Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Risk Factors and Risk Factor Modification
Risk Factors
B - A healthy lifestyle (not smoking, not consuming excess alcohol, avoiding obesity, and maintaining a good dietary intake of fibre, fruit, and vegetables) is associated with reduced risk of oesophageal and gastric cancer and should be encouraged.
Risk Factor Modification
C - Reduction of risk of progression to adenocarcinoma is not an indication for anti-reflux surgery in patients with Barrett's oesophagus.
Chemoprevention
D - Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) should not be used for chemoprevention of oesophageal and gastric cancer.
Presentation and Referral
Uncomplicated Dyspepsia
B - A test and treat policy for Helicobacter pylori should be employed in the initial management of patients with uncomplicated dyspepsia.
C - Irrespective of age, patients should be reviewed after H. pylori eradication treatment. For those with recurrent or persistent symptoms the need for further assessment, including endoscopy, should be considered.
Symptoms of Gastro-oesophageal Reflux
C - In patients with gastro-oesophageal reflux symptoms, endoscopy with the intention of identifying cancer is not indicated unless an alarm symptom is also present.
Alarm Symptoms
B - Patients presenting with any of the following alarm symptoms should be referred for early endoscopy:
- Dysphagia
- Recurrent vomiting
- Anorexia
- Weight loss
- Gastrointestinal blood loss
Diagnosis
Upper Gastrointestinal (GI) Endoscopy
C - Flexible upper GI endoscopy is recommended as the diagnostic procedure of choice in patients with suspected oesophageal or gastric cancer.
Chromoendoscopy
D - Routine use of chromoendoscopy during upper GI endoscopy is not recommended, but may be of value in selected patients at high risk of oesophageal or gastric malignancy.
Histological Diagnosis
Biopsy Technique
C - A minimum of eight biopsies should be taken to achieve a diagnosis of oesophageal malignancy.
C - In patients with Barrett's oesophagus there should be a structured biopsy protocol with quadrantic biopsies every two centimetres and biopsy of any visible lesion.
Histopathology
C - Pathologists should follow the revised Vienna classification for reporting dysplasia.
C - Where radical intervention is contemplated on the basis of high grade dysplasia or early adenocarcinoma the diagnosis should be validated by a second pathologist experienced in this area and further biopsies should be taken if there is uncertainty.
C - Evaluation of suspected high grade dysplasia in Barrett's oesophagus biopsies should be undertaken with knowledge of the clinical and endoscopic background and biopsies should be reviewed at a multidisciplinary meeting with access to the clinical information.
Assessment and Staging
Staging Modalities and Techniques
Computerised Tomography (CT)
B - In patients with oesophageal or gastric cancer CT scan of the chest and abdomen with intravenous contrast and gastric distension with oral contrast or water should be performed routinely. The liver should be imaged in the portal venous phase.
Endoscopic Ultrasound
B - Patients with oesophageal or oesophagogastric junction cancers who are candidates for any curative therapy should have their tumours staged with endoscopic ultrasound (EUS) +/- fine needle aspiration.
Laparoscopy, Cytology and Ultrasound
C - Laparoscopy should be considered in patients with oesophageal tumours with a gastric component, and in patients with gastric tumours being considered for surgery where full thickness gastric wall involvement is suspected.
Magnetic Resonance Imaging
C - Magnetic resonance imaging (MRI) should be reserved for those patients who cannot undergo CT, or used for additional investigation following CT/EUS.
Bronchoscopy
D - Bronchoscopy +/- bronchoscopic ultrasound (BUS) +/- biopsy should be undertaken in patients with clinical or imaging features suspicious of tracheobronchial invasion.
Thoracoscopy
D - Thoracoscopy may be considered for patients where a tissue diagnosis of suspicious nodes (not possible by either EUS or CT guided techniques) is required to determine optimum management.
Positron Emission Tomography (PET)
C - PET is not routinely indicated in the staging of oesophageal and gastric cancers.
Neck Imaging
D - Neck imaging either by US or CT is recommended as part of the staging of oesophageal cancer.
Implications of Tumor Stage
Tumor Stage, Treatment, and Survival
B - Patients with gastric or oesophageal cancer should undergo careful preoperative staging to enable targeting of potentially curative treatment to those likely to benefit.
B - Patients with gastric or oesophageal cancer who have distant metastases or patients with oesophageal cancer who have metastatic lymph nodes in three compartments (neck, mediastinum, and abdomen) on preoperative staging are not candidates for curative treatment.
C - When M1a nodal involvement in oesophageal cancer, or extensive lymphadenopathy in any cancer, is identified on preoperative staging, the anticipated poor prognosis should be carefully considered when discussing treatment options.
Tumor Stage and Quality of Life
D - The possibility of reduction in quality of life after surgery should be considered when discussing treatment options, particularly when preoperative staging suggests that surgery would be unlikely to be curative.
Assessment of Preoperative Fitness
B - All patients being considered for surgery should undergo careful assessment of fitness with emphasis on performance status and respiratory function.
Pathological Staging of Resected Specimens
Important Pathological Parameters
B - Resection specimens of oesophageal and gastric cancer resections should be reported according to, or supplemented by, the Royal College of Pathologists' minimum data sets.
Treatment Principles
Information, Communication, and Support
D - Information relating to local and national support services should be made available to both patients and carers.
Ongoing Support/Follow Up
D - Follow up of patients with oesophageal or gastric cancer should monitor symptoms, signs and nutritional status.
Surgery
Service Delivery
B - Oesophageal and gastric cancer resectional surgery should be carried out in high volume specialist surgical units by frequent operators.
Type Of Operation
B - Surgery for oesophageal or gastric cancer should be aimed at achieving an R0 resection (proximal, distal, and circumferential margin clearance).
Reconstruction
After Oesophagectomy
B - Following oesophagectomy, the route of reconstruction and potential use of pyloric drainage procedure should be determined by the surgeon based on their individual experience.
After Gastrectomy
B - Consideration should be given to pouch formation after total gastrectomy.
Lymphadenectomy
Oesphagus
D - Two-field lymphadenectomy should be considered during oesophagectomy to improve staging and local disease control.
B - Routine extension of lymphadenectomy into the superior mediastinum or neck should not be carried out.
Stomach
B - D2 lymphadenectomy, with a minimum of 25 lymph nodes removed, considered for patients undergoing gastrectomy. Routine resection of additional organs (spleen and pancreas) during gastrectomy is not recommended.
Anaesthetic Management
D - The routine use of epidural analgesia is recommended in gastric and oesophageal cancer surgery.
Perioperative Nutritional Status
B - Patients undergoing surgery for oesophageal or gastric cancer who are identified as being at high nutritional risk should be considered for preoperative nutritional support.
B - All patients undergoing surgery for oesophageal or gastric cancer should be considered for early postoperative nutritional support preferably by the enteral route.
Endoscopic Treatments With Curative Intent
High Grade Dysplasia
B - Patients diagnosed with high grade dysplasia should have careful assessment (CT, EUS, rigorous biopsy protocol +/- endoscopic mucosal resection [EMR]) to exclude coexisting cancer.
B - In the absence of invasive cancer, patients with high grade dysplasia should be offered endoscopic treatment.
C - The assessment and management of patients with high grade dysplasia should be centralised to units with the appropriate endoscopic facilities and expertise.
Early Cancer
B - Superficial oesophageal cancer limited to the mucosa and early gastric cancer limited to the superficial submucosa should be treated by EMR.
D - Mucosal ablative techniques such as photodynamic therapy (PDT), argon plasma coagulation (APC), or laser should be reserved for the management of residual disease after EMR and not for initial management if invasive disease is present in patients fit for surgery.
Neoadjuvant and Adjuvant Therapies
Oesophageal Cancer
Neoadjuvant (Preoperative) Therapies
Chemotherapy In Patients With Oesophageal Cancer
B - Patients with operable oesophageal cancer, who are treated surgically, should be considered for two cycles of preoperative chemotherapy with cisplatin and 5-fluorouracil or offered entry into a clinical trial.
Chemoradiotherapy in Patients with Oesophageal Cancer
B - Preoperative chemoradiotherapy for patients with oesophageal cancer is not recommended outside clinical trials.
Radiotherapy in Patients with Oesophageal Cancer
A - Preoperative radiotherapy is not recommended for patients with oesophageal cancer
Adjuvant (Postoperative) Therapies
Chemotherapy in patients with oesophageal cancer
A - Postoperative adjuvant chemotherapy is not recommended for patients with oesophageal cancer
Gastric Cancer
Neoadjuvant (Preoperative) Therapies
A - The neoadjuvant use of either chemotherapy or radiotherapy for patients with gastric cancer is not recommended outside clinical trials.
Adjuvant (Postoperative) Therapies
Chemotherapy in Patients with Gastric Cancer
B - Postoperative chemotherapy for patients with gastric cancer is not recommended outside a clinical trial.
C - Intraperitoneal chemotherapy and immunotherapy for patients with gastric cancer are not recommended outside a clinical trial.
Downstaging Advanced Oesophageal and Gastric Cancers
D - Patients with locally advanced disease having chemotherapy/chemoradiotherapy should have their response assessed for an impact on the potential to operate; following a good response the patient should be restaged and the role of surgery re-evaluated by the multidisciplinary team.
Non-Surgical Treatments with Curative Intent
Chemoradiotherapy
C - Chemoradiotherapy should be considered in patients with oesophageal cancer who have locally advanced disease, those unfit for surgery, or those who decline surgery.
Radiotherapy
D - In patients with oesophageal cancer who are not suitable for surgery and intolerant to chemoradiotherapy, single modality radiotherapy can be used as a curative treatment in localised disease.
Palliative Care
Changing Priorities: Quality Of Life, Comorbidity and Performance Status
C - Studies of palliative treatments in patients with oesophageal or gastric cancer should use validated questionnaires to measure quality of life outcomes and should include comorbidity and performance status.
Supportive and Palliative Care
D - Studies of supportive care should clearly define interventions and use validated quality of life end points.
Role of Palliative Care Teams
C - Patients with oesophageal or gastric cancer should have access to a specialist palliative care team.
Endoscopic Ablative Therapies
B - Laser or photodynamic therapy should be used for initial control of obstructive symptoms caused by exophytic tumours in the oesophagus including tumours near the upper oesophageal sphincter.
D - Laser or photodynamic therapy should be considered for control of tumour overgrowth in stented patients.
Stenting
Oesophagus
B - Partially covered self expanding metal stents are the intubation of choice for patients with obstructive oesophageal symptoms.
C - Partially covered self expanding metal stents should be used to control obstructive oesophageal symptoms either following or instead of laser therapy, depending on the availability of local expertise.
Dilatation
D - The use of oesophageal dilatation alone should be avoided.
Palliative Surgery
Palliative Resection of the Oesphagus
C - Oesophagectomy (transthoracic or transhiatal) should not be performed with palliative intent in patients with oesophageal cancer.
Palliative Bypass For Oesophageal Cancer
D - Substernal bypass for oesophageal cancer should not be performed with palliative intent.
Palliative Resection of the Stomach
C - Palliative gastrectomy should be avoided in patients with gastric cancer who have disseminated peritoneal disease.
D - D2 lymphadenectomy should be avoided in patients with gastric cancer in the palliative setting.
D - Health professionals should take the following factors into account when considering palliative gastric resection:
- Peritoneal disease (favour minimal)
- Tumour diameter (favour <100 mm)
- Histological type (favour Lauren intestinal type)
- Degree of differentiation (favour moderate to good differentiation)
Palliative Gastric Bypass
D - Laparoscopic bypass or gastric outlet stenting are alternatives to palliative gastric bypass.
D - Palliative gastric bypass should be avoided when malignant ascites or small bowel obstruction are present.
Exploratory Laparotomy
D - Exploratory laparotomy alone should be avoided.
Palliative Chemotherapy and Radiotherapy
Palliative Chemotherapy
B - In patients with locally advanced or metastatic cancer of the oesophagus or stomach with good performance status combination chemotherapy including cisplatin and infusional 5-FU (such as epirubicin, cisplatin and continuous 5-fluorouracil [ECF] or mitomycin C, cisplatin and continuous 5-fluorouracil [MCF]) should be considered.
External-Beam Radiotherapy
D - Palliative external-beam radiotherapy is an appropriate option for the treatment of mild dysphagia in patients with oesophageal cancer.
Brachytherapy
D - Endoluminal brachytherapy is an option for patients with dysphagia from oesophageal cancer.
Control of Other Symptoms
Pain
D - The principles of treatment outlined in the World Health Organisation pain relief programme should be followed (WHO analgesic ladder).
C - Coeliac axis plexus block should be considered in patients with severe upper abdominal pain who are intolerant of, or have pain unresponsive to, other analgesic measures.
Anorexia and Cachexia
D - Corticosteroids or megestrol acetate should be considered for patients with advanced oesophageal or gastric cancer who are anorexic.
Nausea and Vomiting
D - Octreotide and corticosteroids should be considered to relieve symptoms of bowel obstruction caused by malignancy where interventional therapy is not possible or appropriate.
Anemia
C - Blood transfusion is recommended as the standard treatment for symptomatic anaemia.
D - Erythropoietin use should be considered in accordance with agreed guidelines.
Definitions:
Grades of Recommendations
Grade A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Grade D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
