Processes of care in the multidisciplinary treatment of gastric cancer: results of a RAND/UCLA expert panel.
OBJECTIVE
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).


METHODS
RAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries.


METHODS
Gastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care.


METHODS
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
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.
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Savtaj S
SS
Brar
Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada3Sunnybrook Research Institute, Toronto, Ontario, Canada.
Alyson L
AL
Mahar
Department of Surgery, Dalhousie University, Halifax, Canada.
Lucy K
LK
Helyer
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Carol
C
Swallow
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Calvin
C
Law
Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada.
Lawrence
L
Paszat
Sunnybrook Research Institute, Toronto, Ontario, Canada.
Rajini
R
Seevaratnam
Sunnybrook Research Institute, Toronto, Ontario, Canada.
Roberta
R
Cardoso
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Robin
R
McLeod
Department of Surgery, Maimonides Medical Center, Brooklyn, New York.
Matthew
M
Dixon
Department of Surgery, Brown University, Providence, Rhode Island.
Lavanya
L
Yohanathan
Department of Gastroenterology Surgery, São Paulo Federal University, São Paulo, Brazil.
Laercio G
LG
Lourenco
Sunnybrook Research Institute, Toronto, Ontario, Canada.
Alina
A
Bocicariu
Departments of Medicine and Pharmacology, Ohio State University, Columbus.
Tanios
T
Bekaii-Saab
Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom.
Ian
I
Chau
Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
Neal
N
Church
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
Daniel
D
Coit
Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
Christopher H
CH
Crane
Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada14Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Craig
C
Earle
Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas.
Paul
P
Mansfield
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Norman
N
Marcon
Department of Surgery, Brown University, Providence, Rhode Island.
Thomas
T
Miner
Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.
Sung Hoon
SH
Noh
Department of Surgery, Dalhousie University, Halifax, Canada.
Geoff
G
Porter
Department of Surgery, University of Chicago, Chicago, Illinois.
Mitchell C
MC
Posner
Department of Surgery, University of Chicago, Chicago, Illinois.
Vivek
V
Prachand
Department of Surgery, Cancer Institute Hospital, Tokyo, Japan.
Takeshi
T
Sano
Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
Cornelis
C
van de Velde
Department of Surgery, University of Michigan Health System, Ann Arbor.
Sandra
S
Wong
Department of Surgery, University of Toronto, Toronto, Ontario, Canada3Sunnybrook Research Institute, Toronto, Ontario, Canada5Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada.
Natalie G
NG
Coburn
D000230:Adenocarcinoma / Q000628:therapy*; D003131:Combined Modality Therapy; D006801:Humans; D010348:Patient Care Team; D013274:Stomach Neoplasms / Q000628:therapy*