Savtaj S Brar1, Alyson L Mahar2, Lucy K Helyer3, Carol Swallow1, Calvin Law1, Lawrence Paszat4, Rajini Seevaratnam5, Roberta Cardoso5, Robin McLeod1, Matthew Dixon6, Lavanya Yohanathan7, Laercio G Lourenco8, Alina Bocicariu5, Tanios Bekaii-Saab9, Ian Chau10, Neal Church11, Daniel Coit12, Christopher H Crane13, Craig Earle14, Paul Mansfield15, Norman Marcon16, Thomas Miner7, Sung Hoon Noh17, Geoff Porter3, Mitchell C Posner18, Vivek Prachand18, Takeshi Sano19, Cornelis van de Velde20, Sandra Wong21, Natalie G Coburn22. 1. Department of Surgery, University of Toronto, Toronto, Ontario, Canada. 2. Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada3Sunnybrook Research Institute, Toronto, Ontario, Canada. 3. Department of Surgery, Dalhousie University, Halifax, Canada. 4. Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada. 5. Sunnybrook Research Institute, Toronto, Ontario, Canada. 6. Department of Surgery, Maimonides Medical Center, Brooklyn, New York. 7. Department of Surgery, Brown University, Providence, Rhode Island. 8. Department of Gastroenterology Surgery, São Paulo Federal University, São Paulo, Brazil. 9. Departments of Medicine and Pharmacology, Ohio State University, Columbus. 10. Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom. 11. Department of Surgery, University of Calgary, Calgary, Alberta, Canada. 12. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York. 13. Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas. 14. Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada14Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 15. Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas. 16. Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 17. Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea. 18. Department of Surgery, University of Chicago, Chicago, Illinois. 19. Department of Surgery, Cancer Institute Hospital, Tokyo, Japan. 20. Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands. 21. Department of Surgery, University of Michigan Health System, Ann Arbor. 22. Department of Surgery, University of Toronto, Toronto, Ontario, Canada3Sunnybrook Research Institute, Toronto, Ontario, Canada5Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada.
Abstract
IMPORTANCE: There is growing interest in reducing the variations and deficiencies in the multidisciplinary management of gastric cancer. OBJECTIVE: To define optimal treatment strategies for gastric adenocarcinoma (GC). DESIGN, SETTING, AND PARTICIPANTS: RAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries. INTERVENTIONS: Gastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care. MAIN OUTCOMES AND MEASURES: Panelists scored 416 scenarios regarding treatment scenarios for appropriateness from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Agreement was reached when 12 of 16 panelists scored the scenario similarly. Appropriate scenarios agreed on were subsequently scored for necessity. RESULTS: For patients with T1N0 disease, surgery alone was considered appropriate, while there was no agreement over surgery alone for patients T2N0 disease. Perioperative chemotherapy was appropriate for patients who had T1-2N2-3 or T3-4 GC without major symptoms. Adjuvant chemoradiotherapy was classified as appropriate for T1-2N1-3 or T3-4 proximal GC and necessary for T1-2N2-3 or T3-4 distal GC. There was no agreement regarding surveillance imaging and endoscopy following gastrectomy. Surveillance endoscopy was deemed to be appropriate after endoscopic resection. For patients with metastatic GC, surgical resection was considered inappropriate for those with no major symptoms, unless the disease was limited to positive cytology alone, in which case there was disagreement. CONCLUSIONS AND RELEVANCE: Patients with GC being treated with curative intent should be considered for multimodal treatment. For patients with incurable disease, surgical interventions should be considered only for the management of major bleeding or obstruction.
IMPORTANCE: There is growing interest in reducing the variations and deficiencies in the multidisciplinary management of gastric cancer. OBJECTIVE: To define optimal treatment strategies for gastric adenocarcinoma (GC). DESIGN, SETTING, AND PARTICIPANTS: RAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries. INTERVENTIONS: Gastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care. MAIN OUTCOMES AND MEASURES: Panelists scored 416 scenarios regarding treatment scenarios for appropriateness from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Agreement was reached when 12 of 16 panelists scored the scenario similarly. Appropriate scenarios agreed on were subsequently scored for necessity. RESULTS: For patients with T1N0 disease, surgery alone was considered appropriate, while there was no agreement over surgery alone for patients T2N0 disease. Perioperative chemotherapy was appropriate for patients who had T1-2N2-3 or T3-4 GC without major symptoms. Adjuvant chemoradiotherapy was classified as appropriate for T1-2N1-3 or T3-4 proximal GC and necessary for T1-2N2-3 or T3-4 distal GC. There was no agreement regarding surveillance imaging and endoscopy following gastrectomy. Surveillance endoscopy was deemed to be appropriate after endoscopic resection. For patients with metastatic GC, surgical resection was considered inappropriate for those with no major symptoms, unless the disease was limited to positive cytology alone, in which case there was disagreement. CONCLUSIONS AND RELEVANCE: Patients with GC being treated with curative intent should be considered for multimodal treatment. For patients with incurable disease, surgical interventions should be considered only for the management of major bleeding or obstruction.
Authors: Jordan Levy; Vaibhav Gupta; Elmira Amirazodi; Catherine Allen-Ayodabo; Naheed Jivraj; Yunni Jeong; Laura E Davis; Alyson L Mahar; Charles De Mestral; Olli Saarela; Natalie Coburn Journal: Gastric Cancer Date: 2019-11-04 Impact factor: 7.370
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