Developing and implementing an Early Barrett's Oesophageal Cancer detection and treatment programme in the Durham & Tees Valley Region

Objective: The Barrett's Oesophagus early cancer detection programme has been developed to improve the dismal outcomes of Oesophageal Adenocarcinoma, the fastest growing GI Cancer. This UK national programme is part of the government's Cancer Outcomes Strategy of saving an additional 5,000 lives by 2014/15 and is supported by the BSG Guidelines for Diagnosis and management of Barrett's Oesophagus, 2014. It has already been implemented in regional and University tertiary centres across the country, but the roll out to non university hospitals has been slow. The North East of England has the highest mortality related to oesophageal cancer, and so we set out to develop regional guidelines for surveillance of Barrett's Oesophagus and an endoscopic treatment programme (of endoscopic resection and radiofrequency ablation) in the Durham and Tees valley region. This programme covers the regional Upper GI Cancer MDT at Middlesbrough, for 1.2 million population.

The programme has been supported by the Northern Cancer Network Oesophagogastric Tumour Group, and by the Regional Upper GI Cancer MDT, working through participating Trusts and Commissioners.

The primary objective of the programme was to improve our Barrett's surveillance endoscopy in the Trusts and to develop an endotherapy programme to benefit patients diagnosed with Barrett's oesophagus related dysplasia, in the region.

Patients with Barrett's oesophagus and dysplasia were being treated by oesophagectomy before the project was implemented. Over 150 oesophagectomies were done at Middlesbrough in 2012, which has significantly decreased to less than 100 in 2014. The stakeholders who were contacted and engaged in this project were the Northern Cancer Network, clinicians and patient groups.

This project is based on the National Cancer Campaign of 'Saving 5,000 lives', and aims at contributing towards 960 lives that could be saved from OG cancers in 2014-15. This is one of the first projects for Barrett's related early cancer detection and treatment in the North East of England. The incidence of Oesophageal adenocarcinoma in the North east of England is one of the highest in the country, and the National Oesophagogastric Cancer Audit recommended in 2014 that all OG Cancer Networks implement a plan to detect and treat high grade dysplasia (HGD) in Barrett's Oesophagus. This was extended to treatment for low grade dysplasia in June 2014, following NICE guidance.

At County Durham, we decided that we would take the lead to train one Consultant Endoscopist in techniques of endoscopic detection, mucosal resection and radiofrequency ablation for Dysplasia in Barrett's Oesophagus. This Consultant was supported by the Regional Tertiary Centre MDT to be trained at UCL London and Nottingham, with hands on training and certification. A trust-wide programme of Barrett's surveillance was rolled out amongst Nurse endoscopists and interested Gastroenterology Consultants, incorporating BSG guidelines. The EMR/RFA treatment programme started in 2014. So far we have treated 7 patients with EMR and RFA, and are part of the UK National RFA Registry. The service is supported by a trained Endoscopy Sister, and a GI Research Nurse who collects all data and uploads them to the National Database. All new patients with Barrett's Oesophagus are seen in a clinic and empowered with information on the condition and the surveillance programme. All patients with dysplasia are discussed within the regional MDT with 2 pathologists, and are offered endoscopic and surgical treatment choices at a Joint Surgical Clinic.

This is the first Barrett's EMR/RFA Service in the North East of England. The service has been complimented at the Cancer Peer review in 2014, and JAG Accredited for the Endoscopy Unit. The team is a small group of highly motivated and enthusiastic individuals who work well together and have a passion to improve the outcomes for this condition.

The Barrett's Early Cancer Detection and Treatment Programme aims to diagnose early cancer in Barrett's Oesophagus (low grade and high grade dysplasia and intramucosal carcinoma) so that these patients can be treated by endoscopic mucosal resection followed by radiofrequency ablation, with curative intent. The NICE Guidance published in 2012 (for high grade dysplasia) and 2014 (for low grade dysplasia) and the BSG guidelines (Jan 2014) recommend endoscopic treatment over surgical oesophagectomy for early Barrett's Cancer. This improves the outcome for patients, increasing 5 year survival from 15% (post-surgical oesophagectomy) to over 70% (early cancer group). The UK National Barrett's Registry data (published in Gut 2014) clearly shows that endoscopic treatment is effective in over 85% patients and is durable. The programme of detecting early Barretts' neoplasia and treating it was adopted in larger university teaching hospitals in the South of England, but until recently was not adpted in most North of England hospitals and DGHs. The inequity of care was evident from the NOGCA Audit, where majority of patients treated for early Barrett's Neoplasia came from hospitals in the South of England.

Our project aims at removing this inequity for patients living in the North East of England, to offer them the chance of early cancer diagnosis and surviving it. The treatment is also shown to be cost effective (NICE Costing Document 2012) compared to oesophagectomy, and so its implementation in our region will save money for the NHS.

The aim of the programme is also to raise awareness of the need for improving quality of Barrett's surveillance endoscopy in DGHs, to be able to detect early cancers which can then be treated at a reference centre. A number of roadshows have been held to disseminate the information of the new BSG guidelines among medical and nurse endoscopists in the region and we believe that this will bring our region at par with the rest of the country.

In 2014, we have treated 7 patient in this programme and we propose to increase this number to 12 in 2015.

1. Involvement of all stakeholders including hospital trusts, patient groups, commissioners and cancer networks can change practice to bring equity to patient care, and offer the national standard to all patients without a post code lottery.

2. Avoid new projects without approriate guidelines and costing.