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Barrett’s oesophagus: ablative therapy Implementing NICE guidance August 2010 NICE clinical guideline 106 What this presentation covers Background Scope Recommendations Costs and savings Discussion Find out more Background • In some patients, Barrett’s oesophagus can become dysplastic and lead to oesophageal cancer. • Around 465 people per year develop high-grade dysplasia which places these people at greater risk of oesophageal cancer. • Endoscopic mucosal resection (EMR) and ablative treatments have been developed to treat high-grade dysplastic Barrett’s oesophagus or intramucosal cancer. • In the past, the lack of an evidence-based guideline addressing the use of ablative therapies for Barrett’s oesophagus may have lead to variations in practice. Scope This clinical guideline provides evidence-based recommendations for the use of ablative therapies and EMR to treat Barrett’s oesophagus with high-grade dysplasia or with intramucosal cancer. It covers the use of: • • • • • • argon plasma coagulation laser ablation multipolar electrocoagulation radiofrequency ablation photodynamic therapy EMR Key areas for recommendations • Key principle of care • Endoscopic therapies • EMR • Ablative therapies Image reproduced with kind permission of Professor Hugh Barr, Gloucestershire Hospitals NHS FT • EMR in combination with ablative therapies • Patient and carer support and information Key principle of care All treatments for high-grade dysplasia and intramucosal cancer in Barrett’s oesophagus should be performed by specialist oesophago-gastric cancer teams with the experience and facilities to deliver the treatments recommended in this guideline. Endoscopic therapies Consider offering endoscopic therapy as an alternative to oesophagectomy to people with high-grade dysplasia and intramucosal cancer (T1a), taking into account individual patient preferences and general health. Endoscopic therapy is particularly suitable for patients who are considered unsuitable for surgery or who do not wish to undergo oesophagectomy. Endoscopic mucosal resection – localised lesions • Consider using EMR alone to treat localised lesions • Use circumferential EMR with care because of the high incidence of stricture formation. Image reproduced with kind permission of Professor Hugh Barr, Gloucestershire Hospitals NHS FT Ablative therapies – flat high grade dysplasia • Consider using radiofrequency ablation alone or photodynamic therapy alone for flat high-grade dysplasia, taking into account the evidence of their long-term efficacy, cost and complication rates. X Do not use argon plasma coagulation, laser ablation or multipolar electrocoagulation alone, or in combination with each other, unless as part of a clinical trial. Image reproduced with kind permission of Professor Hugh Barr, Gloucestershire Hospitals NHS FT Endoscopic mucosal resection in combination with ablative therapies • If using EMR, consider following with an additional ablative therapy (radiofrequency ablation, argon plasma coagulation or photodynamic therapy) to completely remove residual flat dysplasia, taking into consideration the side-effect profiles • If residual or recurrent disease is suspected, consider additional or repeated therapy with appropriate follow up. Patient and carer support and information Give patients verbal and written information about their diagnosis, available treatments, patient support groups and the uncertainty of the long-term outcomes of ablative therapies. Give patients time to consider this information when making decisions about their care. Offer patients the opportunity to see the same specialist healthcare team more than once to agree treatment. Costs and savings The guideline on Barrett’s oesophagus should not significantly change resource use in the NHS. However, local circumstances may result in additional costs or savings in these areas: • All treatments should be carried out at specialist centres (recommendation 1.1.1) • Offer endoscopic therapy as an alternative to oesophagectomy (recommendation 1.1.2) • Consider ablative therapies for flat high-grade dysplasia (recommendation 1.1.6) Discussion • What governance framework do we have in place to ensure clinicians carrying out these procedures have received adequate training? Does this need updating in light of the NICE recommendations? • What care pathways are in place within our locality? How can we ensure the seamless referral of patients to the appropriate specialist centre? Do we need to establish new care pathways or update existing ones in light of the NICE guidelines? • How are we going to ensure patients receive the appropriate information to allow them to make an informed decision about their treatment? Find out more Visit www.nice.org.uk/guidance/CG106 for: • • • • • the guideline the quick reference guide ‘Understanding NICE guidance’ costing statement baseline assessment tool