Management of Barrett's high-grade dysplasia: initial results from a population-based national audit.
OBJECTIVE
Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines.


METHODS
From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy.


RESULTS
Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001).


CONCLUSIONS
There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Imperial College, Department of Surgery and Cancer, London, United Kingdom.
Georgina
G
Chadwick
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Oliver
O
Groene
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom.
Angelina
A
Taylor
Department of Gastroenterology, Northern General Hospital, Sheffield, United Kingdom.
Stuart
S
Riley
Department of Surgery, Addenbrookes Hospital, Cambridge, United Kingdom.
Richard H
RH
Hardwick
Velindre Cancer Centre, Cardiff, Wales, United Kingdom.
Tom
T
Crosby
Health and Social Care Information Centre, Leeds, United Kingdom.
Kimberley
K
Greenaway
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
David A
DA
Cromwell
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000000981:diagnostic imaging / Q000473:pathology* / Q000628:therapy*; D017115:Catheter Ablation; D000066491:Clinical Decision-Making; D004210:Dissection; D000069916:Endoscopic Mucosal Resection; D004739:England; D016629:Esophagectomy; D004945:Esophagoscopy; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010348:Patient Care Team; D017410:Practice Guidelines as Topic; D057832:Watchful Waiting