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Gastrointestinal cancers

About

What is covered

This interactive flowchart covers gastrointestinal cancers, and includes links to what NICE says on upper aerodigestive tract cancer, Barrett's oesophagus and colorectal cancer.
To find other information about gastrointestinal cancers, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this interactive flowchart

14 November 2017 Regorafenib for previously treated unresectable or metastatic gastrointestinal stromal tumours (NICE technology appraisal guidance 488 ) added to gastrointestinal stromal tumours.
5 September 2017 Paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer (NICE technology appraisal guidance 476) added to pancreas.
2 May 2017 Pegylated liposomal irinotecan for treating pancreatic cancer after gemcitabine (NICE technology appraisal guidance 440) and irreversible electroporation for treating pancreatic cancer (NICE interventional procedures guidance 579) added to pancreas.
27 January 2016 Ramucirumab for treating advanced gastric cancer or gastro-oesophageal junction adenocarcinoma previously treated with chemotherapy (NICE technology appraisal guidance 378) added to gastric and duodenal cancer.
9 December 2014 Fluorouracil chemotherapy: the My5-FU assay for guiding dose adjustment (NICE diagnostics guidance 16) added to gastric and duodenal cancer.
25 November 2014 Imatinib for the adjuvant treatment of gastrointestinal stromal tumours (NICE technology appraisal guidance 326) added to gastrointestinal stromal tumours.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on gastrointestinal cancers in an interactive flowchart

What is covered

This interactive flowchart covers gastrointestinal cancers, and includes links to what NICE says on upper aerodigestive tract cancer, Barrett's oesophagus and colorectal cancer.
To find other information about gastrointestinal cancers, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this interactive flowchart

14 November 2017 Regorafenib for previously treated unresectable or metastatic gastrointestinal stromal tumours (NICE technology appraisal guidance 488 ) added to gastrointestinal stromal tumours.
5 September 2017 Paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer (NICE technology appraisal guidance 476) added to pancreas.
2 May 2017 Pegylated liposomal irinotecan for treating pancreatic cancer after gemcitabine (NICE technology appraisal guidance 440) and irreversible electroporation for treating pancreatic cancer (NICE interventional procedures guidance 579) added to pancreas.
27 January 2016 Ramucirumab for treating advanced gastric cancer or gastro-oesophageal junction adenocarcinoma previously treated with chemotherapy (NICE technology appraisal guidance 378) added to gastric and duodenal cancer.
9 December 2014 Fluorouracil chemotherapy: the My5-FU assay for guiding dose adjustment (NICE diagnostics guidance 16) added to gastric and duodenal cancer.
25 November 2014 Imatinib for the adjuvant treatment of gastrointestinal stromal tumours (NICE technology appraisal guidance 326) added to gastrointestinal stromal tumours.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Improving outcomes in colorectal cancer (2004) NICE guideline CSG5
Capecitabine for the treatment of advanced gastric cancer (2010) NICE technology appraisal guidance 191
Sunitinib for the treatment of gastrointestinal stromal tumours (2009) NICE technology appraisal guidance 179
Irreversible electroporation for treating pancreatic cancer (2017) NICE interventional procedures guidance 579
Minimally invasive oesophagectomy (2011) NICE interventional procedures guidance 407
Endoscopic submucosal dissection of gastric lesions (2010) NICE interventional procedures guidance 360
Endoscopic submucosal dissection of oesophageal dysplasia and neoplasia (2010) NICE interventional procedures guidance 355
Laparoscopic gastrectomy for cancer (2008) NICE interventional procedures guidance 269
Palliative photodynamic therapy for advanced oesophageal cancer (2007) NICE interventional procedures guidance 206
Laparoscopic distal pancreatectomy (2007) NICE interventional procedures guidance 204
Photodynamic therapy for early-stage oesophageal cancer (2006) NICE interventional procedures guidance 200
Laparo-endogastric surgery (2003) NICE interventional procedures guidance 25

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Why we made the recommendations on nab-paclitaxel

NICE reviewed its technology appraisal guidance on paclitaxel as albumin-bound nanoparticles (nab-paclitaxel) in combination with gemcitabine for previously untreated metastatic pancreatic cancer because the company submitted more evidence and proposed a patient access scheme that would make nab-paclitaxel available with a confidential price discount.
Nab-paclitaxel plus gemcitabine would normally be considered for people with metastatic adenocarcinoma of the pancreas who would otherwise have gemcitabine.
Evidence shows that nab-paclitaxel plus gemcitabine is more effective in increasing survival than gemcitabine monotherapy, but is less effective than FOLFIRINOX (a combination of fluorouracil, leucovorin, irinotecan and oxaliplatin) and similarly effective to gemcitabine plus capecitabine (although the results were uncertain).
Nab-paclitaxel plus gemcitabine met NICE's end-of-life criteria when compared with gemcitabine monotherapy, but not when compared with gemcitabine plus capecitabine or FOLFIRINOX because it did not improve survival.
The most likely estimate of cost effectiveness compared with gemcitabine monotherapy is £41,000 to £46,000 per quality-adjusted life year (QALY) gained. Nab-paclitaxel plus gemcitabine is not cost effective compared with gemcitabine plus capecitabine or FOLFIRINOX.
Nab-paclitaxel plus gemcitabine can therefore be recommended for people with metastatic pancreatic cancer only if other combination chemotherapies are not suitable, and they would otherwise have gemcitabine monotherapy.
For more information see the committee discussion in the NICE technology appraisal on paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer.

Why we made the recommendations on regorafenib

Current treatment for unresectable or metastatic gastrointestinal stromal tumours after disease progression on, or intolerance to, prior treatment with imatinib and sunitinib is best supportive care.
The evidence shows that people having regorafenib have longer before their disease progresses compared with those having best supportive care. However there is some uncertainty around how long regorafenib increases the overall length of time people live compared with those on best supportive care.
Regorafenib meets NICE's criteria to be considered a life-extending end-of-life treatment, and the most plausible cost-effectiveness estimate is around £44,000 per quality-adjusted life year gained. Therefore it can be recommended for use in the NHS.
Regorafenib is only recommended for people who have an ECOG performance status of 0 to 1 because in clinical practice, regorafenib is only expected to be used in people who have an ECOG performance status of 0 to 1; there is limited evidence for its use in people with a performance status of 2 or more.
For more information see the committee discussion in the NICE technology appraisal on regorafenib for previously treated unresectable or metastatic gastrointestinal stromal tumours.

Glossary

Paths in this pathway

Pathway created: November 2013 Last updated: November 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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