Receiving a Barrett's oesophagus diagnosis can be a shock and a confusing time for many.  Hospitals have differing ways to support patients, some have support groups and booklets but all too often people leave the hospital with little, if any, information.  One question we are asked fairly regularly at HCUK is "how often will I be checked?". 

Our retired Dr in Residence has recently investigated the most current guidance from NICE (National Institute for Health and Care Excellence) and BSG (British Society of Gastroenterologists) and has provided us with the following blog. 

Barrett’s surveillance

My thoughts about combining the NICE and BSG guidelines are that:

1. Not everyone needs surveillance.
2. The decision to undertake surveillance is based on a discussion between the patient and the hospital who have diagnosed the Barrett’s. The decision is mainly based on the risks related to doing surveillance compared to the risks of not doing surveillance.
3. Guidelines for those with dysplasia and segments more than 3cms is more straightforward and pragmatic.
4. There is variation around the country.
5. New NICE guidelines in 2023 may be more specific and better adopted. It may cover a more reasonable approach to those without dysplasia.
6. GPs will probably use NICE guidelines whereas hospital consultants are more likely to understand and use the BSG guidelines.

The decision for surveillance for many is open to negotiation and interpretation. Lots of decisions in medicine are based on risk/benefit discussions. A good recent example would be COVID vaccinations. It became obvious early on that there was a small but real risk compared to a large benefit and the individual decision to have a vaccine or not was sometimes made based on how people perceived the risk and the benefits to them individually. It was also based on the JCVI (The Joint Committee on Vaccination and Immunisation) weighing up the evidence and the "cost" benefit for specific groups, for instance over 75s vs under 50s and children.

2010 NICE Guidance

In 2010 the NICE guidance covered people diagnosed with high-grade dysplasia or intramucosal (IM) cancer. These are the people with the most severe changes and the most worrying forms of Barrett’s. It did not cover lesser forms of Barrett’s. It was also mainly concerned with the move from surgical removal of the oesophagus to, less invasive treatments, such as endoscopic mucosal resection and ablative treatments

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. The conclusion was that “this indicates a need for earlier intervention”, therefore they concluded that there should be an update to the guidelines to consider management of low-grade dysplasia.

The NICE guidance specifically for patients from that time states:

“It is possible that Barrett's cells in the oesophagus may show signs of abnormal development, which is known as dysplasia. Although these cells are not cancerous, the changes can become more serious and there is a small risk that this will eventually lead to cancer of the oesophagus. For this reason, if you have Barrett's oesophagus, you should see your healthcare professional regularly to monitor any changes. If these cells become seriously abnormal (high‑grade dysplasia) or, more rarely, become cancerous (intramucosal cancer), then you should be offered more tests and treatment”. 

It is very vague about what "if you have Barrett's oesophagus, you should see your healthcare professional regularly to monitor any changes” means. Elsewhere documents refer to the need for a discussion about the risks of gastroscopies compared to the risks related to short segments of Barrett’s with no dysplasia.

Surveillance for people with Barrett's oesophagus 2019

Some specific guidance (but still difficult to interpret for individual patients) was published by NICE in 2019.

1.12.1 Consider surveillance to check progression to cancer for people who have a diagnosis of Barrett's oesophagus (confirmed by endoscopy and histopathology), taking into account:

• the presence of dysplasia (also see the NICE guideline on Barrett's oesophagus: ablative therapy)
• the person's individual preference
• the person's risk factors (for example, male gender, older age and the length of the Barrett's oesophagus segment).

Emphasise that the harms of endoscopic surveillance may outweigh the benefits in people who are at low risk of progression to cancer (for example, people with stable non-dysplastic Barrett's oesophagus). [new 2014]

In November 2020 the NICE started a review process of their guideline. It is called Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management and it is expected to be released in January 2023.  However it is hard to be sure how straightforward and specific the guidance will be and, in particular, if it will cover all degrees of Barrett’s.

The British Society of Gastroenterologists also produce guidelines but they are much more detailed and may be harder for patients to fully understand. They are less likely to be reviewed by GPs who tend to be more inclined to refer to NICE but may influence secondary care (hospital consultants) more. In the need for reviews, NICE has repeatedly acknowledged that there are significant differences in care for Barrett’s and that they want to ensure consistency and evidence-based care, the BSG guidelines look to achieve this.

I have taken a small extract from the BSG guidance. You can see this is much more detailed and refers to the evidence base:

• For Patients with Barrett's oesophagus shorter than 3cm, without IM or dysplasia, a repeat endoscopy with quadrantic biopsies is recommended to confirm the diagnosis. If repeat endoscopy confirms absence of IM, discharge from surveillance is encouraged as risks for endoscopy probably outweigh the benefits (Recommendation grade C).
• Patients with Barrett's oesophagus shorter than 3cm, with IM, should receive endoscopic surveillance every 3-5 years (Recommendation grade C).
• Patients with segments of 3cm or longer should receive surveillance every 2-3 years (Recommendation grade C).