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Optimal Management of Gastric Cancer: Results From an International RAND/UCLA Expert Panel

Coburn, Natalie MD, MPH*,‡,§,‖; Seevaratnam, Rajini MSc; Paszat, Lawrence MD, MSc‡,§; Helyer, Lucy MD, MSc; Law, Calvin MD, MPH*,‡,§,‖; Swallow, Carol MD, PhD*; Cardosa, Roberta RN, PhD; Mahar, Alyson MSc†,‖; Lourenco, Laercio Gomes MD**; Dixon, Matthew MD‖,††; Bekaii-Saab, Tanios MD‡‡; Chau, Ian MD§§; Church, Neal MD¶¶; Coit, Daniel MD‖‖; Crane, Christopher H. MD***; Earle, Craig MD, MSc§,†††; Mansfield, Paul MD‡‡‡; Marcon, Norman MD†††; Miner, Thomas MD§§§; Noh, Sung Hoon MD, PhD¶¶¶; Porter, Geoff MD, MSc; Posner, Mitchell C. MD‖‖‖; Prachand, Vivek MD‖‖‖; Sano, Takeshi MD****; van de Velde, Cornelis MD, PhD††††; Wong, Sandra MD‡‡‡‡; McLeod, Robin MD*

doi: 10.1097/SLA.0b013e318288dd2b
Original Articles

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.

Supplemental Digital Content is Available in the Text.Defining processes of care, which are appropriate and necessary for management of gastric cancer, is an important step toward improving outcomes. We report 22 statements reflecting optimal management of gastric cancer, as determined by an international multidisciplinary expert panel.

*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.

Reprints: Natalie G. Coburn, MD, MPH, FRCSC, FACS, Sunnybrook Health Sciences Centre, Suite T2-60, Division of Surgical Oncology, Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail:

Disclosure: This research is funded by the Canadian Cancer Society (grant 019325). Dr Coburn (Career Scientist Award) and Dr Paszat have received funding through the Ontario Ministry of Health and Long-Term Care; Dr Law is supported by the Hanna Family Research Chair in Surgical Oncology; and Ian Chau would like to acknowledge National Health Service funding to the National Institute for Health Research's Biomedical Research Centre.

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© 2014 by Lippincott Williams & Wilkins.