Diagnosis of Barrett’s oesophagus
If you suffer from longstanding heartburn you may develop Barrett’s Oesophagus. This condition may lead to oesophageal cancer, but regular endoscopy and treatment can reduce the risk of this cancer developing. The benefit of surveillance is however being investigated by a large study – BOSS (Barrett’s Oesophagus Surveillance Study), to which we have recruited patients.
What is Barretts oesophagus?
This is caused by the oesophagus being regularly exposed to regurgitating stomach acid. The damage causes the normal pink lining (squamous cell pattern) to be replaced by a salmon coloured intestinal-type (columnar pattern.) Barrett’s oesophagus increases the risk of adenocarcinoma (cancer originating in glandular tissue) of the oesophagus, which is increasing in prevalence throughout the world. Most people with Barrett’s however do not have any problems and only 10% develop cancer. The difficulty is understanding who is at risk. At University College London, we have been investigating certain markers that may predict risk, although this does not yet form part of routine practice.
How common is Barrett’s oesophagus?
It is estimated that up to 3% of the population may have Barrett’s and up to 40% of whom do not have any symptoms. In those people who have heartburn, up to 10% of people have Barrett’s oesophagus.
How do you diagnose Barrett’s oesophagus?
Barrett’s oesophagus is diagnosed by looking at the oesophagus through an endoscope, whereby a tube with a video is inserted through the mouth. This is called a gastroscopy. The diagnosis is verified by taking samples from the oesophagus. During this endoscopy it is very important to target and diagnose any pre-cancerous (Dysplastic) cells or early cancer (Intra-mucosal cancer). Dr Matthew Banks presents on specialized techniques at a conference.
Barrett’s oesophagus Treatment
There are various techniques for removing the abnormal lining (mucosa) of Barrett’s oesophagus, however the most effective technique is Halo radio-frequency ablation (RFA), although alternatives include cryotherapy and photodynamic therapy.
How is HALO RFA done?
HALO RFA involves passing a catheter (Tube) through the mouth during a standard endoscopy and applying thermal energy to burn off the top layer of cells (Mucosa). It appears to be effective and safe, with very few complications documented. It takes about 30 – 45 minutes and is usually performed as a day case with most people going home within 1 to 2 hours after the procedure. On average 2-3 treatments are required to completely remove the Barrett’s. Typically HALO RFA is combined with removal of visibly abnormal cells (Dysplasia) by a technique called endoscopy resection (ER).
What are the side effects of HALO RFA?
Typical side effects include chest pain, difficulty in swallowing, loss of appetite, tiredness and nausea. These symptoms rarely last more than a week. Some people develop strictures (Approximately 1 in 10), which cause difficulty in swallowing, but this can be treated.
We treat Barrett’s oesophagus where dysplasia has been found but not non-dysplastic Barrett’s. Below is a description of treatments for the different stages of Barrett’s.
High-grade dysplasia in Barrett’s oesophagus
We recommend that patients who have high grade dysplasia consider HALO RFA. Alternatives are surgery or observation only.
How many people with Barrett’s develop high grade dysplasia?
Approximately 2% of patients with Barrett’s develop high grade dysplasia each year.
What is the risk of cancer once high grade dysplasia develops?
The risk of cancer in the next 5 years is around 60%
Does HALO RFA help prevent developing cancer in high grade dysplasia?
Eradication rates of high-grade dysplasia using Halo RFA are between 80 to 90% at 2 years. Our own data from the National Barrett’s registry are in keeping with these success rates. This does mean that some patients will develop cancer despite HALO RFA which is under 5% within 2 years. The National Institute for Health and Clinical Excellence (NICE) has provided guidelines for the use of RFA for high grade dysplasia. Most insurance companies will pay for HALO RFA treatment for high grade dysplasia, but this will need discussing with your insurance company before starting treatment.
Low-grade dysplasia in Barrett’s oesophagus
There have been a few studies investigating the use of HALO RFA for low grade dysplasia demonstrating successful eradication. This risk of developing cancer is however very low (Approximately 1% -2% per year) and for this reason, treatment for low grade dysplasia is not recommended by NICE and most insurance companies will not necessarily pay for this.
Non-dysplastic Barrett’s oesophagus
We do not normally recommend HALO RFA for non-dysplastic Barrett’s due to the very low risk of developing cancer, with an annual risk of between 0.2 and 0.4 % and a lifetime risk of less than 10%.
If you would however like to have HALO RFA for non-dysplastic Barrett’s, the likely success of eradication is approximately 90-95% and usually requires 2-3 treatments. The cost will be expected to be between £5,000 and £20,000 depending on the number of treatments required.
It is important to note that there is no data available demonstrating that ablation of non-dysplastic Barrett’s reduces cancer risk in the long term.
Barrett’s oesophagus Research
There are multiple trials into Barrett’s oesophagus at University College London Hospitals several of which are described below. Dr Matthew Banks is either a chief investigator or investigator in many of these trials:
Barrett’s oesophagus in obese, normal weight-obese and normal weight patients
Chief Investigator: Dr. Matthew Banks UCLH
We are trying to understand the relationship between weight and Barrett’s oesophagus. We believe that obesity and metabolic markers of obesity are related to acid reflux and the development of Barrett’s oesophagus.
The UK HALO Registry
This is a registry of all patients being treated with HALO radiofrequency ablation (RFA) for dysplasia (pre-cancerous changes) and early cancer in Barrett’s oesophagus. It is run from UCL Hospitals and collects all the data and outcomes of the treatment in the whole of the UK. WE have shown so far that HALO RFA is a safe, effective and durable over time.
Pro-BOOST – prospective randomised controlled trial of Barrett’s Oesophagus surveillance using high definition white light endoscopy, with and without enhanced Optical imaging and Spectroscopy to Target high risk lesions.
We are investigating whether advanced endoscopic imaging technology can accurately diagnose dysplasia in patients with Barrett’s oesophagus. We envisage that the technology will improve the detection of pre-cancerous and cancerous lesions and improve outcomes in these patients.
BOSS – Barrett’s Oesophagus Surveillance Study
This is a large national study assessing whether surveillance endoscopy for non-dysplastic Barrett’s is an effective strategy for detecting and treating dysplasia and cancer
BEST2 – Evaluation of a Non-Endoscopic Immunocytological Device (Cytopill) for Barrett’s Oesophagus Screening via a
The aim of this study is to assess whether a swallowed pill/sponge can stratify the risk of cancer in patients with heartburn. A pill on a string is swallowed which then opens up into a sponge in the stomach. This is then removed through the oesophagus and out of the mouth picking up cells from the oesophagus. The cells are then analysed for specific ‘cancer-risk’ markers.