Post-endoscopy upper gastrointestinal cancer – identifying, understanding, and improving

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A major aim of gastrointestinal (GI) endoscopy is to improve patient outcomes by identifying and treating early malignant and premalignant lesions. A key element in achieving this aim is performing high quality GI endoscopy.

Until recently, most quality measures in GI endoscopy have centered on colonoscopy and the diagnosis and prevention of colorectal cancer (CRC). One important metric that has been used as a colonoscopy quality measure is the rate of post-colonoscopy CRC (PCCRC) [1]. PCCRC is defined as CRC diagnosed in a patient who has previously had a colonoscopy at which no cancer was diagnosed. To reduce rates of PCCRC, it is recommended that endoscopy services identify patients with PCCRC, perform a root cause analysis to identify and categorize the most plausible factors that led to the cancer, and use the results of the analysis to inform quality improvement measures [1].

As the global incidence of upper GI (UGI) cancer is close to that of CRC [2], it is also important to examine quality measures in UGI endoscopy. UGI endoscopy plays an important role in the diagnosis, treatment, and prevention of UGI cancers. A recent large Nordic population-based cohort study showed that a negative UGI endoscopy in patients with gastroesophageal disease was associated with a strong and long-lasting decrease in both the incidence of and mortality from UGI cancer [3]. The beneficial effects of a negative UGI endoscopy on cancer incidence are however imperfect – nearly 10 % of patients diagnosed with UGI cancer have had a UGI endoscopy within the preceding 3 years that did not diagnose cancer [4]. This reflects the challenges in endoscopically recognizing subtle early malignant and premalignant UGI lesions [4].

“The findings from this study reinforce the position of professional Societies around the world that have identified improvement in the quality of upper gastrointestinal endoscopy as a priority.”

The study of quality in UGI endoscopy has not developed at the same rate as it has in colonoscopy. In this edition of Endoscopy, Kamran et al. make an important contribution to this area [5]. They report their findings from a retrospective study of patients with post-endoscopy UGI cancer (PEUGIC) in two NHS providers in the UK from 2010 to 2020. PEUGIC was defined as cancer occurring in a patient who had a UGI endoscopy that did not diagnose cancer 6–36 months prior to the diagnosis of the UGI cancer. The authors developed a root cause analysis system based on the framework used for PCCRC and this was used to establish the most plausible explanations for PEUGIC. They found that 6.7 % of UGI cancers were PEUGICs. The PEUGICs were predominately within the esophagus, with 40 % occurring in patients with Barrett’s esophagus (BE). Most of the cancers in patients with BE were at an early stage and amenable to curative endoscopic or surgical resection. In their root cause analysis, the authors found that 71 % of the PEUGICs were potentially avoidable and, in 45 %, the cancer outcome could have potentially been different if diagnosed on the initial endoscopy. They found that the commonest plausible explanations for PEUGICs were inadequate assessment of premalignant or focal lesions, and inadequate endoscopy quality and decision-making around surveillance or follow-up plans.

The findings from this study reinforce the position of professional Societies around the world that have identified improvement in the quality of UGI endoscopy as a priority. [4] [6] [7] [8] These Societies have developed position statements that present a set of quality standards to optimize the diagnosis of early malignant and premalignant UGI lesions. The standards cover a broad range of areas including operator factors, endoscope technology, and endoscopy unit practices. Identified operator factors include: adequate training and currency of practice; adequate mucosal visualization and inspection times; the use of established classification systems to describe endoscopic findings; and identification and photodocumentation of relevant anatomical landmarks and detected lesions. Nonoperator factors include: the use of high resolution endoscopes; adequate allocation of procedure times; and dedicated lists for patients at higher risk of cancer, such as those undergoing surveillance procedures for BE or gastric intestinal metaplasia and atrophy. Importantly, these statements provide a set of auditable performance indicators that both the individual and institution can use for quality assurance and benchmarking.

The British Society of Gastroenterology, in their 2017 quality standards position statement, recommended that a root cause analysis be performed to identify contributing factors in cases of PEUGIC [4]. The Kamran et al. study is the first to report the results of such an analysis of unselected patients with PEUGIC in the setting of a large endoscopy service [5]. The study findings and root cause analysis system used in the study need to be validated in other settings and populations. One key aspect of the system is administratively capturing cases of PEUGIC and linking that information to endoscopy databases, processes that will differ between centers. Additionally, there will likely be different factors leading to PEUGIC in settings with different resource availability and different UGI cancer epidemiology, such as those where gastric cancer predominates over esophageal adenocarcinoma.

A benefit of the root cause analysis system is that the results are derived at the service level. The results can differentiate technical endoscopic, decision-making, and administrative factors that contribute to PEUGICs within the service. These identified factors can then inform service-specific quality improvement measures that are more likely to result in sustained improvement. As with any interventions, it is important to measure their effectiveness with ongoing monitoring of outcomes for quality assurance and benchmarking. One of the barriers to the implementation of such systems are concerns that the findings may be used to define individual accountability or in the medicolegal setting. It is critical that the system should not be used for such purposes, but only for its intended purposes of improving the quality of UGI endoscopy and thereby reducing the rate of PEUGIC [1].

Although the field of quality in UGI endoscopy is not as developed as it is in colonoscopy, this is changing rapidly. The work by Kamran et al. provides a solid foundation on which to build measures to improve the delivery of high quality UGI endoscopy and improve outcomes for our patients.

Publication History

Article published online:
24 November 2022

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