Section 1 - Does Firstline Barium Imaging aid Diagnosis in Upper GI Cancer?
107 patients were diagnosed with upper GI cancer in the year 2017 with 8 patients (7.5%) having barium imaging prior to OGD.
7 patients (87.5%) had barium swallows and 1 (12.5%) had a barium meal.
4 patients (50%) were referred due to non-tolerance/refusal of OGD. The clinical information for the remaining patients did not justify why OGD was not preferentially requested.
Only 4 studies (50%) were actively marked with an "Urgent" label.
6 studies were reported as abnormal and 2 were reported as normal, providing a sensitivity of 75% for barium studies in the diagnosis of upper GI cancer.
All 8 patients were subsequently investigated with OGD with an average wait from barium imaging to OGD of 70 days, ranging between 2 days to 240 days.
The 6 patients with abnormal studies underwent OGDs within 6 weeks.
The 2 patients with normal studies underwent OGDs at 160 and 240 days post-barium imaging.
All 8 patients were found to have stage 4 tumours when staged with cross-sectional imaging following their OGDs.
Fig. 3: Length of delay from barium swallow to OGD. Dotted line = Mean delay of 70 days
References: Department of Radiology, University Hospital of Wales, Cardiff 2019
Section 2 - Are Clinicians Correctly Applying Guidelines?
48 barium investigations were performed between September 2018 and February 2019 for suspected upper GI cancer. Only 6/48 (12.5%) gave failed or refused OGD as the clinical indication.
7/48 (14.5%) had already had normal OGDs. Barium imaging was requested to exclude dysmotility or a structural cause of symptoms such as a web or pouch. This represents an inappropriate use of the urgent cancer pathway.
In the remaining 35/48 (72.9%) of urgent cancer imaging requests, there was no documented justification for barium imaging being preferentially requested over OGD: clinicians are continuing to inappropriately request barium imaging.
Fig. 4: Referrals for barium imaging sorted by request details. Green segment = refused OGD (6/48), yellow segment = OGD already performed (7/48), red segment = no justification for preferential choice of barium (35/48)
References: Department of Radiology, University Hospital of Wales, Cardiff 2019
In this dataset, 4/48 (8.3%) patients went on to have OGDs after barium imaging due to equivocal findings or ongoing symptoms. 1 (2.1%) of these patients was found to have cancer after a normal barium swallow: the use of barium imaging was again shown to be suboptimal and delay diagnosis.
Only 2/48 (4.2%) of barium investigations identified a subsequently confirmed cancer.