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Dysphagia in people with advanced oesophageal cancer can be treated by oesophageal stents, external beam radiotherapy (EBRT) and intraluminal brachytherapy. Despite guidelines recommending brachytherapy for patients with a predicted life expectancy exceeding 3 months, its uptake in the UK has been limited. Here we examine the strength of the evidence supporting the use of brachytherapy compared with oesophageal stents and EBRT and possible reasons for its limited uptake. Trials and observational studies suggest brachytherapy alone confers a benefit to patients, but its impact is less immediate than oesophageal stents; the evidence on effectiveness and value-for-money is limited. Moreover, stronger evidence will probably be insufficient to increase uptake, due to the extra complexity of delivery compared with stents and EBRT and a lack of experience among specialists. [ABSTRACT FROM AUTHOR]

Background: For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.Methods/design: This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.Discussion: We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.Trial Registration: ISRCTN Registry, ISRCTN12595588 . [ABSTRACT FROM AUTHOR]

Abstract: Background: Mortality after oesophagectomy is lower in high-volume than in low-volume surgical units. Case series from cardiothoracic surgeons report lower mortality rates than those from general surgeons. We therefore used a national data set to investigate the effects of surgical specialty and volume on mortality after oesophagectomy. Methods: We analysed Hospital Episode Statistics for oesophagectomy for cancer (n =9034 cases), linked to data from death certificates, in England from 1998 to 2003. Results: After adjustment for patients'' age, sex and deprivation score, the odds ratio (OR) for death of general surgeons'' (GS) patients, compared with cardiothoracic surgeons'' (CTS) patients, was significantly high: 1.62 [95% CI 1.34–1.96] at 30 days and 1.38 [1.18–1.61] at 90 days. The odds ratio for high-volume GS patients was not significantly different from that for high-volume CTS patients. However, the odds ratio for low-volume GS patients compared with high-volume CTS patients was significantly high: 1.72 (1.40–2.11) at 30 days and 1.48 (1.26–1.74) at 90 days. Conclusion: Patients treated by general surgeons in low-volume hospitals had worse mortality outcomes than those treated by general surgeons in high-volume hospitals or by cardiothoracic surgeons. This is important because a majority of patients who underwent oesophagectomy for cancer were in this high-mortality risk group. [Copyright &y& Elsevier]

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40 units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken. [ABSTRACT FROM AUTHOR]

Background: Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited., Methods: Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality., Results: There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years., Conclusion: The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Excessive lower oesophageal sphincter relaxation increases gastro-oesophageal acid reflux, an oesophageal adenocarcinoma risk factor. Medications that relax this sphincter (benzodiazepines, calcium channel blockers, nitrates, β2 agonists and xanthines) could promote cancer. These medications were investigated in two independent datasets. In the Scottish Primary Care Clinical Informatics Unit (PCCIU) database, a nested case-control study of oesophageal cancer was performed using GP prescription records. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CIs) for medication use and oesophageal cancer. In UK Biobank, a cohort study was conducted using self-reported medication use. Cox regression was used to calculate hazard ratios (HRs) and 95% CIs for medication use and oesophageal cancer, and by tumour subtype. Overall, 1,979 oesophageal cancer patients were matched to 9,543 controls in PCCIU, and 355 of 475,768 participants developed oesophageal cancer in UK Biobank. None of the medications investigated were significantly associated with oesophageal cancer risk apart from β2 agonists, which were associated with increased oesophageal cancer risk in PCCIU (adjusted OR 1.38, 95% CI 1.12, 1.70) but not in UK Biobank (adjusted HR 1.21, 95% CI 0.70, 2.08). Medications that relax the lower oesophageal sphincter were not associated with oesophageal cancer, apart from β2 agonists. This increased cancer risk in β2 agonist users merits further investigation., (© 2018 UICC.)

Objective: This study assessed the associations between hospital volume, resection rate and survival of oesophageal and gastric cancer patients in England., Design: 62,811 patients diagnosed with oesophageal or gastric cancer between 2004 and 2008 were identified from a national population-based cancer registration and Hospital Episode Statistics-linked dataset. Cox regression analyses were used to assess all-cause mortality according to hospital volume and resection rate, adjusting for case-mix variables (sex, age, socioeconomic deprivation, comorbidity and type of cancer). HRs and 95% CIs, according to hospital volume, were evaluated for three predefined periods following surgery: <30, 30-365, and >365 days. Analysis of mortality in relation to resection rate was performed among all patients and among the 13 189 (21%) resected patients., Results: Increasing hospital volume was associated with lower mortality (p trend=0.0001; HR 0.87, 95% CI 0.79 to 0.95 for hospitals resecting 80+ and compared with <20 patients a year). In relative terms, the association between increasing hospital volume and lower mortality was particularly strong in the first 30 days following surgery (p trend<0.0001; HR 0.52, (0.39 to 0.70)), but a clinically relevant association remained beyond 1 year (p trend=0.0011; HR 0.82, (0.72 to 0.95)). Increasing resection rates were associated with lower mortality among all patients (p trend<0.0001; HR 0.86, (0.84 to 0.89) for the highest, compared with the lowest resection quintile)., Conclusions: With evidence of lower short-term and longer-term mortality for patients resected in high-volume hospitals, this study supports further centralisation of oesophageal and gastric cancer surgical services in England.