Dysplasia and OAC detection.

Guideline adherence.

Risk stratification.

Inadequate dysplasia detection, with missed OAC up to 12.7% in UK data. Outcomes for OAC remain poor and rates are increasing in the UK.

Poor adherence to current guidelines and biopsy surveillance protocols.

Service pressures on endoscopy, making BO surveillance challenging to achieve.

Widespread use of invasive surveillance despite low overall risk of dysplasia and OAC.

Dedicated endoscopy lists run by clinicians with an interest in BO or who have specific focused training, for example, BORN module.

Dedicated training for and use of adjuncts to support dysplasia detection in BO, for example, artificial intelligence and acetic acid spray.

Adequate time for endoscopy procedures, for example, scheduling on dedicated BO surveillance lists with adequate unit allocation.

Streamlining BO endoscopy to appropriate high-risk cases, including the use of non-endoscopic sampling, for example, Cytosponge, and risk stratification. May require dedicated team to review cases and counsel patients.

Disease-specific knowledge.

Worry of cancer.

Burden of symptoms.

Burden of surveillance.

Poor understanding of their disease due to incomplete education at diagnosis and during the course of their condition.

Disproportionate cancer worry to disease phenotype both for low-risk and high-risk groups.

Lack of clear follow-up pathways/ways to seek help during symptom flairs, poor symptom control linked with higher cancer worry.

Heavy burden of endoscopy, particularly given the low risk of OAC in most cases.

Dedicated BO clinics run by clinicians with an interest or specific training in BO to address education needs, symptom needs, lifestyle education and to discharge those who are inappropriate for surveillance, for example, low risk or multicomorbid.

Dedicated BO follow-up in cases of need beyond the initial diagnosis period, for example, via a helpline, email service or opt-in clinic/telephone clinic.

BO-specific patient-reported outcome measure to detect patients in need of more education/support.

BO-specific education materials.

Augmentation of endoscopic surveillance with less invasive sampling methods, for example, Cytosponge and risk stratification to reduce endoscopy burden and streamline to high-risk groups; with education and counselling by a dedicated, trained BO workforce.