Should endoscopic ablation therapy for Barrett’s-associated neoplasia be limited to academic or tertiary referral centers?

Highly effective endoscopic therapies are now available for the management of Barrett’s esophagus (BE)-associated dysplasia and early stage adenocarcinoma. In many circumstances, complete endoscopic resection of mucosal adenocarcinoma (stage T1a) is associated with a high rate of success and a low rate of local or lymph node recurrence [1] [2]. This is typically followed by endoscopic radiofrequency ablation (RFA) of the residual Barrett’s tissue to prevent development of metachronous cancer.

Successful achievement of this endoscopic eradication therapy (EET) requires a high level of expertise in multiple areas: proper endoscopic identification of mucosal abnormalities, including the use of high definition resolution white-light endoscopy (HDR-WLE) and narrow-band imaging (NBI); proficiency in endoscopic resection to remove focal abnormalities; skilled pathologists for proper dysplasia and cancer staging; proficiency in ablation and follow-up of patients after ablation; sufficient patient volume to maintain proficiency in management of these lesions; and access to surgeons, and medical and radiation oncologists for treatment of lesions not amenable to endoscopic therapy. In a recent Delphi method-based consensus statement, over 90 % of the expert panel agreed that management of these lesions should be performed only in tertiary care referral centers [3]. However, no study has shown that these centers provide better quality care compared with community centers.

In this issue, Schölvinck and colleagues assess one aspect of this process – comparison of detection rates of neoplastic lesions between community and referral centers [4]. In 198 patients, they have shown that tertiary referral centers were significantly more likely to detect lesions in patients with both adenocarcinoma (98 % vs. 75 %) and high grade dysplasia (75 % vs. 47 %). They also showed that many of the lesions missed in the community centers required endoscopic resection or surgery. An earlier study showed similar findings in a smaller cohort [5].

Based on these findings, Schölvinck et al. highlight the value of referral centers for the management of these patients and suggest that improvement in the standard of care is needed at community centers. Given that 72 % of patients in this study who were referred without a visible lesion were found to have one at an expert center and that over half of these lesions were carcinoma, should the management of BE-associated dysplasia and adenocarcinoma be confined to referral centers?

Multiple studies have highlighted the shortcomings of community-based BE surveillance and treatment. Adherence to biopsy guidelines for Barrett’s endoscopic surveillance in the community is poor: in only about half of cases were adequate numbers of surveillance biopsies obtained, with adherence decreasing with the length of Barrett’s segment, and this was associated with a significant decrease in dysplasia detection [6] [7].

Advanced imaging with HDR-WLE and NBI have been shown to improve detection of early BE neoplasia [8] [9]. However, a 2013 survey showed that only 37 % of community gastroenterologists routinely used advanced imaging [10]. In this same group, only 13 % performed endoscopic resection, so referral for management of any focal lesions would be needed.

A 2016 United States nationwide survey regarding the use of EET for BE showed that the majority of respondents had been performing EET for at least 5 years in either community or academic practice; only 28 % participated in an advanced endoscopy fellowship [11]. In addition to mucosal ablation techniques, 74 % offered endoscopic mucosal resection (EMR) with a larger proportion of those offering EMR being from academic practices (88 % vs. 57 %). The majority of respondents from the academic setting (69 %) performed more than six EET procedures per month, a significantly higher percentage than for those practicing in the community setting (31 %). Additionally, 83 % of academic endoscopists reported “always” using HDR-WLE in comparison to 64 % of endoscopists in community practices. Similarly, 79 % of academic endoscopists reported “always” classifying BE vs. 55 % of community endoscopists. These numbers show improvement in skills in community endoscopists over time, but more progress is needed.

The success of RFA in community and academic centers has also been studied. In the U.S. RFA registry, which includes 5521 patients from 35 academic and 113 community centers, the likelihood of recurrence after RFA was not different between academic and community-based practices [12]. Complications were in fact more frequent at academic medical centers, although this may reflect case mix [13]. No data are available about surveillance practices in either the academic or community setting.

While data suggest that management of dysplastic and neoplastic BE may be better in tertiary referral centers, the reality is that, at least in the United States, the management of these patients is commonly performed in the community. How can the standard of care be improved to ensure satisfactory outcomes in this setting? The development of standards, high quality training, and the design and assessment of quality measures are all necessary.

Standardization and systematic training for the identification of lesions with HDR-WLE and NBI are lacking, although attempts are being made to standardize normal and abnormal findings [14]. The number of sessions of RFA needed to achieve complete eradication of intestinal metaplasia (CE-IM) decreases with case volume, indicating a learning curve effect [15]. This trend disappears after the treatment of 30 patients by the center or individual endoscopist. Based on this result, it appears that 30 endoscopic ablations are needed to achieve competence, a number recommended by the British Society of Gastroenterology [16]. Formal training to develop technical proficiency in EET is needed. One such program is the ASGE STAR Certificate Program, which provides standardized, evidence-based education along with hands-on training in Barrett’s endotherapy skills.

Finally, quality measures to evaluate EET are needed. A recent study used the RAND UCLA Appropriateness Method to develop validated quality indicators for EET in BE neoplasia [17]. These indicators include a CE-IM rate of 70 % and the stipulation that all centers that provide ablative therapy should also provide endoscopic resection. Utilization rates of endoscopic resection and appropriate surveillance after ablation are also potential quality measures. There remains the question of what organization or program will monitor maintenance of proficiency and adherence to these outcome measures.

So, should endoscopic ablation therapy for BE-associated neoplasia be limited to academic or tertiary referral centers? The data suggest that many community physicians lack the equipment, training, skills, and patient volume needed to achieve the best outcomes for these patients. However, referral to a tertiary care/academic center does not guarantee that these requirements will be met. What is needed are physicians with proper training in lesion identification with HDR-WLE and NBI, proficiency in endoscopic resection and ablation, a sufficient case volume to maintain these skills, and a commitment to the monitoring of quality outcomes in this population. Presently these expert physicians are more likely to practice in tertiary referral centers, where expert pathologists, surgeons, and oncologists are also on site to treat patients with complications or more extensive disease. All those performing endoscopic eradication therapy, whether in a community or tertiary referral practice, must be committed to achieving and maintaining the proficiencies and standards described to provide the very best outcomes for this patient population.

• References

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