Processes of care in the multidisciplinary treatment of gastric cancer: Results of a RAND/UCLA expert panel

Savtaj S. Brar, Alyson L. Mahar, Lucy K. Helyer, Carol Swallow, Calvin Law, Lawrence Paszat, Rajini Seevaratnam, Roberta Cardoso, Robin McLeod, Matthew Dixon, Lavanya Yohanathan, Laercio G. Lourenco, Alina Bocicariu, Tanios Bekaii-Saab, Ian Chau, Neal Church, Daniel Coit, Christopher H. Crane, Craig Earle, Paul MansfieldNorman Marcon, Thomas Miner, Sung Hoon Noh, Geoff Porter, Mitchell C. Posner, Vivek Prachand, Takeshi Sano, Cornelis Van De Velde, Sandra Wong, Natalie G. Coburn

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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.

Original languageEnglish (US)
Pages (from-to)18-25
Number of pages8
JournalJAMA Surgery
Volume149
Issue number1
DOIs
StatePublished - Jan 2014

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All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Brar, S. S., Mahar, A. L., Helyer, L. K., Swallow, C., Law, C., Paszat, L., Seevaratnam, R., Cardoso, R., McLeod, R., Dixon, M., Yohanathan, L., Lourenco, L. G., Bocicariu, A., Bekaii-Saab, T., Chau, I., Church, N., Coit, D., Crane, C. H., Earle, C., ... Coburn, N. G. (2014). Processes of care in the multidisciplinary treatment of gastric cancer: Results of a RAND/UCLA expert panel. JAMA Surgery, 149(1), 18-25. https://doi.org/10.1001/jamasurg.2013.3959