Over 9,000 patients are diagnosed with oesophageal cancer in the United Kingdom (UK)
annually. The prognosis of these patients is poor, with an overall 5-year survival rate
of 15%.
Most patients (60%) present with advanced disease and palliation is the only treatment
option. Accordingly, oesophageal cancer has considerable unmet research need.
The VALUE trial is a prospective observational study investigating EUS in the modern era
of oesophageal cancer staging. A quantitative study component will examine how often and
why EUS changes treatment decisions after initial staging with CT and PET-CT. A
qualitative study component will explore both clinician and patient attitudes and
opinions towards the utility of EUS in the staging pathway.
EUS is an invasive procedure combining upper gastrointestinal endoscopy with
ultrasonography. An ultrasound probe located at the end of the endoscope allows direct
visualisation of the oesophageal wall layers and adjacent tissues providing local
assessment of the depth of tumour invasion and lymph nodes. This assessment informs local
tumour (T-) and node (N-) staging which are important prognostic indicators of survival.
Patients undergoing EUS require sedation and there are risks of complication. EUS is a
specialist investigation requiring many years of dedicated training to perform
competently.
VALUE aims to recruit patients with oesophageal cancer who are deemed to have potentially
curable disease and who are fit for, and wish to have, radical treatment, and who receive
EUS as part of their standard of care staging pathway. Patients with a range of disease
status (T1-T4; N0-N3) will be considered for recruitment to allow diverse consideration
of the reasons whether EUS impacts treatment decisions in current clinical practice.
VALUE will also recruit clinicians who regularly care for oesophageal cancer patients in
a multi-disciplinary setting to gather their opinions regarding the use of EUS in this
patient population.
A systematic review, updating a prior review, found that current evidence concerning the
impact of EUS on the management and outcome of oesophageal cancer patients in modern
staging with PET-CT was of limited quality. In total, 18 studies with 11,836 patients
were included. Overall, 2,805 patients (23.7%) underwent EUS compared to 9,031 (76.3%)
without. However, only 19.7% of all patients also had PET-CT for staging. Reported change
of management by EUS varied widely from 0% to 56%.
EUS use in oesophageal cancer patients across the NHS is also reported to vary widely.
Considerable variation in EUS practice was found in a survey of oesophageal cancer
multi-disciplinary team (MDT) leads across the UK. Eighty-seven of 97 UK NHS trusts
responded. 29% recommended EUS for all potentially curable patients whereas 46% requested
EUS after PET-CT on a case-by-case basis. 20% reported both a lack of utility and
concerns about treatment delay. Overall, 63% and 43% routinely use EUS for radiotherapy
and surgical planning, respectively. Further, data from the National Oesophago-Gastric
Cancer Audit (NOGCA) all describe the reported decline in EUS use from 62% of all
patients in 2013, to 39% in 2019, and 18.6% to 2021. In 2020/21, EUS was used in 23.6% of
patients who had a curative treatment plan.
The Cancer of Oesophagus or Gastricus-New Assessment of Technology of Endosonography
(COGNATE) trial randomised patients between EUS with CT, and CT alone. EUS led to
improved quality-adjusted survival. However, since COGNATE, oesophageal cancer staging
has been transformed by PET-CT, a cross-sectional nuclear imaging test usually performed
prior to EUS. PET-CT has greater sensitivity for distant metastases than CT, and
therefore identifies more patients unsuitable for radical treatment, meaning that local
staging with EUS becomes less critical in these patients.
This conclusion is supported by data from a large retrospective cohort study by Findlay
et al which included 953 patients, of which 798 had EUS, and 918 had PET-CT. The authors
found that patient management was changed by EUS in 11% of cases, but when probability
thresholds were calculated, the utility of EUS in the majority of patients (71.8% staged
T2-T4a) was minimal (0.4%), concluding that the risk of EUS exceeded its benefit.
However, these data have not been validated outside of this single-centre study but does
question the value of EUS in the modern staging pathway.
In summary, the use of PET-CT for oesophageal cancer staging is increasing, and use of
EUS declining, which supports the modern tendency of clinicians to favour non-invasive
cross-sectional imaging. However, evidence supporting the basis for this recent change in
practice is limited.
There will also be a qualitative part of the trial where a qualitative researcher will
interview 30 patients who consent to this in the patient information sheet and 30
clinicians who can carry out EUS, and ask both for their opinions and thoughts on the
procedure.