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Original Investigation |

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

Savtaj S. Brar, MD, MSc1; Alyson L. Mahar, MSc2,3; Lucy K. Helyer, MD, MSc4; Carol Swallow, MD, PhD1; Calvin Law, MD, MPH1; Lawrence Paszat, MD, MSc5; Rajini Seevaratnam, MSc3; Roberta Cardoso, RN, PhD3; Robin McLeod, MD1; Matthew Dixon, MD6; Lavanya Yohanathan, MD7; Laercio G. Lourenco, MD8; Alina Bocicariu, MD3; Tanios Bekaii-Saab, MD9; Ian Chau, MD10; Neal Church, MD11; Daniel Coit, MD12; Christopher H. Crane, MD13; Craig Earle, MD, MSc5,14; Paul Mansfield, MD15; Norman Marcon, MD14; Thomas Miner, MD7; Sung Hoon Noh, MD, PhD16; Geoff Porter, MD, MSc4; Mitchell C. Posner, MD17; Vivek Prachand, MD17; Takeshi Sano, MD18; Cornelis van de Velde, MD, PhD19; Sandra Wong, MD20; Natalie G. Coburn, MD, MPH, FRCSC1,3,5
[+] Author Affiliations
1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
2Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada
3Sunnybrook Research Institute, Toronto, Ontario, Canada
4Department of Surgery, Dalhousie University, Halifax, Canada
5Institute for Clinical Effectiveness Studies, Toronto, Ontario, Canada
6Department of Surgery, Maimonides Medical Center, Brooklyn, New York
7Department of Surgery, Brown University, Providence, Rhode Island
8Department of Gastroenterology Surgery, São Paulo Federal University, São Paulo, Brazil
9Departments of Medicine and Pharmacology, Ohio State University, Columbus
10Department of Medicine, Royal Marsden Hospital, Sutton, Surrey, United Kingdom
11Department of Surgery, University of Calgary, Calgary, Alberta, Canada
12Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
13Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
14Department of Medicine, University of Toronto, Toronto, Ontario, Canada
15Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
16Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
17Department of Surgery, University of Chicago, Chicago, Illinois
18Department of Surgery, Cancer Institute Hospital, Tokyo, Japan
19Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
20Department of Surgery, University of Michigan Health System, Ann Arbor
JAMA Surg. 2014;149(1):18-25. doi:10.1001/jamasurg.2013.3959.
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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.

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