Improving endoscopy efficiency with risk stratification for oesophageal cancer

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Barrett’s oesophagus is estimated to affect 1.6-3 per cent of the global adult population.^1,2 In the UK, this could equate to 1.08-2.02 million people, yet only 115,000 have been diagnosed. As a result, a significant proportion of the population may be living with the condition unknowingly, despite hundreds of thousands of diagnostic upper GI endoscopies being performed across the NHS every year. For those diagnosed, surveillance is lifelong; endoscopies are repeated regularly and, even after successful treatment, continual monitoring is essential due to the risk of recurrence or progression to neoplasia.²

However, endoscopy services are already at capacity; referrals are at an all-time high and waiting lists continue to grow. Endoscopy remains the gold standard for monitoring Barrett’s patients³ but, in a system under pressure, it is crucial to ensure that services are used as effectively and efficiently as possible. Services are all too frequently turning to insourcing to keep up with demands, but this seemingly temporary fix is in danger of becoming permanent practice for already cash-strapped departments. Instead, the focus should be on creating more sustainable change by improving the efficiency of endoscopy services. 

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Challenges in the current endoscopy referral pathway

Delivering endoscopy at scale has several well-recognised challenges. It is invasive and, while generally safe, it can be uncomfortable for patients and often requires sedation, introducing additional risks, recovery time and resource requirements. It requires specialist equipment, highly trained staff, clinical space and post-procedure recovery capacity. Increasing demand means endoscopists are often working within tight procedural windows while still striving to maintain high diagnostic standards. This creates an inherent tension between efficiency and thoroughness.

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The efficacy of endoscopy under pressure

There is also growing interest in how effective current Barrett’s surveillance strategies using endoscopy are for assessing the risk of oesophageal cancer. The recently published BOSS (Barrett’s Oesophagus Surveillance Study) compared regular surveillance endoscopy with an on-demand approach in patients with non-dysplastic Barrett’s oesophagus.⁵ The authors concluded that surveillance did not improve overall survival or cancer-specific survival.⁵ This suggests that current surveillance approaches may be over monitoring too many low risk patients, while some high risk cases are not identified early enough.⁵ 

There are several ways to interpret these findings. The limited benefit may be the result of the relatively low progression to cancer rate (0.3 percent per year),⁶ meaning that most patients under surveillance will not develop cancer. It might also highlight variability in surveillance quality and patient selection, suggesting that current approaches are not optimally targeted. It is therefore important to consider whether surveillance is targeting the right patients, at the right time, with the right level of scrutiny, reinforcing the need to refine current endoscopy pathways.

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Reducing inappropriate endoscopy referrals

In contrast, a risk-based approach that selects which patients really need endoscopy would enhance surveillance programmes, ensuring that higher risk cases are managed in specialist settings. Endoscopists can then focus their time and resources on the patients who need it the most, reducing the number of low yield endoscopies.

This front-line risk stratification phase could be addressed using the EndoSign^® capsule sponge, which could help to determine the patients who would be most likely to benefit from a full diagnostic endoscopy. EndoSign is a small capsule containing a compressed sponge attached to a thin thread. The patient swallows the capsule, which dissolves in the stomach after a few minutes. The sponge is then gently withdrawn, pulled by the thread, collecting cells from the entire lining of the oesophagus as it passes upward. This sampling spans the full length of the oesophagus, which reduces the risk of missing focal or patchy disease. The collected cells are then analysed for biomarkers associated with Barrett’s oesophagus and dysplasia.

Risk stratification with a non-invasive solution such as EndoSign could help address the imbalance highlighted in the BOSS study,⁵ by enabling clinicians to characterise patients into low, moderate and high risk groups.⁷ High risk patients can then be fast-tracked to expert-led endoscopy in specialist centres. In NHS Scotland, this approach identified that 23 per cent of patients were at higher risk and therefore most in need of endoscopy, suggesting a potential 77 per cent reduction in endoscopies within this patient group.⁸ In doing so, capsule sponge testing effectively reduces pressure on services by directing endoscopy resources towards those most likely to benefit.

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Supporting NHS endoscopy teams

EndoSign capsule sponge technology offers a way to improve patient prioritisation and protect endoscopy capacity for complex and high risk cases. Ultimately, the goal is not to change the role of endoscopy, but to ensure it is used as effectively as possible. Combining clinical expertise with smarter risk stratification approaches make it possible to deliver more efficient, more targeted, and ultimately more impactful care for patients at risk of oesophageal cancer.

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Contact us to find out more about how EndoSign can fit into your endoscopy service.

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References

1. Ronkainen J, Aro P, Storskrubb T, et al. (2005). Prevalence of Barrett's esophagus in the general population: an endoscopic study. Gastroenterology. 129(6):1825-31.
2. Gilbert EW, Luna RA, Harrison VL, et al. (2011) Barrett's esophagus: a review of the literature. J Gastrointest Surg. 2011;15(5):708-18.
3. NICE. (2023). Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management. Available at: Available at: https://www.nice.org.uk/guidance/ng231/chapter/Recommendations#endoscopic-surveillance. Accessed 19^th of March 2026.
4. Kamran U, Evison F, Morris E J A, et al. (2025). The variation in post-endoscopy upper gastrointestinal cancer rates among endoscopy providers in England and associated factors: a population-based study. Endoscopy. 57(1):17-28. doi:10.1055/a-2378-1464
5. Old O, Jankowski J, Attwood S, et al. (2025) Barrett's Oesophagus Surveillance Versus Endoscopy at Need Study (BOSS): A Randomized Controlled Trial. Gastroenterology. 169(6):1233-1243.e8. doi:10.1053/j.gastro.2025.03.021
6. Desai TK, Krishnan K, Samala N, et al. (2012) The incidence of oesophageal adenocarcinoma in non-dysplastic Barrett's oesophagus: a meta-analysis. Gut 61:970-976.
7. Tan WK, Ross-Innes CS, Somerset T, et al. (2025) Biomarker risk stratification with capsule sponge in the surveillance of Barrett's oesophagus: prospective evaluation of UK real-world implementation. Lancet. 406(10500):271-282. doi:10.1016/S0140-6736(25)01021-9
8. Scottish Health Technologies Group Assessment. (2023) Capsule sponge technologies for the detection of Barrett’s oesophagus and early stage oesophageal cancer. Available at: https://shtg.scot/media/2410/20231002-capsule-sponge-assessment-v10.pdf. Accessed 16^th of March 2026.

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