Management of Barrett's esophagus in the UK: overtreated and underbiopsied but improved by the introduction of a national randomized trial.
OBJECTIVE
To assess the variation in practice of Barrett's esophagus (BE) management in comparison with accepted international guidelines before and after the introduction of a large BE randomized controlled trial (RCT) with protocols including those of tissue sampling.


METHODS
A validated anonymized questionnaire was sent to 401 senior attending gastroenterologists asking for details of their current management of BE, especially histological sampling. Of the 228 respondents, 57 individuals (each from a different center) were in the first group to enter the ASPirin Esomeprazole (BE) Chemoprevention Trial (AspECT), and we assessed change in practice in these centers.


RESULTS
Ninety percent of specialists did not take adequate biopsies for histological diagnosis. Furthermore, 74% would consider aggressive surgical resection for prevalent cases of high-grade dysplasia in BE as their first-line choice despite the associated perioperative mortality. Ninety-two percent claim their lack of adherence to guidelines is because there is a need for stronger evidence for surveillance and medical interventions. Effect of the AspECT trial: Those clinicians in centers where the AspECT trial has started have improved adherence to ACG guidelines compared with their previous practice (P < 0.05). BE patients now get 18.8% more biopsies compared with previous practice, and 37.7% if the patient is entered into the AspECT trial (P < 0.01).


CONCLUSIONS
This large study indicates both wide variation in practice and poor compliance with guidelines. Because optimal histology is arguably the most important facet of BE management, the improvement in practice in centers taking part in the AspECT trial indicates an additional value of large international RCTs.
Das
Debasish
D
Digestive Disease Centre, Leicester Royal Infirmary, Leicester, UK.
Ishaq
Savid
S
Harrison
Rebecca
R
Kosuri
Kiran
K
Harper
Edward
E
Decaestecker
John
J
Sampliner
Richard
R
Attwood
Stephen
S
Barr
Hugh
H
Watson
Peter
P
Moayyedi
Paul
P
Jankowski
Janusz
J
D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001471:Barrett Esophagus / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001706:Biopsy / Q000706:statistics & numerical data*; D003625:Data Collection; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D004945:Esophagoscopy / Q000706:statistics & numerical data; D004947:Esophagus / Q000473:pathology*; D019983:Guideline Adherence; D006801:Humans; D008403:Mass Screening / Q000706:statistics & numerical data; D009367:Neoplasm Staging; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011230:Precancerous Conditions / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016032:Randomized Controlled Trials as Topic; D012306:Risk; D013222:State Medicine / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D015996:Survival Rate; D006113:United Kingdom; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*