Processes of Care in the Multidisciplinary Treatment of Gastric Cancer Results of a RAND/UCLA Expert Panel

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.Canadian Cancer SocietyOntario Ministry of Health and Long-Term CareHanna Family Research Chair in Surgical OncologyUniv Toronto, Dept Surg, Toronto, ON, CanadaQueens Univ, Dept Epidemiol & Community Hlth, Kingston, ON, CanadaSunnybrook Res Inst, Toronto, ON, CanadaDalhousie Univ, Dept Surg, Halifax, NS B3H 4H2, CanadaInst Clin Effectiveness Studies, Toronto, ON, CanadaMaimonides Hosp, Dept Surg, Brooklyn, NY 11219 USABrown Univ, Dept Surg, Providence, RI 02912 USAUniversidade Federal de São Paulo, Dept Surg Gastroenterol, São Paulo, BrazilOhio State Univ, Dept Med, Columbus, OH 43210 USAOhio State Univ, Dept Pharmacol, Columbus, OH 43210 USARoyal Marsden Hosp, Dept Med, Sutton, Surrey, EnglandUniv Calgary, Dept Surg, Calgary, AB, CanadaMem Sloan Kettering Canc Ctr, Dept Surg, New York, NY 10021 USAUniv Texas Houston, MD Anderson Canc Ctr, Dept Radiat Oncol, Houston, TX 77030 USAUniv Toronto, Dept Med, Toronto, ON, CanadaUniv Texas Houston, MD Anderson Canc Ctr, Dept Surg Oncol, Houston, TX 77030 USAYonsei Univ, Coll Med, Dept Surg, Seoul, South KoreaUniv Chicago, Dept Surg, Chicago, IL 60637 USACanc Inst Hosp, Dept Surg, Tokyo, JapanLeiden Univ, Med Ctr, Dept Surg, Leiden, NetherlandsUniv Michigan Hlth Syst, Dept Surg, Ann Arbor, MI USAUniversidade Federal de São Paulo, Dept Surg Gastroenterol, São Paulo, BrazilCanadian Cancer Society: 019325Web of Scienc