinical practice in the UK.

Endoscopic therapies

The guideline currently recommends considering endoscopic mucosal resection alone or ablative therapy alone (radiofrequency ablation or photodynamic therapy). However, evidence on the use of radiofrequency ablation after endoscopic mucosal resection suggests that combination treatment may be more effective than either treatment alone. The 2018 UK National Oesophageal-Gastric Cancer Audit indicates that about a third of people who have endoscopic resection have subsequent radiofrequency ablation. The update should consider whether a single-treatment strategy remains appropriate.

Low-grade dysplasia

The scope of the guideline on Barrett's oesophagus specifically excluded the management of low-grade dysplasia. Since the guideline was published, the evidence base on treating low-grade dysplasia to prevent progression to high-grade dysplasia or cancer has grown. UK audit data also indicate a clinical need for the guideline to cover treatment of low-grade dysplasia.

NICE has issued interventional procedures guidance on endoscopic radiofrequency ablation for Barrett's oesophagus with low-grade dysplasia or no dysplasia (IPG496). This recommends that radiofrequency ablation for low-grade dysplasia may be performed with normal arrangements for clinical governance, consent and audit or research. Topic experts noted gastroenterology guidelines produced by other organisations now address management of low-grade dysplasia.

Additionally, a large randomised controlled trial suggested that treatment with high-dose proton pump inhibitors plus aspirin may reduce progression or death in people with low-grade dysplasia. However, all comparator groups in this study received drug treatments. It is therefore difficult to ascertain the effects on progression from low-grade dysplasia to high-grade dysplasia compared with endoscopic therapies or with surveillance.

The 2018 UK National Oesophageal-Gastric Cancer Audit showed that about one-third of people diagnosed with high-grade dysplasia in the UK then receive a diagnosis of oesophageal or junction cancer within a year. This indicates a need for earlier intervention; therefore the update to the guideline should consider management of low-grade dysplasia.

For further details and a summary of all evidence identified in surveillance, see appendix A.


This page was last updated: 29 November 2018