Organisational factors and Post Endoscopy Upper Gastrointestinal Cancer (PEUGIC): results of the English national PEUGIC project

Aims Post endoscopy upper gastrointestinal cancers (PEUGIC) are often missed opportunities to diagnose earlier or even prevent cancer. A national process for identifying all PEUGIC in the English National Health Service and performing root cause analysis was developed. In parallel, a survey of diagnostic and surveillance upper gastrointestinal endoscopy practices was undertaken to investigate organisational factors which may contribute to variations in endoscopy quality and PEUGIC.

Methods PEUGIC occurring 3-36 months after an index endoscopy without a cancer diagnosis between 2017 and 2023 were identified from National Cancer Registration and Hospital Episode Statistics Datasets. Data from local root cause analysis were uploaded onto a secure portal for national analysis. Endoscopy providers taking part in the project were asked to complete an online organisational survey, covering diagnostic and surveillance endoscopic practices, equipment, the management of dysplasia and early cancer.

Results 3151 PEUGIC were examined by local reviewers in 144 hospitals in England. 635 were excluded. Data were available for 2516 PEUGIC. 1897 PEUGIC (75.4%) were following diagnostic endoscopy and 618 (24.6%) were undergoing surveillance. 80% of hospitals responded to the organisational survey. Hospitals with no guidelines for diagnostic endoscopy were associated with PEUGIC resulting in harm OR 1.50 (95% CI 1.23-1.84). For diagnostic PEUGIC, less than 20 minutes allocated to endoscopy were associated with no abnormalities detected in the PEUGIC segment OR 1.25 (95% CI 1.04-1.50). Oesophageal squamous cell PEUGIC were also associated with less time allocated per endoscopy OR 1.28 (95% CI 1.03-1.59) [1]. For surveillance PEUGIC, organisational factors associated with increased detection of stage 1 (success of surveillance) PEUGIC compared with stage 2 or greater were: dedicated surveillance sessions OR 2.08 (95% CI 1.46-2.98),>20 minutes for endoscopy OR 2.05 (95% CI 1.48-2.84), surveillance in an endoscopic resection centre OR 3.50 (95% CI 1.99-6.13) and guidelines for surveillance endoscopy OR 1.86 (95% CI 1.35-2.55). Booking delays and errors were noted in 12% of PEUGIC, patient factors were noted in 11% and poor clinical decision making in 11.7% (inappropriate or not acted upon decision 7.5% and histology not actioned in 4.2%). Surveillance was delayed in 27% of PEUGIC and this was associated with adverse treatment outcomes OR 1.79 (95% CI 1.72-2.73).

Conclusions A survey of endoscopy providers’ organisational structure has revealed a number of factors which contribute to PEUGIC not captured during individual root cause analysis. Hospitals that have local endoscopy guidelines perform better than those without. Surveillance outcomes are better in patients that have their endoscopies in dedicated surveillance sessions, with more time allocated and undertaken in endoscopic resection centres. However, surveillance delays are common and associated with worse outcomes

Publication History

Article published online:
27 March 2025

• References

• 1 Kamran U, King D, Abbasi A, Coupland B, Umar N, Chapman WC, Hebbar S, Trudgill NJ.. A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer. Endoscopy 2023; 55 (02): 109-118 Epub 2022 Aug 31. PMID: 36044914