Introduction

Post endoscopy upper gastrointestinal cancers (PEUGIC) are often missed opportunities to diagnose earlier or even prevent cancer. A national process for identifying all PEUGIC in the English National Health Service (NHS) and performing root cause analysis was developed. In parallel, a survey of NHS endoscopy providers diagnostic and surveillance UGI endoscopy practices was undertaken to investigate organisational factors which may contribute to endoscopy quality and PEUGIC.

Aims & Methods

PEUGIC occurring 3-36 months after an index endoscopy without a cancer diagnosis between 2017 and 2023 were identified from National Cancer Registration and Hospital Episode Statistics datasets. Data from local root cause analysis were uploaded onto a secure portal for national analysis. Endoscopy providers taking part in the project were asked to complete an online organisational survey, covering diagnostic and surveillance endoscopic practices, equipment and the management of dysplasia and early cancer.

Results

3151 PEUGIC were examined by local reviewers in 144 hospitals in England. 635 (20%) were excluded on local review. Data were available for 2516 PEUGIC. 1897 PEUGIC (75.4%) were following diagnostic endoscopy and 618 (24.6%) were undergoing surveillance. 80% of endoscopy providers responded to the survey.
For diagnostic PEUGIC, less than 20 minutes being allocated to UGI endoscopy was associated with no abnormalities detected in the PEUGIC segment at index endoscopy OR 1.25 (95% CI 1.04-1.50). Oesophageal squamous cell PEUGIC were associated with less time allocated per endoscopy OR 1.28 (95% CI 1.03-1.59). Endoscopy providers with lower number of procedures during an endoscopy session were associated more frequently with adequate management of lesions OR 2.6 (95% CI 1.03-6.87). Patient harm and adverse treatment outcomes were associated with an inadequate index endoscopy OR 1.56 (95% CI 1.28-1.91). The most common reason for inadequate endoscopy was inadequate management of lesions identified, which were most likely to be cancer associated lesions OR 1.43 (95% CI 1.11-1.69), specifically oesophageal strictures (24%) and gastric ulcers (23%).
For surveillance PEUGIC, organisational factors associated with increased detection of stage 1 (success of surveillance) PEUGIC compared with stage ≥2 were: dedicated surveillance sessions OR 2.08 (95% CI 1.46-2.98), >20 minutes allocated per endoscopy OR 2.05 (95% CI 1.48-2.84) and surveillance in an endoscopic resection centre OR 3.50 (95% CI 1.99-6.13).
Booking delays and errors were noted in 12% of PEUGIC, patient factors (e.g. non-attendance) were noted in 11% and clinical error in 11.7% (inappropriate decision 7.5% and histology not actioned in 4.2%). Surveillance was delayed in 27% of PEUGIC and associated with adverse treatment outcomes OR 1.79 (95%CI 1.72-2.73).

Conclusion

A survey of endoscopy providers’ organisational structure has revealed factors which contribute to PEUGIC not captured during individual root cause analysis. Less time allocated for endoscopy was associated with no abnormalities being found during endoscopies that lead to PEUGIC. Surveillance outcomes were better in patients who had their endoscopies in dedicated surveillance sessions, with more time allocated and undertaken in endoscopic resection centres. Surveillance delays are common and associated with worse outcomes.