Assessment and management of oesophago-gastric cancer: summary of NICE guidanceBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k213 (Published 29 January 2018) Cite this as: BMJ 2018;360:k213
- May Oo Khin, systematic reviewer1,
- Nathan Bromham, senior systematic reviewer1,
- Mark Harrison, consultant oncologist and lead clinician2,
- Hilary Eadon, guideline lead1
- on behalf of the Guideline Committee
What you need to know
Nutritional support is an important part of management for people who receive treatment for oesophago-gastric cancer: tailor dietetic support to the person and their clinical situation
Routine clinical follow-up or routine radiological surveillance is not normally offered for detection of recurrent disease: if a person with a history of oesophago-gastric cancer presents with symptoms, refer directly to specialist services with rapid access
People with oesophago-gastric cancer benefit from psychosocial support, verbal and written information about their cancer and care, and other sources of advice including peer groups
Oesophago-gastric cancer is the fourth commonest cause of cancer death in the UK, with 16 000 new cases each year, and its incidence is rising.1 Those affected by the disease often undergo a complex investigative pathway as a prelude to a variety of treatments with wide ranging short term and long term effects that require continued support throughout the initial period of care and beyond. Radical treatments for oesophago-gastric cancer are carried out in specialist centres where there will be access to a range of specialist healthcare professionals, but people with oesophago-gastric cancer will also require input from primary care. People whose cancer is suitable for palliative management will also benefit from the support of professionals from various disciplines, such as cancer care dietitians and palliative care professionals.
This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on diagnosis and management of oesophago-gastric cancer.2 The guidance was developed with the aim of improving and standardising care in all disciplines that treat people with oesophago-gastric cancer, including specialist centres, but some of the recommendations will affect non-specialist services too, and these are highlighted and summarised below.
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
What the guideline covers
The overall guideline is divided into the sections listed below:
Information and support, both for people undergoing radical (that is, curative) treatment as well as those who are suitable only for palliative management (see further details below).
Organisation of services—including the configuration of multidisciplinary teams and surgical services
Recommendations provide guidance on the composition and role of local and specialist multidisciplinary teams for people with oesophago-gastric cancer
The use of specialist surgeons and specialist surgical centres for curative resections is recommended.
Staging investigations, including testing for the HER2 gene:
Guidance is provided on the use of positron emission tomography-computed tomography (PET-CT), endoscopic ultrasonography, and laparoscopy for the staging of both oesophageal and gastric cancer
HER2 testing is recommended in metastatic disease to allow appropriate use of the anticancer drug trastuzumab (which targets the HER2 receptor) in people whose cancer is HER2 positive.
Treatment options for early and localised disease, including surgery, chemotherapy, and radiotherapy:
Recommendations provide guidance for surgical options and use of chemotherapy and chemoradiotherapy in early or localised disease, including gastric cancer and squamous cell carcinoma of the oesophagus
Guidance is provided on the best surgical approaches for oesophagectomy, and for the extent of lymph node dissection that should be carried out concurrently with oesophagectomy or gastrectomy.
Palliative treatments for non-metastatic disease that is not suitable for surgery, or for locally advanced or metastatic oesophago-gastric cancer include palliative chemotherapy, radiotherapy, stenting, and best supportive care.
Guidance is provided on the level and type of dietary support that should be provided to people with oesophago-gastric cancer (see below).
Recommendations provide advice on how and when patients who have had curative treatment should be followed up (see below).
Information and support for people with confirmed oesophago-gastric cancers who are undergoing radical or palliative treatment
Much of the information and support for people with confirmed oesophago-gastric cancers will be provided by specialist teams, but general practitioners and other healthcare professionals can provide psychosocial support and assist in signposting to other sources of help—for example, local support groups for people with cancer, organisations such as Macmillan Cancer Support (www.macmillan.org.uk), or more specific organisations such as the Oesophageal Patients Association (www.opa.org.uk).
For all people with oesophago-gastric cancer
Offer access to an oesophago-gastric clinical nurse specialist through the patient’s multidisciplinary care team.
Make sure each person with oesophago-gastric cancer has information in a format that is appropriate for them, to take away and review in their own time after you have spoken to them about their cancer and care.
Inform people with oesophago-gastric cancer about peer-to-peer local or national support groups for them to join if they wish.
Provide psychosocial support to the person with oesophago-gastric cancer and those important to them (as appropriate). Cover:
Potential impact on family life, changing roles, and relationships
Uncertainty about the disease course and prognosis
Concerns over heredity of cancer, recovery, and recurrence
Where they can get further support.
[Based on very low to high quality evidence from qualitative studies and the experience and opinion of the Guideline Committee (GC)]
For people receiving radical treatment
Provide information about possible treatment options—such as surgery, radiotherapy, or chemotherapy—in all discussions with people with oesophago-gastric cancer who are going to have radical treatment. Make sure the information is consistent and covers:
Treatment outcomes (prognosis and future treatments)
Recovery, including the consequences of treatment and how to manage them
Nutrition and lifestyle changes.
Follow the recommendations in NICE’s guideline on patient experience in adult NHS services.3
[Based on very low to high quality evidence from qualitative studies and the experience and opinion of the GC]
For people receiving palliative management
For people who can only have palliative management, offer personalised information and support to them and the people who are important to them (as appropriate), at a pace that is suitable for them. This could include information on:
Life expectancy, if the person has said they would like to know about this
The treatment and care available, and how to access this both now and for future symptoms
Holistic issues (such as physical, emotional, social, financial, and spiritual issues) and how they can get support and help
Dietary changes and how to manage these and access specialist dietetic support
Which sources of information in the public domain give good advice about the issues listed above.
Follow the recommendations in NICE’s guideline on patient experience in adult NHS services.3
Consider providing support from:
A specialist cancer care dietitian
A specialist palliative care team
A peer support group, if available.
Follow the recommendations in the NICE guideline on improving supportive and palliative care for adults with cancer.4
[Based on very low to low quality evidence from qualitative studies and the experience and opinion of the GC]
Which kind of nutritional support should be provided?
People with oesophago-gastric cancer will receive specialist dietetic support but may also require support in the community, particularly if they are discharged home on enteral (or even parenteral) nutrition. This may include prescribing feeds, providing supplements, or nursing help with managing equipment. Additional advice to primary care teams has already been provided by NICE in its guideline on nutrition support for adults.5
For people receiving radical treatment
Offer nutritional assessment and tailored specialist dietetic support to people with oesophago-gastric cancer before, during, and after radical treatments.
Offer immediate enteral or parenteral nutrition after surgery to people who are having radical surgery for oesophageal and gastro-oesophageal junctional cancers.
[Based on very low to moderate quality evidence from quantitative studies and the experience and opinion of the GC]
For people receiving palliative care
Consider support from a specialist cancer-specific dietitian for people with oesophago-gastric cancer receiving palliative care.
Together with members of the multidisciplinary team and the hospital and community palliative care teams, tailor dietetic support to the person with oesophago-gastric cancer and their clinical situation.
Follow the recommendations in the NICE guidelines on improving supportive and palliative care for adults with cancer.4
[Based on the experience and opinion of the GC]
What assessments should be done at follow-up?
People who have undergone successful curative treatment for oesophago-gastric cancer will not be routinely followed-up by specialist centres for the detection of recurrent disease, but will be provided with rapid access if symptoms return. Awareness of the symptoms that indicate recurrent disease is therefore important for non-specialists and healthcare professionals in the community, who can then facilitate access to specialist services.
For people who have no symptoms or evidence of residual disease after treatment for oesophago-gastric cancer with curative intent:
Provide information about the symptoms of recurrent disease and what to do if these symptoms develop
Offer rapid access to the oesophago-gastric multidisciplinary team for review if symptoms develop.
For people who have no symptoms or evidence of residual disease after treatment for oesophago-gastric cancer with curative intent, do not offer:
Routine clinical follow-up solely for the detection of recurrent disease
Routine radiological surveillance solely for the detection of recurrent disease.
[Based on very low to moderate quality of evidence from quantitative studies and the experience and opinion of the GC]
Challenges to implementation:
The main challenges to the implementation of this guidance for specialist services are likely to be the appropriate organisation of services and the availability of specialists. It is not anticipated that there will be other specific financial challenges associated with implementing the recommendations.
List of different support groups for people with confirmed oesophago-gastric cancer
• Macmillan Cancer Support (www.macmillan.org.uk)
• Oesophageal Patients Association (www.opa.org.uk)
Guidelines into practice
Do you have a local peer-to-peer cancer support group that people with oesophago-gastric cancer can join?
What services in your area are there to provide nutritional support to people with cancer and how do you access them rapidly?
Are you aware of the symptoms of recurrent oesophago-gastric cancer that would prompt you to refer people to specialist services?
How patients were involved in the creation of this article
Committee members involved in this guideline included one patient member and one carer member with direct experience of oesophago-gastric cancer, who contributed to the formulation of the recommendations summarised here.
Further information on the guidance
This guidance was developed by the National Guideline Alliance in accordance with NICE guideline methodology (www.nice.org.uk/media/default/about/what-we-do/our-programmes/developing-nice-guidelines-the-manual.pdf). A Guideline Committee (GC) was established by the National Guideline Alliance, which incorporated healthcare and allied healthcare professionals (one consultant head and neck surgeon, one consultant oncologist, one consultant clinical oncologist, one consultant medical oncologist in gastrointestinal cancers and associate director of clinical research, two consultant upper gastrointestinal surgeons, one consultant radiologist, one upper gastrointestinal clinical nurse specialist, one principal dietitian, one consultant gastroenterologist, one Macmillan consultant in palliative medicine, and two patient or carer members).
The committee identified relevant review questions; collected and appraised the best available evidence, diagnostic test accuracy studies, and qualitative studies; and evaluated the cost effectiveness of proposed recommendations where possible. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes or themes rather than the quality of the study. The GC agreed recommendations for clinical practice based on the available evidence or, when evidence was not found, based on their experience and opinion using informal consensus methods.
The scope and the draft of the guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment. The GC took all comments into consideration when producing the final version of the guideline.
Two different versions of this guideline have been produced: a full version containing all the evidence, the process undertaken to develop the recommendations, and all the recommendations, known as the “Full guideline”; and a short version containing a list of all the recommendations, known as the “Short guideline.” All of these versions are available from the NICE website (www.nice.org.uk/guidance/ng83).
NICE will conduct regular reviews after publication of the guidance to determine whether the evidence base has progressed significantly enough to alter the current guideline recommendations and require an update.
The GC prioritised the following research recommendations:
Can the addition of surgery to chemoradiotherapy improve disease-free and overall survival in people with squamous cell carcinoma of the oesophagus?
Is endoscopic treatment comparable to open surgery for T1bN0 adenocarcinoma of the oesophagus?
What are safe and effective nutritional support interventions to reduce postoperative complications?
Is long term jejunostomy support as effective as intensive dietary counselling and support along with symptom management for people having radical surgery?
Should computed tomography and tumour markers be offered routinely to detect disease recurrence for asymptomatic people who have had radical treatment for oesophago-gastric cancer?
The members of the Guideline Committee were (in alphabetical order) Andrew Bateman, David Brooks, Hugh Burnett, David Exon, Mark Harrison, Orla Hynes, Cyrus Kerawala, Nick Maynard, Mimi McCord, David Simpson, Naureen Starling, Robert Willert, Venetia Wynter-Blyth.
The members of the National Guideline Alliance technical team were (in alphabetical order) Sabine Berendse, Katrina Blears, Nathan Bromham, Amy Burt, Hilary Eadon, John Graham, Lianne Gwillim, May Oo Khin, Abigail Moore, Natasha Pillai, Matthew Prettyjohns, Victoria Titshall.
Contributors: All authors contributed to the initial draft of this article, helped revise the manuscript, and approved the final version for the publication.
Funding: The National Guideline Alliance was commissioned and funded by NICE to develop this guideline and write this BMJ summary.
Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (available at www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). The authors’ full statements can be viewed at www.bmj.com/content/bmj/360/bmj.k213/related#datasupp.
Provenance and peer review: Commissioned; not externally peer reviewed