INTRODUCTION: Upper GI cancer in the UK is associated with a poor prognosis. This thesis was
concerned with clarifying the reasons for this, including delays in the diagnosis and the effect of
antisecretory drug therapy (AST).
METHODS: A retrospective cohort study of 685 patients with oesophago-gastric
adenocarcinoma (ACA) diagnosed in South Tees between April 1991-2001 and prospective
studies of gastric ulcer disease and chromoendoscopy
RESULTS: The time course to diagnosis was determined and showed a mean time to diagnosis
of 30 weeks. Patients with oesophageal cancer took longer to present to their GP and longer
to be seen in secondary care once referred. The part of the diagnostic process in primary care
was double that in secondary care.
AST prescribed prior to endoscopy resulted in a delay in diagnosis of 18 weeks (mean) but
this had no effect on long-term outcome.
The Urgent Referral Guidelines for upper GI cancer, known as the "two week rule"
guidelines showing they fail to identify 29% of patients.
27% of patients have an endoscopy within 3 years of diagnosis where the diagnosis of cancer
is not made. Lesions are often seen at the prior endoscopy, and are often ulcerated.
Inadequate biopsying seems responsible, which is influenced by the endoscopist's perception
of whether the lesion is malignant. Only 9.2% of cancers are truly "missed".
Chromoendoscopy identified benign minor abnormalities in 14%: an aggressive biopsy
policy even in patients "at risk" by virtue of age is therefore hard to justify.
CONCLUSION: There are significant delays in the diagnosis of oesophago-gastric ACA.
Treatment with AST delays diagnosis but without affecting outcome. Current endoscopic
practice could be improved to reduce the missed cancer rate through the use of a rigorous
biopsy protocol especially for ulcerated lesions. As symptoms are used to determine who is
endoscoped and are a poor predictor of pathology alternative means of determining "high
risk" need to be developed.