Introduction Gastric and oesophageal cancers have a high mortality rate, particularly if diagnosed at a late stage. We aimed to determine whether Upper Gastrointestinal (UGI) cancers are being missed either endoscopically or histologically in Leeds, and the reasons for any delays identified.
Methods As part of our rolling annual audit programme, histopathology records were gathered for all UGI cancers detected between September 2009 and August 2010 at Leeds Teaching Hospitals Trust. The endoscopy database was searched for endoscopies in the previous 3 years and the Trust Patient Pathway Manager reviewed for possible delays to diagnosis. Patients were classified into <1 month (m) from most recent endoscopy (delay not significant) and >1 m (possible significant delay). Previous biopsies were reviewed by a consultant histopathologist.
Results 211 cases of UGI cancers were detected (range 25–94 years, mean 70 years, 1.89:1 M:F) representing malignancy in 6.1% of 3460 endoscopies with gastric/oesophageal biopsy. Excluded from further study were: no endoscopy report (13); follow-up of previous diagnosis (38); not primary adenocarcinoma (12). 16/148 (10.8%) cases had had endoscopy within the last 3 years, 6/16 (37.5%) had repeat endoscopy within 1m (mean delay 16.2 days). Reasons included: (2) suspicious endoscopy without histological confirmation of malignancy, (1) previous failed intubation, (1) follow-up of oesophageal ulcer. Of the 10 cases with previous endoscopy >1 m earlier, preventable delays were identified in six cases: Bleeding GU not biopsied at index endoscopy (42 days); failure to biopsy GOJ nodule due to triple anti-platelet therapy (91 days); a patient with known High Grade Dysplasia awaiting cardiology opinion before repeat under general anaesthetic (192 days); delayed surveillance interval for Barrett's Oesophagus (1035 days from previous endoscopy). Only in two cases was the cancer likely to have been missed on the first endoscopy: delayed follow-up after EMR, synchronous gastric carcinoma in separate site (180 days) and repeat endoscopy for symptomatic dysphagia (SCC in high oesophagus) (526 days). The other 4 cases had endoscopies unrelated to the subsequent diagnosis more than 2 years earlier and the delay was considered unavoidable. Review of previous biopsies, including further stains, showed that no malignant diagnosis had been missed.
Conclusion 6/148 (4.1%) patients had significant potentially avoidable delays to diagnosis of upper GI cancer. This is commensurate with audits in other centres. Most delays are systematic problems with bookings and appointments rather than endoscopic misses. We believe this simple rolling audit should be adopted as a mandatory Quality Assessment tool for MDTs and/or endoscopy units in order to improve delays in the diagnosis of UGI cancer in all hospitals.
Competing interests None declared.