Download Slide set

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