key: cord-0851697-u9pgqjbg authors: Turkington, Richard C.; Lavery, Anita; Donnelly, David; Cairnduff, Victoria; McManus, Damian T.; Coleman, Helen G. title: The Impact of the COVID-19 Pandemic on Barrett’s Esophagus and Esophago-gastric Cancer date: 2021-01-26 journal: Gastroenterology DOI: 10.1053/j.gastro.2021.01.208 sha: 4152929dcd27493ad8cb289f981630a2c2801e51 doc_id: 851697 cord_uid: u9pgqjbg nan The COVID-19 pandemic has dramatically impacted gastroenterology services worldwide. As coronavirus infection rates rose many professional bodies advised that all endoscopy, except emergency and essential procedures be stopped immediately. 1, 2 Upper gastrointestinal endoscopy was considered a high risk procedure due to a greater potential for aerosolisation and transmission of the SARS-CoV-2 virus. 2 The resulting decline in endoscopic activity has been swift and profound. Markar et al demonstrated that by April 2020 activity was over 90% lower than the previous year in 68% of health trusts in England with an estimated 750 esophago-gastric (EG) cancers undiagnosed. 3 In the US, 98.6% of centers postponed all elective endoscopies for a mean of 5.8 weeks with remaining uncertainty on how to address the backlog. 4 The British Society for Gastroenterology (BSG) guidance on restarting endoscopy in the deceleration and early recovery phase of the pandemic continues to advise against surveillance endoscopy with capacity reserved for urgent procedures. 5 We aimed to describe the impact of the COVID-19 pandemic on the pathological diagnosis of Barrett's esophagus (BE) and EG cancer within population-based databases in Northern Ireland. Figure 1A&C ). There was evidence of recovery in the summer months with diagnoses in the first half of September returning to expected levels. In total, 53 fewer EG cancer cases than expected were diagnosed between March and September 2020. Our study represents the first report to quantify the impact of the COVID-19 pandemic on pathological diagnoses of BE. The BSG advised that all endoscopy, except emergency and essential procedures, be stopped immediately, resulting in the suspension of BE surveillance. 1 Whilst the American Gastroenterology professional societies guidelines commented that surveillance or treatment of premalignant conditions should not be delayed. 6 Worldwide, these guidelines have led to variations in practice but other contributing factors may include local service pressures such as staffing levels and the availability of PPE. Further updated guidance released by the BSG during the deceleration and early recovery phase of the first wave of the pandemic recommended that surveillance of BE remain suspended. 5 This is illustrated by our data which has quantified the slow recovery in BE diagnoses, with rates remaining below their historical baseline. An important strength of our study is its population-based data from Northern Ireland. However, caution is required over the identification of unique patients and data stability due to reporting delays and the use of pathological BE diagnoses detected by SNOMED codes compared to the more accurate curation methods employed by the Northern Ireland Barrett's esophagus register (NIBR). The NIBR is a populationbased registry of all patients diagnosed with columnar-lined esophagus in Northern J o u r n a l P r e -p r o o f Ireland since 1993. 7 The detailed data extraction undertaken by the NIBR was not feasible for the rapid reporting of BE cases. Comparison of the SNOMED coding used here with NIBR data for 2016-2018, indicates that SNOMED coding will detect approximately two thirds of BE cases (VC 2020, personal communication). Therefore, we are likely to be underestimating the absolute number of cases, however it is likely that the proportional decline in BE diagnoses remains the same. Efforts to mitigate the effects of COVID-19 on endoscopy services are ongoing. Recommendations on best practice have been rapidly instituted worldwide to limit SARS-CoV-2 infections in patients and healthcare workers. 2, 5 The introduction of non-endoscopic strategies, such as the use of the Cytosponge device, have also been suggested to triage patients with mild-to-moderate dysphagia. 8 Implementation of these procedures has been challenging and the preservation of endoscopic activity during subsequent waves of the pandemic will require ring-fenced resources to prevent further disruption to diagnostic services. The disruption to BE surveillance may have long term clinical consequences. The risk of progression of non-dysplastic, short segment BE is low and so a six month or more delay may not be a major risk for this patient group. However, for other, higher risk patients the effect of the suspension of BE surveillance programs may be more substantial. 7 Detailed follow up will be required for to assess for changes in dysplasia or cancer incidence in the BE surveillance population in the future. In summary, we have shown the profound impact of COVID-19 on EG cancer and BE with a marked fall in pathological diagnoses in the initial stages of the pandemic. While the diagnosis of EG cancer shows some signs of recovery, BE detection and monitoring continues to lag behind expected rates. It is imperative that endoscopic J o u r n a l P r e -p r o o f services are protected during subsequent waves of the pandemic to preserve the ability to rapidly detect and diagnose cancer and pre-malignant conditions. 1 Electronic pathology reports were received by the NICR, and used to identify all Descriptive statistics (frequencies and proportions over time) are presented for the number of patients diagnosed with BE and EG cancer in Northern Ireland between March and September 2020, respectively. Comparisons were made to the same week range for 2017-2019, for which a three-year average was estimated. British Society of Gastroenterology. Endoscopy activity and COVID-19: BSG and JAG guidance. 2020. 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