Introduction
UGI cancer detected within 5 years of a gastroscopy (termed post-OGD UGI cancer – POUGIC) may reflect delayed diagnosis and contribute to poorer prognosis. It has been estimated to be as high as 14% and BSG quality standards (2017) recommend rates do not exceed 10%. UGI cancer often presents late and with limited curative treatment options efforts are increasingly focused on improved screening methods and earlier diagnosis. We undertook a retrospective review of all histological diagnoses of oesophageal and gastric carcinoma at our hospital over a 10-year period to describe this cohort in our own practice.
Aims & Methods
Medical records for 588 histological diagnoses of gastric and oesophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) between 13/01/10 and 24/08/20 were reviewed, including previous OGDs, histology reports, radiological staging and past medical history.
The aim was to profile patients to identify risk factors for the development of POUGIC.
Results
42/588 pts (7%) underwent OGD up to 5y (med 22m) prior to cancer diagnosis.
POUGIC pts: aged 53-96y (med 74.5y), 21% female, 60% White, 10% Asian, 10% Black, and 20% mixed/other.
Non-POUGIC (546pts): aged 24-94y (med 71.5y), 34% female, 57% White, 10% Asian, 11% Black, and 22% mixed/other.
| OGD findings within 5 years prior to UGI cancer, 42 pts (%) |
“Benign” oesophageal stricture / lesion
| 14 |
Oesophagitis
| 12 |
Oesophageal candidiasis
| 2 |
Barretts oesophagus (BO)
| 24 |
| Hiatus hernia | 14 |
Gastric ulcer
| 2 |
Gastritis
| 12 |
Normal
| 24 |
Unknown
| 7 |
7% OGDs <5y prior to cancer diagnosis were by a Consultant.
POUGIC: 57% oesophageal (33% AC, 24% SCC), 7% GOJ AC, 36% gastric AC.
Non-POUGIC: 30% oesophageal (18% AC, 12% SCC), 8% GOJ (7% AC, 1% SCC), and 19% gastric AC.
POUGIC staging at presentation: 12% T1-2, 45% T3-4, 14% metastatic and 43% unknown. Pts died 0-35m (med 5m) after diagnosis.
Non-POUGIC staging at presentation: 13% T1-2, 50% T3-4, 19% metastatic and 35% unknown. Pts died 0-120m (med 7m) after diagnosis.
All patients with POUGIC and BO were known to have had BO prior to their cancer diagnosis and had undergone endoscopic screening as per BSG guidelines.
Conclusion
POUGIC were <10% of UGI cancer diagnoses, in accordance with BSG quality standards.
Age, gender and ethnicity were similar in both POUGIC and non-POUGIC, and so were not predictive factors.
Staging and median survival were also similar between POUGIC and non-POUGIC, suggesting that these outcomes were not affected by an OGD within the previous 5y.
Oesophageal cancer was more common in those that had OGD in the preceding 5y compared to those that had not, and BO was the most common abnormality in these procedures. 78% POUGIC had risk factors for UGI cancer on their initial OGD (inflammation, ulcer, BO, hiatus hernia, stricture), raising the possibility that treatment could have been optimised, e.g. acid suppression (45% of POUGIC were on PPI before their cancer diagnosis), anti-reflux surgery, lifestyle modifications or improved surveillance. Importantly, 24% of POUGIC also had a “normal” preceding OGD, and with only 7% of these OGD performed by a Consultant, it is possible that pathology may have been missed on initial OGD. Additional novel screening techniques, such AI-assisted endoscopy, volatile organic compounds and Cytosponge may help obtain earlier diagnoses in future.
References
Beg S, Ragunath K, Wyman A, et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the BSG and AUGIS, Gut (2017).