This specialist Guidelines summary covers monitoring, treatment, and follow-up for people aged 18 and over with Barrett’s oesophagus and stage 1 oesophageal adenocarcinoma. It includes advice on endoscopic and non-endoscopic techniques. It aims to improve outcomes by ensuring the most effective investigations and treatments are used.
This summary is intended for secondary care oncology teams. For further information, please refer to the full guideline.
Information and Support
- Offer a clinical consultation to people with newly diagnosed Barrett's oesophagus to discuss risk of cancer, endoscopic surveillance plans and symptom control
- Give the person verbal and written information about their diagnosis, available treatments, and patient support groups. Give them time to consider this information when making decisions about their care
- After each surveillance procedure, provide the person with an endoscopy report that includes a lay summary of the findings and a reference to ongoing symptom control
- Follow the recommendations on communication and information in the NICE guidelines on patient experience in adult NHS services and shared decision making.
- Follow the recommendations on interventions for gastro-oesophageal reflux disease in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.
Preventing Disease Progression
- Do not offer aspirin to people with Barrett's oesophagus to prevent progression to oesophageal dysplasia and cancer.
- Discuss the benefits and risks of endoscopic surveillance with the person diagnosed with Barrett's oesophagus
- Offer high resolution white light endoscopy with Seattle biopsy protocol for surveillance of Barrett's oesophagus. Take into account the health of the person and ensure the benefits of surveillance outweigh the risks.
Frequency of Endoscopic Surveillance
- Offer high resolution white light endoscopic surveillance with Seattle protocol biopsies:
- every 2 to 3 years to people with long-segment (3 cm or longer) Barrett's oesophagus
- every 3 to 5 years to people with short-segment (less than 3 cm) Barrett's oesophagus with intestinal metaplasia
- Assess a person's risk of cancer based on their age, sex, family history of oesophageal cancer, and smoking history, and tailor the frequency of endoscopic surveillance accordingly, within the intervals given in the previous recommendation
- Do not offer endoscopic surveillance to people with short-segment (less than 3 cm) Barrett's oesophagus without intestinal metaplasia, provided the diagnosis has been confirmed at two endoscopies.
Staging for Suspected Stage 1 Oesophageal Adenocarcinoma
- Offer endoscopic resection for staging to people with suspected stage 1 oesophageal adenocarcinoma
- Do not use computed tomography before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma
- Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a oesophageal adenocarcinoma
- Consider EUS for nodal staging for people with suspected T1b oesophageal adenocarcinoma, based on endoscopic appearances, or diagnosed with T1b oesophageal adenocarcinoma, based on histological examination of endoscopic resection specimens.
Managing Barrett's Oesophagus with Dysplasia
- Offer endoscopic resection of visible oesophageal lesions as first-line treatment to people with high-grade dysplasia
- Offer endoscopic ablation of any residual Barrett's oesophagus to people with high-grade dysplasia after treatment with endoscopic resection
- Offer radiofrequency ablation to people with low-grade oesophageal dysplasia diagnosed from biopsies taken at two separate endoscopies. Two gastrointestinal pathologists should confirm the histological diagnosis
- Consider endoscopic surveillance at 6 monthly intervals with dose optimisation of acid-suppressant medication for people diagnosed with indefinite dysplasia of the oesophagus
- Offer endoscopic follow-up to people who have received endoscopic treatment for Barrett's oesophagus with dysplasia
- Follow the NICE interventional procedures guidance on endoscopic radiofrequency ablation for Barrett's oesophagus with low-grade dysplasia or no dysplasia and epithelial radiofrequency ablation for Barrett's oesophagus.
Managing Stage 1 Oesophageal Adenocarcinoma
- Offer a clinical consultation to people with stage 1 oesophageal adenocarcinoma to discuss and evaluate the suitability of treatment options, including endoscopic resection or oesophagectomy
- Offer endoscopic resection as first-line treatment to people with T1a oesophageal adenocarcinoma
- Offer endoscopic ablation of any residual Barrett's oesophagus to people with T1a oesophageal adenocarcinoma after treatment with endoscopic resection
- Offer endoscopic follow-up to people who have received endoscopic treatment for stage 1 oesophageal adenocarcinoma
- Offer oesophagectomy to people with T1b oesophageal adenocarcinoma who are fit for surgery and at high risk of cancer progression. For example, where there is:
- incomplete endoscopic resection
- evidence of lymphovascular invasion or deep submucosal invasion (more than 500 micron) on histological examination of endoscopic resection specimens.
Non-surgical Treatment for T1b Oesophageal Adenocarcinoma
- Consider radiotherapy (alone or in combination with chemotherapy) for people with T1b oesophageal adenocarcinoma at high risk of cancer progression (for example, incomplete endoscopic resection, or evidence of lymphovascular invasion or deep submucosal invasion [more than 500 micron] on histological examination of endoscopic resection specimens) and who are unfit for oesophagectomy
- Offer endoscopic follow-up to people who have received radiotherapy for T1b oesophageal adenocarcinoma.
- Do not offer anti-reflux surgery to people with Barrett's oesophagus to prevent progression to dysplasia or cancer
- Follow the recommendations on laparoscopic fundoplication for gastro-oesophageal reflux disease in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.