Point-of-care testing for atrophic gastritis can help relieve the pressure on endoscopy services
Point-of-care testing for atrophic gastritis can help relieve the pressure on endoscopy services
Patients with atrophic gastritis due to Helicobacter pylori (H. pylori) infection or autoimmune disease are known to have an increased risk of gastric adenocarcinoma, the 16th most common cancer in the UK and a frequent cause of death globally.1 British Society of Gastroenterology (BSG) guidelines1 state that non-invasive identification of high-risk patients prior to endoscopy is key for the early detection and diagnosis of cancer, and to improve cancer survival rates. Point-of-care testing (POCT) for atrophic gastritis with the GastroPanel® Quick Test NT is an effective triage tool that can be used both within and outside of secondary care settings, aligning with the current UK government’s drive to move healthcare away from hospitals2 and towards community and primary care environments. We asked our Market Access and Development Manager, Angela Gore, for her thoughts on the current diagnostic pathway, and how she envisages non-invasive POCT helping to reduce the strain on endoscopy services and allow high-risk individuals to be tested sooner.
What do you see as the main challenges in the current diagnostic pathway for gastric adenocarcinoma?
The current diagnostic pathway is endoscopy, a resource-heavy procedure that carries risks for the patient and has a low diagnostic yield,3 even for individuals referred via the suspected cancer two-week-wait pathway. For non-urgent referrals, patients might wait up to a year for the procedure, which obviously delays diagnosis, and spotting an abnormality among the 90+ per cent endoscopies that are negative3 can be challenging.
Which patients get referred for endoscopy?
Endoscopy referrals are categorised as either urgent or non-urgent, dictated by the prevailing symptoms. Patients perceived to have the greatest need – for example, individuals with alarm symptoms such as weight loss, bleeding, anaemia, upper abdominal mass or persistent vomiting – are classified as urgent. Non urgent cases are mostly those with no alarm symptoms, who have visited their GP two or three times without finding a resolution to their problem, and there is obviously some consideration of family and individual medical history too. Typically, GPs err on the side of caution, and refer the patient to gastroenterology after a couple of unsuccessful treatments.
Could testing for atrophic gastritis outside of secondary care help to direct endoscopy referrals?
The BSG guidelines1 recognise the benefits and need of triage by identifying patients at greatest risk of gastric adenocarcinoma before endoscopy, stressing that those individuals with chronic atrophic gastritis should undergo surveillance endoscopy every three years. This is a very strong message, but it falls short because there is currently no option for identifying such patients in today’s pathway. The GastroPanel Quick Test is a straightforward, 15-minute fingerprick test that could bridge this gap in primary care or hospital outpatient clinics. All you need is a lancet and a GastroPanel Reader; a device that is small enough to be used wherever it is needed. Patients who repeatedly present at the GP surgery with unresolved stomach problems, but no red flags for a suspected cancer diagnosis, could be screened in primary care for atrophic gastritis. With instant results, anyone testing positive could potentially be fast-tracked for endoscopy, while patients testing negative could be monitored in case the situation changed.
How can screening for atrophic gastritis guide endoscopic investigations?
We know that atrophic gastritis increases the risk of gastric adenocarcinoma, but endoscopists currently have no prior indication of whether a patient is positive or negative. Pre-screening patients attending for endoscopy with the GastroPanel Quick Test would therefore help to guide investigations. If the test was positive, then the endoscopist would know that the patient is at higher risk of cancer, and that enhanced imaging and biopsies were necessary. On the other hand, a patient with a negative test might be able to avoid having an endoscopy, instead discussing alternative options with the consultant. With around 90 per cent of upper endoscopies proving negative,3 this could significantly reduce waiting lists and allow resources to be directed to high-risk patients, potentially saving the NHS as much as £81 million a year.*
What are the barriers to adoption?
One of the challenges in the UK has been a lack of published data supporting a recommendation that changes the current pathway to become better aligned with clinical needs and demand. Fortunately, a recent publication in BMJ Open Gastroenterology4 – reporting the results of a clinical study at Homerton University Hospital – is helping to address this. The other major stumbling block is funding, despite the immense potential cost and efficiency savings for the NHS. If a patient is referred for endoscopy from primary care, the cost is funded by the service provider. If the GP surgery uses POCT to triage referrals, the practice is responsible for the costs incurred, including providing staff to perform the test. It’s important to increase awareness of the benefits of pre-screening at the commissioning care network level, looking at the holistic savings to the NHS rather than individual budgets. The advantages for patient care are clear, and this approach would fit well with the government’s aim of putting the emphasis on community and primary care, keeping people away from hospitals whenever possible.
What is the current situation?
The feedback we have received has been very positive, with growing interest in using the GastroPanel Quick Test not only as an aid to direct referrals and guide biopsies, but also as a potential alternative to endoscopy for monitoring patients on a surveillance pathway. The benefits for primary care, secondary care and patients are obvious, but funding remains an obstacle; all interested parties – commissioning groups, the BSG and GPs – need to be on board. It’s a clear win-win situation, offering a faster route to cancer diagnosis while simultaneously saving costs and resources, but changing an established care pathway is challenging and takes time.
What’s next on the agenda?
One of the main objectives is the completion of pilot studies in referral settings, to generate more evidence supporting the use of GastroPanel Quick Test in these environments. Some of the ongoing studies are linked with local health innovation networks and cancer alliances, who I hope will be able to share positive data at a higher level nationally. Ideally, we’d like sufficient data to be generated to present it to the National Institute for Health and Care Excellence (NICE), with the aim of establishing guidelines for the use of the GastroPanel Quick Test as part of the gastric adenocarcinoma care pathway. With key opinion leaders coming on board – for example, BSG, the Primary Care Society for Gastroenterology, and via Health Innovation Networks – supplemented by evidence from clinical studies, the future is looking very bright.
*Calculated based on 2021 UK population figures (68 million) and an estimated 3,000 oesophagogastroduodenoscopy (OGDS) investigations per 250,000 population annually,5 conservatively estimating that 25 per cent of the 800,000 diagnostic OGDS procedures performed will be for the stomach. Assumes best practice tariff cost of £486.00 per diagnostic endoscopic upper gastrointestinal tract procedure with biopsy, 19 years and over, (endoscopy 2024/25 pay award prices, NHS England https://www.england.nhs.uk/wp-content/uploads/2023/03/23-25-NHSPS-24-25-prices-workbook-pay-award.xlsx6), and per GastroPanel test at a cost of £35.00. Saving represents a 90 % switch from endoscopy to GastroPanel.
References
- Banks M, Graham D, Jansen M, et al. 2019. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut 2019;68(9):1545-1575. https://doi.org/10.1136/gutjnl-2018-318126.
- Woodhead K. Moving healthcare away from hospitals. Clinical Services Journal. October 2024;15-17.
- Beaton DR, Sharp L, Lu L, et al. Diagnostic yield from symptomatic gastroscopy in the UK: British Society of Gastroenterology analysis using data from the National Endoscopy Database. Gut 2024;73:1421-1430. https://doi.org/10.1136/gutjnl-2024-332071.
- Beg S, Ragunath K, Wyman A, et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS). Gut 2017:66(11);1886-1899. https://doi.org/10.1136/gutjnl-2017-314109
- NHS England. 2023/25 NHS Payment Scheme: 2024/25 prices workbook. https://www.england.nhs.uk/wp-content/uploads/2023/03/23-25-NHSPS-24-25-prices-workbook-pay-award.xlsx
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