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Oesophageal and gastric cancer

About

What is covered

This interactive flowchart covers assessing and managing non-stromal oesophageal and gastric cancer in adults, including radical and palliative treatment and nutritional support. It also covers service organisation, and what information and support people with cancer and their families and friends should have. It aims to reduce variation in practice and improve survival.

Updates

Updates to this interactive flowchart

12 December 2018 Oesophago-gastric cancer (NICE quality standard 176) added.

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 assessing and managing non-stromal oesophageal and gastric cancer in adults

What is covered

This interactive flowchart covers assessing and managing non-stromal oesophageal and gastric cancer in adults, including radical and palliative treatment and nutritional support. It also covers service organisation, and what information and support people with cancer and their families and friends should have. It aims to reduce variation in practice and improve survival.

Updates

Updates to this interactive flowchart

12 December 2018 Oesophago-gastric cancer (NICE quality standard 176) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Capecitabine for the treatment of advanced gastric cancer (2010) NICE technology appraisal guidance 191
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
Photodynamic therapy for early-stage oesophageal cancer (2006) NICE interventional procedures guidance 200
Laparo-endogastric surgery (2003) NICE interventional procedures guidance 25
Oesophago-gastric cancer (2018) NICE quality standard 176

Quality standards

Oesophago-gastric cancer

These quality statements are taken from the oesophago-gastric cancer quality standard. The quality standard defines clinical best practice for oesophago-gastric cancer and should be read in full.

Quality statements

Clinical nurse specialist

This quality statement is taken from the oesophago-gastric cancer quality standard. The quality standard defines clinical best practice for oesophago-gastric cancer and should be read in full.

Quality statement

Adults with oesophago-gastric cancer have access to an oesophago-gastric clinical nurse specialist.

Rationale

Adults with oesophago-gastric cancer need information and support to help them adapt to physical changes and reduced quality of life. A clinical nurse specialist in oesophago-gastric cancer can provide consistent and tailored information throughout care, potentially reducing the impact of these changes.

Quality measures

Structure
Evidence of the availability of clinical nurse specialists who specialise in the care and support of adults with oesophago-gastric cancer.
Data source: Local data collection, for example, workforce plans or staff rotas.
Process
Proportion of adults with oesophago-gastric cancer who have contact details for an oesophago-gastric clinical nurse specialist.
Numerator – the number in the denominator who have contact details for an oesophago-gastric clinical nurse specialist.
Denominator – the number of adults with oesophago-gastric cancer.
Data source: Local data collection, for example, records of contact details, such as name and telephone number, being given for clinical nurse specialists in patient records.
Outcome
a) Patient satisfaction with the availability of a clinical nurse specialist, reported by adults with oesophago-gastric cancer.
Data source: Quality Health National Cancer Patient Experience Survey. The survey contains the following question: How easy or difficult has it been for you to contact your clinical nurse specialist?
b) Patient satisfaction with information provided by the clinical nurse specialist, reported by adults with oesophago-gastric cancer.
Data source: Quality Health National Cancer Patient Experience Survey. The survey contains the following question: When you have had important questions to ask your clinical nurse specialist, how often have you got answers you could understand?

What the quality statement means for different audiences

Service providers (secondary and tertiary care centres) ensure that they have the capacity and expertise for adults with oesophago-gastric cancer to have access to a clinical nurse specialist at all stages of their care.
Healthcare professionals (members of oesophago-gastric cancer multidisciplinary teams) ensure that adults with oesophago-gastric cancer have access to a clinical nurse specialist. The clinical nurse specialist should provide support and consistent information for adults with oesophago-gastric cancer, as well as details of how to contact them in the future. This means that people have support at all stages of their care.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that can provide clinical nurse specialists with expertise in oesophago-gastric cancer to support all adults with oesophago-gastric cancer throughout all stages of care.
Adults with oesophago-gastric cancer are able to contact a clinical nurse specialist (a nurse experienced in treating oesophago-gastric cancer) who can provide information, advice and support throughout their care.

Source guidance

Oesophago-gastric cancer: assessment and management in adults (2018) NICE guideline NG83, recommendation 1.1.1

Equality and diversity considerations

People should be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with health and social care services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. People should have access to an interpreter or advocate if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Multidisciplinary review

This quality statement is taken from the oesophago-gastric cancer quality standard. The quality standard defines clinical best practice for oesophago-gastric cancer and should be read in full.

Quality statement

Adults with oesophago-gastric cancer have their treatment reviewed by a multidisciplinary team (MDT) that includes an oncologist and a specialist radiologist who both have an interest in oesophago-gastric cancer.

Rationale

Adults with oesophago-gastric cancer have their care reviewed in an MDT meeting so that their treatment can be planned. Including a radiologist and an oncologist who both have a specialist interest in oesophago-gastric cancer means that the MDT has a range of specialist expertise. When these 2 roles and associated specialist expertise are included in local MDTs this can help reduce time to treatment and unnecessary referrals to specialist MDTs.

Quality measures

Structure
Evidence that an oncologist and a radiologist who both have a specialist interest in oesophago-gastric cancer take part in multidisciplinary team meetings.
Data source: Local data collection, for example, attendance records gathered to support the Quality Surveillance Programme, minutes of MDT meetings or MDT annual reports.
Process
Proportion of adults with newly diagnosed oesophago-gastric cancer whose treatment is reviewed at a multidisciplinary meeting that includes an oncologist and a radiologist who both have a specialist interest in oesophago-gastric cancer.
Numerator – the number in the denominator whose treatment is reviewed at a multidisciplinary meeting that includes an oncologist and a radiologist who both have a specialist interest in oesophago-gastric cancer.
Denominator – the number of adults with newly diagnosed oesophago-gastric cancer.
Data source: Local data collection, for example, attendance records gathered to support the Quality Surveillance Programme, minutes of MDT meetings or MDT annual reports.
Outcome
a) Rates of referral from a local MDT to a specialist oesophago-gastric cancer MDT.
Data source: Local data collection.
b) Average time from MDT to first treatment for oesophago-gastric cancer.
Data source: National Oesophago-Gastric Cancer Audit waiting times between key dates in the patient pathway by treatment modality in England and Wales (table 5.2).

What the quality statement means for different audiences

Service providers (secondary care services) ensure that arrangements are in place for MDTs planning and reviewing treatment for adults with oesophago-gastric cancer to have an oncologist and a radiologist who both have a specialist interest in oesophago-gastric cancer as core members of the team. When these core members are unable to attend meetings, they arrange cover from oncologists and radiologists with the same specialist interest.
Healthcare professionals (oncologists and radiologists with a specialist interest in oesophago-gastric cancer) take part in MDT reviews of treatment for adults with oesophago-gastric cancer and are core members of the team.
Commissioners (clinical commissioning groups and NHS England) have clinical protocols and network policies in place to ensure that MDTs responsible for planning and reviewing treatment for adults with oesophago-gastric cancer include as core members an oncologist and radiologist who both have a specialist interest in oesophago-gastric cancer. Their attendance at MDT reviews is monitored.
Adults with oesophago-gastric cancer are cared for by a team of healthcare professionals who have training and experience in caring for people with oesophago-gastric cancer. The team is responsible for planning care.

Source guidance

Oesophago-gastric cancer: assessment and management in adults (2018) NICE guideline NG83, recommendation 1.2.1

Definitions of terms used in this quality statement

Multidisciplinary team
The focus of the statement is on the roles of the oncologist and specialist radiologist. The core roles of the full MDT would include:
  • clinical nurse specialist
  • specialist clinical oncologist with an interest in oesophago-gastric cancer
  • gastroenterologist
  • specialist medical oncologist (if the responsibility for chemotherapy is not undertaken by the clinical oncologist) with an interest in oesophago-gastric cancer
  • palliative care specialist
  • specialist radiologist with an interest in oesophago-gastric cancer
  • upper gastrointestinal surgeon.
Other roles will form part of an extended local or specialist MDT.
[Adapted from NHS Executive (2001) Guidance on commissioning cancer services: improving outcomes guidance in upper gastro-intestinal cancers: the manual. London, Department of Health: topic area 3; expert opinion]

Assessment after endoscopy and CT scan

This quality statement is taken from the oesophago-gastric cancer quality standard. The quality standard defines clinical best practice for oesophago-gastric cancer and should be read in full.

Quality statement

Adults with oesophageal or gastro-oesophageal junctional tumours (except T1a tumours) for whom radical treatment is suitable, have 18-fluorodeoxyglucose positron emission tomography (F-18 FDG PET-CT) requested and reported within 1 week.

Rationale

F-18 FDG PET-CT staging after endoscopy and whole-body CT allows the more accurate detection of metastatic disease. This helps to determine whether the disease is suitable for radical treatment, or whether it is too advanced. Timely requesting and reporting of F-18 FDG PET-CT will help avoid unnecessary investigations for staging (such as endoscopic ultrasound) in adults with metastatic oesophago-gastric cancer and oesophago-junctional cancer, and delays to treatment.

Quality measures

Structure
a) Evidence of the availability of equipment and systems to request and report the results of F-18 FDG PET-CT scans.
Data source: Local data collection, for example, service protocols and referral pathways.
b) Evidence of local processes to identify F-18 FDG PET-CT scans reported more than 1 week after they have been requested.
Data source: Local data collection, for example, service specifications and local protocols.
Process
Proportion of adults with oesophageal or gastro-oesophageal junctional cancer for whom radical treatment is suitable who have staging using F-18 FDG PET-CT with results reported within 1 week of the decision to request the scan.
Numerator – the number of adults in the denominator who have the results of F-18 FDG PET-CT staging reported within 1 week of the decision to request the scan.
Denominator – the number of adults with oesophageal or gastro-oesophageal junctional cancer for whom radical treatment is suitable.
Data source: Local data collection, for example, patient records.
Outcome
a) Proportion of adults with oesophageal or gastro-oesophageal junctional cancer who have accurate staging.
Data source: Local data collection, for example, patient records.
b) Proportion of adults with metastatic oesophageal or gastro-oesophageal junctional cancer who have endoscopic ultrasound.
Data source: Local data collection, for example, patient records.

What the quality statement means for different audiences

Service providers (specialist oesophago-gastric cancer centres/tertiary care centres) have systems in place for adults with oesophageal and gastro-oesophageal junctional tumours (apart from T1a tumours) to have staging using F-18 FDG PET-CT, with results reported within 1 week of the decision to scan, if radical treatment is considered suitable after endoscopy and whole-body CT. This allows accurate diagnosis, classification and staging before treatment planning.
Healthcare professionals (radiologists and nuclear medicine physicians) report the results of staging using F-18 FDG PET-CT for adults with oesophageal or gastro-oesophageal junctional tumours (apart from T1a tumours) within 1 week of the decision to scan. F-18 FDG PET-CT more accurately detects metastatic disease, avoids unnecessary further testing and supports treatment planning.
Commissioners (NHS England) ensure that they commission services in which adults with oesophageal or gastro-oesophageal junctional tumours (apart from T1a tumours) have staging using F-18 FDG PET-CT, with results reported within 1 week of the decision to scan, if radical treatment is considered suitable after endoscopy and whole-body CT.
Adults with oesophageal or gastro-oesophageal junctional cancer who are being considered for treatment to remove the cancer have a scan, with the results reported within 1 week of the decision to arrange it. The aim of the scan is to show how far the cancer has spread. If the scan shows that the cancer is advanced, palliative care (for example, palliative radiotherapy) should be planned.

Source guidance

Oesophago-gastric cancer: assessment and management in adults (2018) NICE guideline NG83, recommendation 1.3.1
The timeframe of 1 week is based on expert consensus.

Definitions of terms used in this quality statement

Radical treatment is suitable
The suitability of radical treatment depends on people having none of the following:
  • metastatic disease identified during earlier staging investigations (whole-body CT scan)
  • comorbidities, reduced fitness or performance status
  • personal preference to avoid surgery or chemoradiotherapy
  • tumour-related issues.
[Adapted from NICE’s guideline on oesophago-gastric cancer: full guideline, glossary, section 9.1.1; expert opinion].

Dietetic support

This quality statement is taken from the oesophago-gastric cancer quality standard. The quality standard defines clinical best practice for oesophago-gastric cancer and should be read in full.

Quality statement

Adults with oesophago-gastric cancer have tailored specialist dietetic support before and after radical treatment.

Rationale

Nutrition plays an important role in the management of oesophago-gastric cancer because of the physical changes associated with this type of cancer such as difficulty swallowing, loss of weight and malnutrition. Specialist dietetic support, tailored to the person’s clinical situation, can help manage specific difficulties associated with the complex nutritional needs of adults with oesophago-gastric cancer. This support would be ideally provided by a dietitian. People with better nutrition are more likely to have an improved quality of life.

Quality measures

Structure
Evidence of the availability of tailored, specialist dietetic support for adults with oesophago-gastric cancer before and after radical treatment.
Data source: Local data collection, for example, local protocols, staff rotas.
Process
a) Proportion of adults with oesophago-gastric cancer with radical treatment planned who have tailored, specialist dietetic support.
Numerator – the number in the denominator who have tailored, specialist dietetic support before radical treatment.
Denominator – the number of adults with oesophago-gastric cancer who have radical treatment planned.
Data source: Local data collection, for example, from patient records (such as a documented discussion with a dietitian or individualised care plan).
b) Proportion of adults with oesophago-gastric cancer who have tailored specialist dietetic support after radical treatment.
Numerator – the number in the denominator who have tailored specialist dietetic support after radical treatment.
Denominator – the number of adults with oesophago-gastric cancer who have radical treatment.
Data source: Local data collection, for example, from patient records (such as a documented discussion with a dietitian or individualised care plan).
Outcome
Health-related quality of life for adults who have radical treatment for oesophago-gastric cancer.
Data source: Local data collection. Health-related quality of life scores for adults with oesophago-gastric cancer, for example, ECOG (Eastern Cooperative Oncology Group) performance status scores from a survey of quality of life questionnaires.

What the quality statement means for different audiences

Service providers (specialist oesophago-gastric cancer centres/tertiary care centres) ensure that they have the expertise and capacity to support delivery of tailored specialist dietetic support before and after radical treatment for oesophago-gastric cancer in adults.
Healthcare professionals (such as dietitians and clinical nurse specialists) provide specialist tailored dietetic support to adults with oesophago-gastric cancer before and after radical treatment. The support should be tailored to individual needs, depending on the stage of disease and its effects. An optimal nutritional status helps people to complete a treatment that aims to remove or destroy the cancer completely.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services with capacity and expertise to enable adults with oesophago-gastric cancer to access tailored, specialist dietetic support before and after radical treatment. They should monitor contracts and seek evidence of support being provided.
Adults with oesophago-gastric cancer are helped with any problems they have eating or drinking both before and after treatment to remove the cancer (radical treatment). This should enable them to get the most from their diet so they are in the best possible health to start and recover from the treatment.

Source guidance

Oesophago-gastric cancer: assessment and management in adults (2018) NICE guideline NG83, recommendation 1.6.1

Definitions of terms used in this quality statement

Tailored specialist dietetic support
Specialist dietetic support could consist of:
  • advice about routes for delivering nutrition (including oral supplements, tube feeding, surgical jejunostomy, total parenteral nutrition) and their management in hospital and community settings (including support from home enteral feeding teams)
  • support (counselling, advice) to help adults with oesophago-gastric cancer adjust their diet to maximise their nutritional input after radical treatment. Examples include supporting them to choose suitable food and change the size of portions and frequency of meals in response to changes in tolerance of food after treatment.
The support should be tailored to the dietary requirements of the individual adult with oesophago-gastric cancer. It is important before, during and after radical treatment.
[Adapted from NICE’s guideline on oesophago-gastric cancer: full guideline, sections 5.1.7.2, 10.1.1, 10.1.7.6; expert opinion].

Equality and diversity considerations

People should be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with health and social care services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. People should have access to an interpreter or advocate if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

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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

Glossary

Paths in this pathway

Pathway created: January 2018 Last updated: December 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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