BSG CSSC Service Development Prize 2023 1st place submission by Dr Danielle Morris

Names of team involved: Dr Danielle Morris  and the early diagnosis and Cytosponge team: Sr Kim Shaw, Anne Alebin, Sr Francoise Cole, Sylwie Machej, Dr James Evans, East and North Herts NHS Trust

Background and recognising the need for change

Pre-pandemic the rising incidence and poor survival for Oesophago-gastric cancers in the UK needed addressing. Despite improved techniques for treating dysplasia and cancer the challenge of early enough diagnosis to impact survival remains elusive due to late presentation and the majority with Barrett’s oesophagus remain undiagnosed.

During the pandemic, timely Barrett’s surveillance and investigation of patients with upper Gastrointestinal symptoms was challenging. The National endoscopy database reported 37% oesophageal and 52% gastric cancer diagnoses missing. Review of our endoscopy data confirmed 25% reduction in serious oesophageal disease, with 21% reduction in upper GI cancer diagnoses and a 31% in strictures and ulceration. Ongoing recovery pressure led to long waiting lists for routine investigation and diagnostic delay.

We recognised the need for change to identify early disease, streamline services, avoid unnecessary gastroscopy, and facilitate quicker access to endoscopy when really needed.

We acknowledged the need to avoid unnecessary Barrett’s surveillance in those with very low risk. We wanted to improve patient experience and move towards greener, sustainable endoscopy and create seamless upper gastrointestinal investigation service.

Time pressures on staff as well as escalating costs indicated need for change to utilise non consultant medical expertise and facilitate appropriate use of resources.

How we addressed the challenges-the new early diagnosis pathway

Seizing the opportunities for change during the early pandemic we established a new consultant-led nurse-run early diagnostic service incorporating Cytosponge triage for patients awaiting Barrett’s surveillance or with acid reflux. Starting November 2020 it was the first trust offering a Cytosponge clinical service for both Barrett’s surveillance and reflux triage in England.

Having contributed to the BEST research for evaluating Cytosponge our nurse was experienced in the technique and trained 3 specialist nurses and 2 research nurses. We have administrative support. The service started with DELTA project, Local CCG and NHSE funding support with plans to be commissioned.

2 upper GI consultant gastroenterologists triage referrals, provide prompt advice and review cytology results. Regular data reviews are undertaken to ensure quality, monitoring rates of success and adequacy of sampling and abnormal results.

All patients receive an letter/email invitation and nurse- led telephone triage to ensure no contraindications. 4 Cytosponge lists occur weekly across 2 hospitals with 6 patients per list . These take place in a treatment room within the endoscopy department, a patient experience survey is completed after.

Cytosponge cytology is processed by Cyted  <4 weeks (usually less) and results relayed either by letter (Barrett’s surveillance ) or by nurse run dyspepsia telephone clinic within 6 weeks (reflux). This is a vital step in the pathway ensuring patient education, optimising medication and identifying patients with ongoing or concerning symptoms needing further investigation.

TFF3 is the biomarker for intestinal metaplasia, p53 and atypia markers for dysplasia. Other findings such as eosinophilia, Candida, inflammation, ulcer slough and squamous atypia are recorded and managed accordingly.

Timely Gastroscopy is arranged  for patients with abnormal cytology or ongoing symptoms and also to facilitate  appropriate discharge from Barrett’s surveillance (if tff3-ve and low risk)

These are performed by endoscopists who are part of the early diagnosis team as they are familiar with the patients and the implications of the results. Nationally produced pathways are now being followed for Barrett’s surveillance intervals based on evolving data.

The service feeds into the upper GI cancer MDT and into our pH manometry service.

What we have established – review of the outcomes from the first 1000 patients

We have the largest single site experience of Cytosponge with >1000 patients accepting Cytosponge. Adequate samples were reported in 91% with no adverse effects. 670 patients avoided unnecessary gastroscopy.

In the Barrett’s cohort we prevented delays in surveillance and have no waiting list.  9% patients had suspected dysplasia with 13 new patients confirming dysplasia going on to treatment as appropriate. We have discharged 11.5% very low risk patients from surveillance.

In the reflux cohort the waiting list for Cytosponge is <4 weeks. 12% had +ve TFF3 of which 5.6% confirmed Barrett’s at endoscopy and 1% had high risk biomarkers: 1 intramucosal cancer and 2 patients with dysplasia have been identified. 1 distal gastric cancer was promptly identified in a routine referral following negative Cytosponge due to persistent symptoms. 72% patients have been discharged to their GP with safety netting advice.

Patient experience survey

Our survey of the first 435 patients reported 94% would have another Cytosponge, 85% preferred Cytosponge, 91% described having only mild discomfort or less.

A sustainable service for the future

Delivering Cytosponge utilises considerably less water and plastic compared with gastroscopy and we estimated 670 gastroscopies were avoided with a subsequent saving of 86855.5l of water and 36.57 kg CO2, a reduction of 68%. In addition avoiding plastic waste of 1005kg representing 3153.2 kg CO2. Manpower and cost of Cytosponge are also considerably less than gastroscopy and aerosol production is minimal.

What we have learnt and how the knowledge has been utilised

Being an early adopter we have learnt how to improve Cytosponge delivery techniques to improve success, and have helped advise other centres nationally.

We have learnt that new ways of working can benefit patients with earlier diagnosis, and facilitate judicious use of endoscopy services.

Our lead Nurse is a National Cytosponge trainer as well as a nurse Endoscopist and prescriber and is enjoying a more holistic clinical role managing patient continuity.

We established a new early diagnosis service and have the largest single site experience of Cytosponge in the UK. As a major contributor to the body of knowledge surrounding the use of Cytosponge in both DELTA study and the NHSE pilot study we have helped train and advise newer secondary care sites, help design national pathways and will be involved in primary care support in the CYTOPRIME study.

Our local GP’s, medical and surgical colleagues have accepted new ways of working and overcome scepticism as evidence accrued
We are expanding  Cytosponge to other conditions such as eosinophilic oesophagitis as part of new research programmes.

Importantly our patients strongly support the service and find Cytosponge highly acceptable.

Outcomes for patients undergoing Barrett’s Surveillance over 2 years

Outcomes for patients with Symptomatic acid reflux over 2 Years