Aims
- Determine the burden of post-endoscopy upper gastrointestinal cancer (PEUGIC) across all Welsh Health Boards
- Identify modifiable endoscopic and system-related factors contributing to diagnostic delay.
Methods
A retrospective multicenter review was conducted across six Health Boards in Wales (Complete data available for 5 at the time of writing), including all patients diagnosed with upper GI cancer between August 2021 and July 2024. PEUGIC cases were identified using cancer-tracking systems, MDT records and endoscopy databases. Patient demographics (age, sex); tumour characteristics (site, stage) and endoscopy quality indicators (quality of inspection, mucosal visibility and image quality and record [1]) were recorded using a standardised proforma. For each identified PEUGIC case, root-cause analysis (RCA) was undertaken across four domains: endoscopist, lesion, system and patient factors. These characterised avoidable factors, considering known associations with PEUGIC described previously, e.g. young age, co-morbidity, known Barrett’s oesophagus (BO) or oesophagal stricture (OS), gastric ulceration or Unit accreditation status [2]. A panel categorised PEUGIC cases into five types. Overall and individual Health Board PEUGIC rates were calculated. Rates of identified contributory factors and PEUGIC type were compared across Health Boards.
Results
Across Wales, 1350 upper GI cancers were diagnosed, of which 82 fulfilled PEUGIC criteria (6.1%). Rates varied between Health Boards from 3.5% to 6.3%. The 82 patients had a mean age of 73 ± 13.8 years, with a gender distribution of 62.2% male and 37.8% female. Tumour sites were distributed as follows: oesophagus 51.2%, GOJ 22.0%,stomach 23.2%, and duodenum 3.7%. Staging showed predominantly advanced disease (T3/T4 = 62%), frequent nodal involvement (N+ = 40%), and metastasis in 15%. Most patients received palliative treatment (62%), with 38% managed with curative intent. Only 14% underwent endoscopic resection
Low-quality endoscopic examinations were associated with higher institutional PEUGIC rates, 7% evidence of mucosal cleaning, and 13% of documented blue light imaging. In over 60% of PEUGIC cases, no recorded images were available, and even in cases where images were recorded, BSG Standards on the image record were rarely met.
In 73/82 (89%) cases, avoidable factors were identified. Inadequate lesion assessment accounted for 81.3% of all potentially avoidable cases (Table).
|
Group |
Descriptor |
Number of cases (%) |
|---|---|---|
|
A |
Focal cancer-associated or pre-malignant lesion with adequate assessment & decision-making |
7 (8.8%) |
|
B |
Focal cancer-associated or pre-malignant lesion with inadequate assessment and/or decision-making |
65 (81.3%) |
|
C |
Possible missed lesion; endoscopy & decision-making adequate |
2 (2.5%) |
|
D |
Possible missed lesion; endoscopy & decision-making inadequate |
6 (7.5%) |
|
E |
System-level contributory factors (delays, booking, triage, pathway failures) |
2 (2.4%) |
Conclusions
PEUGIC rates in Wales are 6.1%, consistent with reported rates in other UK series. In most cases, avoidable factors have been identified. Mucosal cleaning and inspection, digital enhancement and photo-documentation represent modifiable targets. These findings have informed an all-Wales PEUGIC quality-improvement bundle including mandatory image-capture sets, mucosal-inspection checklists and focused training in subtle-lesion recognition. This model offers a transferable framework for enhancing diagnostic safety and reducing post-endoscopy cancer rates across European endoscopy services.