OC-012 How Commonly is Oesophageal Cancer Missed at Endoscopy (A UK Primary Care Based Study)?

Abstract

Background: The frequency of upper gastrointestinal cancer being diagnosed following a negative esophagogastroduodenoscopy (EGD) up to 3 years previously in selected single unit series ranges from 6.7-14%. We have examined how often esophageal cancer (EC) is missed at EGD in a large unselected primary care cohort and associated risk factors. Methods: All subjects with EC from a UK primary care database (The Health Improvement Network (THIN)) were studied. THIN covers over 6 million patients and is regionally and demographically representative of the UK population. A nested case-control study was performed with cases of 'missed EC' subjects who underwent EGD 1-5 years prior to their EC diagnosis and controls subjects who did not have EGD 1-5 years prior to their EC diagnosis. Logistic regression analysis was used to study associations with having an EGD that potentially missed EC. Results: 5354 subjects with EC were identified (3561(67%) male, mean age 71 ±11years) and 9187 EGD were analyzed. 380 subjects (237(62%) male, mean age 72 ±11years) had EGD 1-5 years prior to EC diagnosis (715 EGD, mean 1.9 per subject). 266(5.0%) subjects had EGD 1-3 years and 144(2.7%) had EGD 3-5 years prior to EC diagnosis. 180(47.4%) of EGD which did not diagnose EC 1-5 years previously had an abnormality detected (Esophagus - Barrett's 59 (15.5%), hiatus hernia 45, esophagitis 16, gastro-esophageal reflux disease 17, stricture 8, ulcer 7; Stomach - gastritis 25, ulcer 7, polyp 4; Duodenum - duodenitis 17, ulcer 8, coeliac disease 1). The 'missed EC' subjects had a total 329 primary care consultations 1 year prior to their EGD that missed EC. 'Alarm symptoms' were present at 139 consultations (38 anemia, 1 abdominal mass, 78 dysphagia, 20 hematemesis/melena and 6 weight loss). Subjects presenting with anemia (OR 2.05, 95%CI 1.4-3.1, p=0.0006), hematemesis/melena (1.82, 1.1-3.2, p=0.03) or dyspepsia (2.20, 1.7-2.8, p<0.05) were more likely to have had an EGD that missed EC. In contrast, subjects with dysphagia (0.74, 0.5-0.9, p=0.04) or weight loss (0.39, 0.2-0.9, p=0.02) were less likely to have an EGD that missed EC. Logistic regression did not find any association between age (0.7, -0.5-1.8, p=0.3) or female gender (1.2, 0.9-1.5, p=0.07) with EGD that failed to diagnose EC 1-5 years prior to EC diagnosis. Conclusions: Missing EC at EGD was relatively uncommon in this unselected cohort with 5% of EC subjects having had an EGD 1 - 3 years prior to diagnosis that did not diagnose EC. Presenting with anemia, hematemesis/melena or dyspepsia were positively associated with missing EC at EGD. In contrast, subjects with dysphagia or weight loss were less likely to have EC missed at EGD. Many of the EGD which missed EC had an abnormality recorded, with Barrett's esophagus reported in 15.5%.