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Gut Online First, published on June 24, 2011 as 10.1136/gut.2010.228254 Guidelines
Guidelines for the management of oesophageal and gastric cancer William H Allum,1 Jane M Blazeby,2 S Michael Griffin,3 David Cunningham,4 Janusz A Jankowski,5 Rachel Wong,4 On behalf of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, the British Society of Gastroenterology and the British Association of Surgical Oncology 1 Department of Surgery, Royal Marsden NHS Foundation Trust, London, UK 2 School of Social and Community Medicine, University of Bristol, Bristol, UK 3 Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK 4 Gastrointestinal Oncology Unit, Royal Marsden NHS Foundation Trust, London, UK 5 Department of Oncology, University of Oxford, Oxford, UK
Correspondence to William H Allum, Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK;
[email protected] Revised 11 April 2011 Accepted 17 April 2011
INTRODUCTION Over the past decade the Improving Outcomes Guidance (IOG) document has led to service re-configuration in the NHS and there are now 41 specialist centres providing oesophageal and gastric cancer care in England and Wales. The National Oesophago-Gastric Cancer Audit, which was supported by the British Society of Gastroenterology, the Association of Upper Gastrointestinal Surgeons (AUGIS) and the Royal College of Surgeons of England Clinical Effectiveness Unit, and sponsored by the Department of Health, has been completed and has established benchmarks for the service as well as identifying areas for future improvements.1e3 The past decade has also seen changes in the epidemiology of oesophageal and gastric cancer. The incidence of lower third and oesophago-gastric junctional adenocarcinomas has increased further, and these tumours form the most common oesophago-gastric tumour, probably reflecting the effect of chronic gastro-oesophageal reflux disease (GORD) and the epidemic of obesity. The increase in the elderly population with significant co-morbidities is presenting significant clinical management challenges. Advances in understanding of the natural history of the disease have increased interest in primary and secondary prevention strategies. Technology has improved the options for diagnostic and therapeutic endoscopy and staging with cross-sectional imaging. Results from medical and clinical oncology trials have established new standards of practice for both curative and palliative interventions. The quality of patient experience has become a significant component of patient care, and the role of the specialist nurse is fully intergrated. These many changes in practice and patient management are now routinely controlled by established multidisciplinary teams (MDTs) which are based in all hospitals managing these patients.
STRUCTURE OF THE GUIDELINES The original guidelines described the management of oesophageal and gastric cancer within existing practice. This paper updates the guidance to include new evidence and to embed it within the framework of the current UK National Health Service (NHS) Cancer Plan.4 The revised guidelines are informed by reviews of the literature and collation of evidence by expert contributors.5 The key recommendations are listed. The sections of the guidelines are broadly the same layout as the
earlier version, with some evidence provided in detail to describe areas of development and to support the changes to the recommendations. The editorial group (WHA, JMB, DC, JAJ, SMG and RW) have edited the individual sections, and the final draft was submitted to independent expert review and modified. The strength of the evidence was classified guided by standard guidelines.6
Categories of evidence Ia: Evidence obtained from meta-analysis of randomised controlled trials (RCTs). Ib: Evidence obtained from at least one randomised trial. IIa: Evidence obtained from at least one welldesigned controlled study without randomisation. IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study. III: Evidence obtained from well-designed descriptive studies such as comparative studies, correlative studies and case studies. IV: Evidence obtained from expert committee reports, or opinions or clinical experiences of respected authorities.
Grading of recommendations Recommendations are based on the level of evidence presented in support and are graded accordingly. Grade A requires at least one RCT of good quality addressing the topic of recommendation. Grade B requires the availability of clinical studies without randomisation on the topic of recommendation. Grade C requires evidence from category IV in the absence of directly applicable clinical studies.
SUMMARY OF RECOMMENDATIONS Prevention < There is no established chemoprevention role for
upper gastrointestinal (UGI) cancer, and trials are currently assessing this (grade C). < The role of surveillance endoscopy for Barrett’s oesophagus or endoscopy for symptoms remains unclear, and trials are currently assessing this (grade B).
Diagnosis < All patients with recent-onset ‘dyspepsia’ over
the age of 55 years and all patients with alarm symptoms (whatever their age) should be referred for rapid access endoscopy with biopsy (grade C).
Allum WH, Blazeby JM, author Griffin SM, (or et al.their Gut (2011). doi:10.1136/gut.2010.228254 1 of 24 Copyright Article employer) 2011. Produced by BMJ Publishing Group Ltd (& BSG) under licence.
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Guidelines < A minimum of six biopsies should be taken to achieve
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