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Optimal management of gastric cancer: results from an international RAND/UCLA expert panel
Natalie Coburn1, Rajini Seevaratnam, Lawrence Paszat
1*Department of Surgery, University of Toronto, Toronto, ON, Canada †Department of Community Health and Epidemiology, Queens's University, Kinston, ON, Canada ‡Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada §Institute for Clinical Evaluative Sciences, Toronto, ON, Canada ¶Department of Surgery, Dalhousie University, Halifax, NS, Canada ‖Sunnybrook Research Institute, Toronto, On, Canada **Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil ††Department of Surgery, Maimonides Medical Center, Brooklyn, NY ‡‡Departments of Medicine and Pharmacology, Ohio State University, Columbus OH §§Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, UK ¶¶Department of Surgery, University of Calgary, Calgary, AB, Canada ‖‖Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY ***Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX †††Department of Medicine, University of Toronto, Toronto, ON, Canada ‡‡‡Department of Surgical Oncology, MD Anderson Cancer Center, Houston TX §§§Department of Surgery, Brown University, Providence, RI ¶¶¶Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea ‖‖‖Department of Surgery, University of Chicago, Chicago, IL ****Department of Surgery, Cancer Institute Hospital, Tokyo, Japan ††††Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands; and ‡‡‡‡Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
Objective:
Defining processes of care, which are appropriate and necessary for management of gastric cancer (GC), is an important step toward improving outcomes.
Methods:
Using a RAND/UCLA Appropriateness Method, an international multidisciplinary expert panel created 22 statements reflecting optimal management. All statements were scored for appropriateness and necessity.
Results:
The following tenets were scored appropriate and necessary: (1) preoperative staging by computed tomography of abdomen/pelvis; (2) positron-emission tomographic scans not routinely indicated; (3) consideration for adjuvant therapy; (4) further clinical trials; (5) multidisciplinary decision making; (6) sufficient support at hospitals; (7) assessment of 16 or more lymph nodes (LNs); (8) in metastatic disease, surgery only for palliation of major symptoms; (9) surgeons experienced in GC management; (10) and surgeons experienced in both GC management and advanced laparoscopic surgery for laparoscopic resection. The following were scored appropriate, but of indeterminate necessity: (1) diagnostic laparoscopy before treatment; (2) a multidisciplinary approach to linitis plastica; (3) genetic assessment for diffuse GC and family history, or age less than 45 years; (4) endoscopic removal of select T1aN0 lesions; (5) D2 LN dissection in curative intent cases; (6) D1 LN dissection for early GC or patients with comorbidities; (7) frozen section analysis of margins; (8) nonemergent cases performed in a hospital with a volume of more than 15 resections per year; and (9) by a surgeon with more than 6 resection per year.
Conclusions:
The expert panel has created 22 statements for the perioperative management of GC patients, to provide guidance to clinicians and improve the care received by patients.
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