Post-endoscopy upper gastrointestinal cancer: how to move from the dark side

Upper gastrointestinal (UGI) endoscopy is the gold standard for the diagnosis of esophageal, gastric, and duodenal disorders including cancer, as it allows direct access to the lumen, detection of lesions, and biopsies if applicable. Despite its high diagnostic accuracy, for various reasons a high proportion of UGI cancers are missed during UGI endoscopy, leading to a delay in diagnosis, advanced stages of disease, and poorer prognosis [1].

In this issue of Endoscopy, Kamran et al. present data on UGI cancers missed during a UGI endoscopy [2]. Missed UGI cancer, referred to as post-endoscopy upper gastrointestinal cancer (PEUGIC), is probably the best quality performance indicator for any endoscopic procedure. Unfortunately, it is also probably the most difficult to measure.

“...the wide PEUGIC rate range of about threefold between endoscopy providers means that there remains much room for improvement in the quality of our endoscopy performance, with an unacceptable figure of underperformers.”

In this retrospective, population-based, case–control study, endoscopic and cancer databases from England were used to combine the diagnosis of an esophageal or gastric cancer with a UGI endoscopy performed within the previous 3 years. PEUGIC was defined as a cancer diagnosed between 6 and 36 months after a UGI endoscopy that did not diagnose that cancer. The study included 106 557 UGI endoscopies performed in 98 801 patients with a diagnosis of UGI cancer within 3 years.

The rate of PEUGIC was 8.5%, ranging from 5% to 13% among endoscopy providers. This means that roughly 1 in every 10 UGI cancers were missed during a recently performed UGI endoscopy. These extremely worrying data are in line with data from other relevant studies, namely meta-analyses, which reached similar results with PEUGIC rates of 11.3% and 9.4% [3] [4].

A very relevant fact is that this dreadful rate is not improving. The previous meta-analyses included studies from 1966 to 2015, and these new data from Kamran et al. report on cancers and UGI endoscopies performed between 2009 and 2018 [2] [3] [4]. The PEUGIC rate increased from 8.4% in 2009 to 8.9% in 2018 in the latter study. We need to acknowledge that during this period, new high definition scopes and processors were introduced and disseminated, endoscopy centers in England evolved to a wide national accreditation system with centrally reported databases, and quality publications specific to upper endoscopy were published [5]. But, instead of an improvement, we observe a worse scenario.

The wide PEUGIC rate range of about threefold between endoscopy providers means that there remains much room for improvement in the quality of our endoscopy performance, with an unacceptable figure of underperformers.

The study also highlights some features statistically associated with an increased rate of missed cancers, not only clinical features such as younger age, female sex, and more comorbidities, but also endoscopic features such as esophageal ulcer, stricture, Barrett’s esophagus, gastric atrophy, and ulcer. Some of these data still lack clinical explanation but should alert endoscopy providers to red flag variables associated with a higher cancer rate miss. Interestingly, and not surprisingly, endoscopy providers requiring improvement, or not accredited at all, showed a higher rate of missed cancers.

All these facts together are probably promoting the advanced stage at diagnosis of most of these cancers, ending in dismal 5-year survival rates in England of only 17% for esophageal cancer and 21% for gastric cancer, although cancer staging was not available in this study [6].

The findings highlight the major limitation of this type of study, which relies on the quality of the data available in the databases, and this is particularly relevant regarding the usual lack of available data on quality of the UGI endoscopies performed. Specifically for the current study, no data were available regarding the patient’s tolerance, use of sedation, duration of the procedure, adequate visibility, and number of pictures or biopsies, if applicable [5] [7] [8].

In conclusion, the rate of missed UGI cancers, or PEUGIC, remains unacceptably high, and even rising, contrasting to what is happening in colonoscopy, where the focus on quality has been a constant, achieving decreased rates of missed colorectal cancers. This means that we all, as UGI endoscopy providers, need to overcome our underperformance in UGI endoscopy, acknowledge that we can and must do much better, adhere to external quality assurance and accreditation when available, measure our quality performance indicators according to published guidelines, receive frequent feedback, and move away from the current dark side status.

Publication History

Article published online:
16 September 2024

• References

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