Advertisement
Original article Clinical endoscopy: Editorial| Volume 89, ISSUE 6, P1150-1151, June 2019

Download started.

Ok

Routine gastric biopsies: Should we be doing more?

      Abbreviations:

      EBR (endoscopic biopsy rate), GC (gastric cancer), GPC (gastric premalignant condition)
      Although extensive research has been focused on the role of quality metrics in the performance of colonoscopy, relatively less attention has been given to the performance of upper endoscopy. The American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy has published quality indicators for upper endoscopy; however, most measures were process related, and the lack of recognized outcome measures was described.
      • Park W.G.
      • Shaheen N.J.
      • Cohen J.
      • et al.
      Quality indicators for EGD.
      There are currently no metrics for the detection of gastric premalignant conditions (GPCs) or gastric cancers (GCs). This may be particularly relevant because GPCs and even GCs can be subtle and difficult to detect with standard white-light endoscopy.
      In this issue of Gastrointestinal Endoscopy, Januszewicz et al
      • Januszewicz W.
      • Wieszczy P.
      • Bialek A.
      • et al.
      Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation.
      present a fascinating study describing the use of endoscopic biopsy rate (EBR) during ambulatory upper endoscopy as a potential quality metric in the detection of GCs and GPCs. In this multicenter retrospective cohort study incorporating data from nearly 30,000 upper endoscopies and 26 endoscopists over a 13-year period, the rate of EBR was calculated for each endoscopist and was used to associate with rate of detection of GPC (defined as atrophic gastritis, gastric intestinal metaplasia, or gastric dysplasia), the risk for a missed GC (defined as GCs diagnosed after 1 month and within 3 years of an upper endoscopy), and the rate of negative results of analysis of biopsies (defined as gastric biopsies without significant histologic pathologic changes).
      The authors demonstrate a wide variability in rates of EBR between endoscopists, ranging from 22% to 66%. Using this novel metric, the authors demonstrate that rate of EBR is highly associated with the detection of GPCs (which ranged from as low as 1% to as high as 13% of endoscopies). High-EBR endoscopists also missed fewer GCs, inasmuch as 81% of all missed cancers in the cohort were attributed to endoscopists with an EBR below median. The authors report that this improved sensitivity came at the cost of a higher rate of negative biopsy results, which were associated inversely with EBR. These data are novel and timely, and they behoove the broader gastroenterology community to more closely examine the clinical and economic impact of gastric biopsies on the early detection of gastric neoplasia.
      Different interpretations can be made of these data. One view may be that careful, detail-oriented endoscopists see more pathologic changes, perform biopsies more frequently, and therefore achieve a higher rate of diagnosis of GPCs and GCs. In North America and Europe, the Sydney System of targeted “mapping” biopsies from prespecified areas of the stomach (2 sites from the antrum, the incisura angularis, and sites from the body along both lesser and greater curvatures) has been promulgated as a means to increase diagnostic yield and define the extent of atrophy or intestinal metaplasia.
      • Dixon M.F.
      • Genta R.M.
      • Yardley J.H.
      • et al.
      Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994.
      A corollary to the Sydney System has been the development of staging systems for both atrophic gastritis and intestinal metaplasia, which combine both the histologic severity and topographic extent of changes to assess cancer risk.
      In contrast to Western histopathology-oriented systems, East Asian nations with programs of endoscopic surveillance (notably Japan and South Korea) have developed a tradition of careful endoscopic visualization and inspection, beginning with the first description of the line of gastric atrophy by Kimura and Takemoto in 1969.
      • Kimura K.
      • Takemoto T.
      An endoscopic recognition of the atrophic border and its significance in chronic gastritis.
      Even at this nascent stage of endoscopic technology, Kimura and Takemoto showed through the use of Congo red staining that atrophy progressed from antrum to body, and generally along the lesser curvature. Progressive improvement in endoscopic resolution and the development of advanced imaging modalities such as narrow-band imaging have increased the diagnostic yield of endoscopic inspection, with an improved rate of detection of GC at early and curable stages. Even independently of the performance of biopsy, longer examination times seem to improve the detection of upper digestive tract neoplasms. A retrospective analysis of data from 111,962 individuals who underwent upper endoscopy as part of a comprehensive health-screening program in South Korea found that “slow” endoscopists had a higher rate of neoplasm detection compared with faster counterparts; in this study, EBR also correlated positively with neoplasm detection rate.
      • Park J.M.
      • Huo S.M.
      • Lee H.H.
      • et al.
      Longer observation time increases proportion of neoplasms detected by esophagogastroduodenoscopy.
      Thus, a high EBR may lead to improved detection not only through increased histopathologic detection but also because the increased time to perform biopsy may allow the endoscopist further opportunity for careful mucosal inspection.
      The decision to perform a biopsy, the number of biopsies, and the location of biopsies performed on upper endoscopy must take into account cost considerations. As Januszewicz et al
      • Januszewicz W.
      • Wieszczy P.
      • Bialek A.
      • et al.
      Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation.
      show, although high-EBR endoscopists have higher rates of GPC detection and lower rates of GC misses, they also have a higher negative biopsy rate. The prevalence of GPCs and incidence of GC can vary widely between different regions of the world and also between ethnic and racial groups within a given region. Thus, cost effectiveness must also take into consideration differential population-based risks. A recent modeling study suggested that screening upper endoscopy at the time of index colonoscopy, along with continued surveillance if GPC is diagnosed, may be cost effective for non-Hispanic blacks, Hispanics, and Asians within the United States, based on higher rates of GPC and GC in these groups compared with non-Hispanic whites.
      • Saumoy M.
      • Schneider Y.
      • Shen N.
      • et al.
      Cost effectiveness of gastric cancer screening according to race and ethnicity.
      Another way to improve cost effectiveness while continuing to perform biopsies at a high rate may be to aggregate specimens into a single bottle because an experienced GI pathologist should be able to determine the anatomic location of a histologic fragment (from either oxyntic or antral mucosa) based on glandular characteristics.
      Finally, this study highlights the need for better data to guide the management of GPCs discovered on endoscopy, and for a more careful consideration of the role of GC screening in select populations. Despite a decrease in incidence over the past half century, GC remains the third leading cause of cancer-related morbidity worldwide.
      World Health Organization International Agency for Research on Cancer (IARC)
      GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2018.
      Within the United States, GC is diagnosed in 27,000 Americans annually, resulting in almost 11,000 deaths.
      SEER*Explorer: An interactive website for SEER cancer statistics Internet. Surveillance Research Program, National Cancer Institute.
      GPCs represent a unique opportunity to intervene early in the disease process and to improve morbidity and mortality through early GC detection. Although guidelines for the management of GPCs have existed in Europe since 2012,
      • Dinis-Ribeiro M.
      • Areia M.
      • de Vries A.C.
      • et al.
      Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).
      currently there exist no North American surveillance guidelines. As such, screening for GC and surveillance of GPCs remains a highly variable practice around the world.
      We again congratulate Januszewicz et al
      • Januszewicz W.
      • Wieszczy P.
      • Bialek A.
      • et al.
      Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation.
      on their thoughtful and well-conducted study introducing the concept of EBR as a potential quality metric for the detection of GPC and GC during upper endoscopy. This study adds to the sparse literature regarding quality metrics in upper endoscopy, and we can hope that it will serve as a stimulus for increased research on this relatively neglected field.

      Disclosure

      The authors disclosed no financial relationships relevant to this publication.

      References

        • Park W.G.
        • Shaheen N.J.
        • Cohen J.
        • et al.
        Quality indicators for EGD.
        Gastrointest Endosc. 2015; 81: 17-30
        • Januszewicz W.
        • Wieszczy P.
        • Bialek A.
        • et al.
        Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation.
        Gastrointest Endosc. 2019; 89: 1141-1149
        • Dixon M.F.
        • Genta R.M.
        • Yardley J.H.
        • et al.
        Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994.
        Am J Surg Pathol. 1996; 20: 1161-1181
        • Kimura K.
        • Takemoto T.
        An endoscopic recognition of the atrophic border and its significance in chronic gastritis.
        Endoscopy. 1969; 1: 87-97
        • Park J.M.
        • Huo S.M.
        • Lee H.H.
        • et al.
        Longer observation time increases proportion of neoplasms detected by esophagogastroduodenoscopy.
        Gastroenterology. 2017; 153: 460-469 e1
        • Saumoy M.
        • Schneider Y.
        • Shen N.
        • et al.
        Cost effectiveness of gastric cancer screening according to race and ethnicity.
        Gastroenterology. 2018; 155: 648-660
        • World Health Organization International Agency for Research on Cancer (IARC)
        GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2018.
        (Available from:)
        http://gco.iarc.fr/
        Date accessed: January 23, 2019
      1. SEER*Explorer: An interactive website for SEER cancer statistics Internet. Surveillance Research Program, National Cancer Institute.
        (Available at:)
        https://seer.cancer.gov/explorer/
        Date accessed: April 14, 2017
        • Dinis-Ribeiro M.
        • Areia M.
        • de Vries A.C.
        • et al.
        Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).
        Endoscopy. 2012; 44: 74-94

      Linked Article