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A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus.

ABSTRACT: BACKGROUND:Published guidelines do not address what the minimum incremental diagnostic yield (IDY) for detection of dysplasia/cancer is required over the standard Seattle protocol for an advanced imaging modality (AIM) to be implemented in routine surveillance of Barrett's esophagus (BE) patients. We aimed to report expert practice patterns and attitudes, specifically addressing the minimum IDY in the use of AIMs in BE surveillance. METHODS:An international group of BE experts completed an anonymous electronic survey of domains relevant to surveillance practice patterns and use of AIMs. The evaluated AIMs were conventional chromoendoscopy (CC), virtual chromoendoscopy (VC), volumetric laser endomicroscopy (VLE), confocal laser endomicroscopy (CLE), and wide-area transepithelial sampling (WATS3D). Responses were recorded using five-point balanced Likert items and analyzed as continuous variables. RESULTS:The survey response rate was 84% (61/73)-41 US and 20 non-US. Experts were most comfortable with and routinely use VC and CC, and least comfortable with and rarely use VLE, CLE, and WATS3D. Experts rated data from randomized controlled trials (1.4?±?0.9) and guidelines (2.6?±?1.2) as the two most influential factors for implementing AIMs in clinical practice. The minimum IDY of AIMs over standard biopsies to be considered of clinical benefit was lowest for VC (15%, IQR 10-29%) and highest for VLE (30%, IQR 20-50%). Compared to US experts, non-US experts reported higher use of CC for BE surveillance (p?

SUBMITTER: Machicado JD

PROVIDER: S-EPMC6541486 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus.

Machicado Jorge D JD Han Samuel S Yadlapati Rena H RH Simon Violette C VC Qumseya Bashar J BJ Sultan Shahnaz S Kushnir Vladimir M VM Komanduri Sri S Rastogi Amit A Muthusamy V Raman VR Haidry Rehan R Ragunath Krish K Singh Rajvinder R Hammad Hazem T HT Shaheen Nicholas J NJ Wani Sachin S

Digestive diseases and sciences 20180903 12

<h4>Background</h4>Published guidelines do not address what the minimum incremental diagnostic yield (IDY) for detection of dysplasia/cancer is required over the standard Seattle protocol for an advanced imaging modality (AIM) to be implemented in routine surveillance of Barrett's esophagus (BE) patients. We aimed to report expert practice patterns and attitudes, specifically addressing the minimum IDY in the use of AIMs in BE surveillance.<h4>Methods</h4>An international group of BE experts com ...[more]

PMID: 30178283

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Project description:INTRODUCTION: The American Society for Gastrointestinal Endoscopy (ASGE) has published a Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) statement on incorporating an imaging-guided surveillance protocol to replace the current practice of four-quadrant biopsies every two centimeters for Barrett's esophagus (BE) surveillance. We sought to determine if current gastroenterologists would be willing to apply these changes to their practice and identify any barriers to implementation. METHODS: We collected data using surveys that were distributed at two national meetings and using a random selection process emailed surveys to members listed in the American Gastroenterological Association directory. Physicians from a variety of practice settings participated. Primary outcomes of our study included determining whether clinicians would be willing to accept an imaging-based surveillance protocol, their reasons for not doing so, and whether a financial incentive would be persuade them to implement the protocol. Continuous variables were reported as mean ± standard deviation. Categorical variables were summarized with percentages and 95 % confidence intervals. RESULTS: Gastroenterologists (172) completed the survey; and 140 (81.4 %) of them stated they would implemented the PIVI recommendations into practice. Using a multivariate analysis of the data, physicians who reported a financial incentive for submitting biopsy specimens to pathology were less likely to implement the PIVI recommendations. The two main barriers to implementation of the protocol were medical-legal and financial reasons. Of the 32 gastroenterologists who were not willing to implement the imaging-guided surveillance protocol, 20 (62.5 %) stated that they would implement it if there were a financial incentive. DISCUSSION: The PIVI statement focuses on re-evaluating our current method of surveillance for BE. The results of our survey show that gastroenterologists may be willing to implement an imaging-guided surveillance program, but concerns regarding financial compensation and proper training in advanced imaging techniques remain.

Project description:Background & aimsBarrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Guidelines recommend that patients with nondysplastic BE (NDBE) undergo surveillance endoscopy every 3-5 years. We aimed to identify factors associated with surveillance endoscopy of patients with NDBE and identify trends in appropriate surveillance endoscopy of NDBE at a large tertiary care center.MethodsWe performed a retrospective analysis of data from a Barrett's Esophagus Registry, identifying patients with NDBE who underwent endoscopy in 2002 or later. We identified patients with NDBE and collected data on length of BE segment, esophageal lesions, demographic features, medications, histology findings, comorbidities, development of EAC, and dates of follow-up endoscopies. We defined appropriate surveillance as 3-5 years between 2nd and 3rd endoscopies, over-utilizers as patients who had less than 3 years between their 2nd and 3rd endoscopies, under-utilizers as patients who had more than 5 years between their 2nd and 3rd endoscopies; and never-surveilled as patients who never received a 2nd endoscopy. The primary outcomes were effects of patient factors, year, and referring providers on appropriateness of surveillance intervals.ResultsWe identified 477 patients with NDBE. Only 15.9% had appropriate surveillance; 37.9% were over-utilizers 15.7% were under-utilizers and 30.4% were never surveilled. Patients were less likely to be over-surveilled if their primary care physician referred them for their 3rd endoscopy instead of a gastroenterologist (adjusted odds ratio, 0.51; 95% CI, 0.27-0.95). Male patients or those with an increased number of comorbidities were more likely to be under-surveilled or never-surveilled, whereas patients with long BE segment were more likely to be over-surveilled.ConclusionsIn a retrospective analysis of data from a registry of patients with BE, we found that less than 16% receive appropriate surveillance for NDBE. A primary care provider in the same health system as the endoscopy clinic reduced risk of over-surveillance. This could reflect better coordination of care between specialists and primary care providers.

Project description:Early detection of esophageal neoplasia enables curative endoscopic therapy, but the current diagnostic standard of care has low sensitivity because early neoplasia is often inconspicuous with conventional white-light endoscopy. Here, we hypothesized that spectral endoscopy could enhance contrast for neoplasia in surveillance of patients with Barrett's esophagus. A custom spectral endoscope was deployed in a pilot clinical study of 20 patients to capture 715 in vivo tissue spectra matched with gold standard diagnosis from histopathology. Spectral endoscopy was sensitive to changes in neovascularization during the progression of disease; both non-dysplastic and neoplastic Barrett's esophagus showed higher blood volume relative to healthy squamous tissue (P = 0.001 and 0.02, respectively), and vessel radius appeared larger in neoplasia relative to non-dysplastic Barrett's esophagus (P = 0.06). We further developed a deep learning algorithm capable of classifying spectra of neoplasia versus non-dysplastic Barrett's esophagus with high accuracy (84.8% accuracy, 83.7% sensitivity, 85.5% specificity, 78.3% positive predictive value, and 89.4% negative predictive value). Exploiting the newly acquired library of labeled spectra to model custom color filter sets identified a potential 12-fold enhancement in contrast between neoplasia and non-dysplastic Barrett's esophagus using application-specific color filters compared with standard-of-care white-light imaging (perceptible color difference = 32.4 and 2.7, respectively). This work demonstrates the potential of endoscopic spectral imaging to extract vascular properties in Barrett's esophagus, to classify disease stages using deep learning, and to enable high-contrast endoscopy. SIGNIFICANCE: The results of this pilot first-in-human clinical trial demonstrate the potential of spectral endoscopy to reveal disease-associated vascular changes and to provide high-contrast delineation of neoplasia in the esophagus. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/81/12/3415/F1.large.jpg.

Dataset Information

A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus.

Publications

A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus.

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