WIREDGOV

NICE has yesterday (10 March) published a draft clinical guideline on the use of ablative therapies for the treatment of Barrett’s oesophagus.  Ablative therapies destroy the abnormal cells within the oesophagus caused by the condition, without removing an entire section of oesophagus. This is the first time national guidelines have considered the use of these therapies to treat Barrett’s oesophagus, and NICE is now opening a consultation on the draft recommendations. 

Barrett’s oesophagus (also known as Barrett’s)¹ is a condition which affects the lower oesophagus and develops as a consequence of long-term, chronic gastro-oesophageal reflux disease².  The cells that line the affected area of the oesophagus become inflamed and if this happens over many years, these cells may start to change, becoming more like the cells that line the intestine. In some patients, these changes can lead to oesophageal cancer. 

Surgical removal of part of the oesophagus (oesophagectomy) is the current standard NHS treatment for Barrett’s oesophagus, but less invasive techniques such as endoscopic resection (ER)³ and ablative treatments have now been developed.

This draft guideline covers the use of ablative therapies (argon plasma coagulation APC, laser ablation, multipolar electrocoagulation MPEC, radiofrequency ablation RFA and photodynamic therapy PDT) and endoscopic resection (ER) compared with oesophageal surgery, and surveillance with proton-pump inhibitors for treating Barrett’s oesophagus with high-grade dysplasia⁴ or with intramucosal cancer (including T1a⁵) in adults (18 years and older) in secondary care.

The draft guideline recommends that patients are offered endoscopic removal (ER) of high-grade dysplasia and intramucosal cancer (including T1a) as an alternative to oesophagectomy, taking into consideration patient preference and general health.  An additional ablative therapy (RFA, APC, or PDT) could be used after ER to completely remove dysplasia, and RFA or PDT ablation alone could be considered for flat high-grade dysplasia.  APC, laser or MPEC should not be used alone or in combination with each other unless part of a clinical trial. 

Dr Fergus Macbeth, Centre for Clinical Practice Director at NICE, said:

“Barrett's oesophagus can sometimes lead to cancer of the oesophagus; therefore, it’s important that the NHS is using the very best evidence-based practice in treating it.  This will be the first national guideline to cover the use of ablative therapies, and will ensure that the widest range of options is considered for patients suffering with this serious condition.”

This draft guidance has been issued for consultation; NICE has not yet issued final guidance to the NHS. 

The draft guidance is available on the NICE website.

These preliminary recommendations are available for consultation until Wednesday 7 April 2010.

¹Another name sometimes used by doctors for Barrett's oesophagus is columnar-lined oesophagus (CLO).

²Chronic gastro-oesophageal reflux disease is defined as chronic symptoms or mucosal damage in the oesophagus, produced by the liquid content of the stomach when it regurgitates into the oesophagus. This liquid can inflame and damage the lining, and usually contains acid and pepsin that are produced by the stomach. It may also contain bile that has backed-up into the stomach from the duodenum.

³ER is a procedure whereby specialised endoscopic devices are used to remove abnormal areas in the lining of the oesophagus.

⁴Abnormal cell growths that can sometimes lead to oesophageal cancer.

⁵T1a is a classification of cancer that shows less than 5% of cancerous cells in the tissue sample.