Oesophago-gastric cancer : factors influencing presentation and the effects of antisecretory drug therapy on symptoms and diagnosis

• Main Author: Panter, Simon J.
• Published: University of Edinburgh 2008
• Subjects: 616.994
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.660317

Methods: A retrospective cohort study of 685 patients with oesophago-gastric adenocarcinoma (ACA) diagnosed in South Tees between April 1991-2001 and prospective studies of gastric ulcer disease and chromoendoscopy. Results: The time course to diagnosis was determined and showed a mean time to diagnosis of 30 weeks. Patients with oesophageal cancer took longer to present to their GP and longer to be seen in secondary care once referred. The part of the diagnostic process in primary care was double that in secondary care. Antisecretory drug therapy (AST) prescribed prior to endoscopy resulted in a delay in diagnosis of 18 weeks (mean) but this had no effect on long-term outcome. The Urgent Referral Guidelines for upper GI cancer, known as the “two week rule” guidelines showing they fail to identify 29% of patients. 27% of patients have an endoscopy within 3 years of diagnosis where the diagnosis of cancer is not made. Lesions are often seen at the prior endoscopy, and are often ulcerated. Inadequate biospying seems responsible, which is influenced by the endoscopist’s perception of whether the lesion is malignant. Only 9.2% of cancers are truly “missed”. Chromoendoscopy identified benign minor abnormalities in 14%: an aggressive biopsy policy even in patients “at risk” by virtue of age is therefore hard to justify. Conclusion: There are significant delays in the diagnosis of oesophago-gastric ACA. Treatment with AST delays diagnosis but without affecting outcome. Current endoscopic practice could be improved to reduce that missed cancer rate through the use of a rigorous biopsy protocol especially for ulcerated lesions. As symptoms are used to determine who is endoscoped and are a poor predictor of pathology alternative means of determining “high risk” need to be developed.