With quality in the bag it's enhanced services' turn now
Why endoscopy should be for the few and not the many
Dr Mark Follows, a GPwSI in gastroenterology, makes a plea for GPs to follow the logical NICE advice on dyspepsia referral
a GPwSI in gastroenterology, makes a plea
for GPs to follow the logical
NICE advice on dyspepsia referral
Dr Goddard is not alone in his opposition to the NICE dyspepsia guidelines published last August1-3.
But his alarming statistics that one in 15 patients over age 55 presenting without alarm symptoms had cancer, and the guidelines delay diagnosis by three months4, are not representative.
In a cohort of 1,852 patients referred for urgent endoscopy based on the two-week rule5 only one of the 70 UGI cancers identified presented without alarm symptoms6.
Dysphagia and weight loss were the strongest predictive factors for cancer while uncomplicated dyspepsia was a negative predictive factor. The researchers concluded that 'routine investigation of uncomplicated dyspepsia in older subjects appears to be the weakest of the alarm symptoms for cancer detection'6.
In another review of 1,000 open-access endoscopies, all of the 17 patients diagnosed with an UGI cancer presented with alarm symptoms7.
The relationship between clinical symptoms and endoscopic findings is poor8,9 and although dyspepsia is common, UGI cancer as a cause is rare even in patients with alarm symptoms. In a review of 240 two-week rule referrals to Airedale Hospital only one in 20 was found to have an UGI cancer, similar to other published figures6,10.
The 'huge disparity' in Dr Goddard's figures can be accounted for. Only 17 of the 32 cases had an UGI cancer (oesophagus 13, stomach four) that could have been diagnosed by endoscopy alone. This represents 3.5 per cent of the patients, which is comparable with other studies.
The remaining 15 included pancreas (six), biliary tract (three), lung (two), ovary (one), colon (one) and unknown primary (two). We are not told how these cases presented or the type of cancer in the 10 patients without alarm symptoms. It is not possible to draw the conclusion that following the NICE dyspepsia guidelines delays the diagnosis of UGI cancer in patients without alarm symptoms from this data.
Considering dyspepsia is prevalent in 25-40 per cent of the population it could be coincidental in the 15 patients with non-UGI cancer.
It has been suggested that following the NICE guidance delays diagnosis of cancer by three months in patients without alarm symptoms. The concern is that potentially curable lesions become incurable in the intervening time.
There is no evidence to support this and most lesions are advanced at presentation11.
A study of 747 UGI cancer patients found prior use of antisecretory medication for benign symptoms delayed diagnosis by 17.6 weeks but had no effect on tumour stage or surviva · 12.
I am in the process of setting up an integrated dyspepsia service. I reviewed the current referral practice and found of the 65 patients awaiting endoscopy, 38 had uncomplicated dyspepsia, of whom 24 had not received a PPI and 35 had not been tested for H. pylori.
The average age of this group was 54; 17 patients had documented alarm symptoms, including eight with dysphagia and four with dyspepsia and weight loss. At least one of these patients has been found to have a cancer.
These figures suggest the guidelines are not being adhered to. There may be many reasons for this, including lack of awareness or understanding of the guidelines, obsolete referral forms and complicated referral pathways.
NICE has provided logical, evidence-based guidelines for the management of patients presenting with dyspepsia. If the patient has alarm symptoms or is over 55 with other risks then they need an endoscopy.
If not then medication review, lifestyle advice, PPI and H. pylori testing are the next steps.
Given a choice, most patients would be grateful to avoid an endoscopy as it is unpleasant and not without risk. Endoscopy is not a cost-effective screening tool for UGI cancer while colorectal cancer (CRC) screening has been shown to save lives. The only way an effective CRC screening service can be implemented is by reducing endoscopy numbers.
However, the guidelines do not 'override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient'1.
There will always be circumstances eg patient (or doctor!) anxiety in which an endoscopy will be appropriate outside of the guidelines and should be offered.
In my opinion GPs should follow the NICE dyspepsia guidelines because they improve patient care not diminish it.
1 The management of dyspepsia in adult patients in Primary Care. NICE, London, UK 2004
2 Griffin SM et al. Upper gastrointestinal surgeons comment on NICE dyspepsia guidelines. BMJ 2005; 330: 308-9
3 Bramble MG et al. NICE dyspepsia guidelines will worsen prognosis of upper GI cancer. BMJ.com Feb 13 2005
4 Stokes A, Goddard AF. NICE guidance will delay diagnosis of cancer in patients over 55 with new-onset dyspepsia. Gut April 2005; supp 11, vol 54: A60
5 Department of Health. Guidance on commissioning of cancer services: improving outcomes in upper gastrointestinal cancers the manual. London: Department of Health 2001
6 Kapoor N et al. Predictive value of alarm features in a rapid access
upper gastrointestinal cancer service. Gut 2005; 54: 40-5
7 Boulton-Jones JR et al. Open-access endoscopy: are age-based guidelines justified? An audit of experience of 1,000 open-access endoscopies in a district general hospital. Endoscopy 35(1): 76-8
8 Agreus L, Talley NJ. The challenge of managing dyspepsia in general practice. BMJ 1997; 315:1284-1288 (November 15)
9 Thompson AB et al. The prevalence of clinically significant endoscopic finding in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment-Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Ther 17(12): 1481-91, 2003 June 15
10 Saeed AA et al. NICE dyspepsia guidelines. BMJ.com March 4 2005.
11 Canga C 3rd, Vakil N. Upper GI malignancy, uncomplicated dyspepsia, and the age threshold for early endoscopy. Am J Gastro. 97(3): 600-3, March 2002
12 Panter SJ et al. Empirical use of antisecretory drug delays diagnosis of upper gastrointestinal adenocarcinoma but does not effect outcome. Aliment Pharmacol Ther. 19(9); 981-8. May 2004
Mark Follows is a salaried GP and GPwSI in gastroenterology for Airedale PCT,