Improving the quality of pretreatment staging in patients with esophageal carcinoma - a fast track study.
BACKGROUND
Current guidelines for esophageal cancer recommend series of diagnostic investigations to determine pretreatment TNM stage. When investigations are done sequentially, diagnostic work-up time may be prolonged considerably. Aim of the study was to determine the feasibility and efficacy of a fast track staging strategy within five days after the first consultation.


METHODS
Between 2007 and 2010 all patients presenting with esophageal cancer at the Department of Gastroenterology in a tertiary referral center were prospectively analyzed. At Day 1 all patients underwent computed tomography (CT), endoscopic ultrasound (EUS) and ultrasonography of the neck (US). Results and treatment implications were discussed within a multidisciplinary meeting. This fast track strategy was considered completed successfully if pre-treatment TNM classification was achieved and therapy was proposed to the patient at the outpatient clinic at Day five. In those cases where staging period time was prolonged, the number and type of additional tests were documented including the ensuing time delay.


RESULTS
In 111 patients CT, EUS and US were performed in 100%, 88.3% and 97.3% respectively. A final TNM stage and treatment proposal was reached at Day 5 in 60% of the patients. Additional tests were diverse and mainly used to prove local irresectabilty or presence of distant metastasis. Multivariate analysis identified presence of lymphadenopathy (HR 0.25 p = 0.03) and metastasis (HR 0.27 p = 0.03) as significant predictors of not completing the staging period within five days. In 18% of patients overuse of at least one test occurred, most commonly because CT already revealed distant metastasis.


CONCLUSIONS
Employment of a fast track five day staging strategy in patients with esophageal carcinoma is feasible. Definite TNM stage and treatment proposal can be achieved in 60% of cases, but comes at the expense of test overuse in about one fifth of patients.
Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Paul
P
Didden
Manon C W
MC
Spaander
Bas P L
BP
Wijnhoven
Ernst J
EJ
Kuipers
Marco J
MJ
Bruno
D000230:Adenocarcinoma / Q000145:classification / Q000000981:diagnostic imaging / Q000473:pathology*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000145:classification / Q000000981:diagnostic imaging / Q000473:pathology*; D019160:Endosonography; D004938:Esophageal Neoplasms / Q000145:classification / Q000000981:diagnostic imaging / Q000473:pathology*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000592:standards* / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011300:Preoperative Care; D011379:Prognosis; D011446:Prospective Studies; D011787:Quality of Health Care; D014057:Tomography, X-Ray Computed