Radical treatment

1.1.5.

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. [2018]

Palliative management

1.1.6.

For people with oesophago-gastric cancer 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. [2018]

1.1.7.

For people with oesophago-gastric cancer who can only have palliative management, consider providing support from:

• a specialist cancer care dietitian
• a specialist palliative care team
• a peer support group, if available. [2018]

1.1.8.

For people with oesophago-gastric cancer who are having palliative care, follow the recommendations in NICE’s guideline on improving supportive and palliative care for adults with cancer. [2018]

Determining suitability for radical treatment of histologically-confirmed oesophageal or oesophago-gastric junctional cancer after endoscopy and whole-body CT scan diagnosis

1.3.1.

Offer F-18 FDG PET-CT to people with oesophageal and oesophago-gastric junctional tumours that are suitable for radical treatment (except for T1a tumours). [2018]

1.3.2.

Do not offer endoscopic ultrasound only to distinguish between T2 to T3 tumours in people with oesophageal and oesophago-gastric junctional tumours. [2018]

1.3.3.

Only offer endoscopic ultrasound to people with oesophageal and oesophago-gastric junctional cancer when it will help guide ongoing management. [2018]

1.3.4.

Only consider staging laparoscopy for people with oesophageal or oesophago-gastric junctional cancer when it will help guide ongoing management. [2018]

Determining suitability for radical treatment of histologically-confirmed gastric cancer after endoscopy and whole-body CT scan diagnosis

1.3.5.

Offer staging laparoscopy to all people with potentially curable gastric cancer. [2018]

1.3.6.

Only consider endoscopic ultrasound for people with gastric cancer if it will help guide ongoing management. [2018]

1.3.7.

Only consider F-18 FDG PET-CT in people with gastric cancer if metastatic disease is suspected and it will help guide ongoing management. [2018]

HER2 testing in metastatic oesophago-gastric adenocarcinoma

1.3.8.

Offer HER2 testing to people with metastatic oesophago-gastric adenocarcinoma (see the NICE technology appraisal guidance on trastuzumab for HER2-positive metastatic gastric cancer). [2018]

T1N0 oesophageal cancer

1.4.1.

Offer endoscopic mucosal resection for staging for people with suspected T1N0 oesophageal cancer. [2018]

1.4.2.

For recommendations on stage 1 oesophageal adenocarcinoma, see NICE’s guideline on Barrett’s oesophagus and oesophageal adenocarcinoma: monitoring and management. [2018]

1.4.3.

Offer people with T1bN0 squamous cell carcinoma of the oesophagus the choice of:

• definitive chemoradiotherapy or
• surgical resection.
  Only make this choice after the surgeon and oncologist have discussed the benefits, risks and treatment consequences of each option with the person and those who are important to them (as appropriate). [2018]

Surgical treatment of oesophageal cancer

1.4.4.

Consider an open or minimally invasive (including hybrid) oesophagectomy for surgical treatment of oesophageal cancer. [2018]

Lymph node dissection in oesophageal and gastric cancer

1.4.5.

When performing a curative gastrectomy for people with gastric cancer, consider a D2 lymph node dissection. [2018]

1.4.6.

When performing a curative oesophagectomy for people with oesophageal cancer, consider two-field lymph node dissection. [2018]

Localised oesophageal and oesophago-gastric junctional adenocarcinoma

1.4.7.

For people with localised oesophageal and oesophago-gastric junctional adenocarcinoma (excluding T1N0 tumours) who are going to have surgical resection, offer a choice of:

• chemotherapy, before or before and after surgery or
• chemoradiotherapy, before surgery.
  Make the choice after discussing the benefits, risks and treatment consequences of each option with the person and those important to them (as appropriate).
  Encourage people to join relevant clinical trials, if available. [2018]

Gastric cancer

1.4.8.

Offer chemotherapy before and after surgery to people with gastric cancer who are having radical surgical resection. [2018]

1.4.9.

Consider chemotherapy or chemoradiotherapy after surgery for people with gastric cancer who did not have chemotherapy before surgery with curative intent. [2018]

Squamous cell carcinoma of the oesophagus

1.4.10.

Offer people with resectable non-metastatic squamous cell carcinoma of the oesophagus the choice of:

• radical chemoradiotherapy or
• chemoradiotherapy before surgical resection.
  Discuss the benefits, risks and treatment consequences of each option with the person and those who are important to them (as appropriate). [2018]

Non-metastatic oesophageal cancer that is not suitable for surgery

1.5.1.

Consider chemoradiotherapy for people with non-metastatic oesophageal cancer that can be encompassed within a radiotherapy field. [2018]

1.5.2.

When the cancer cannot be encompassed within a high-dose radiotherapy field, consider one or more of:

• chemotherapy
• local tumour treatment, including stenting or palliative radiotherapy
• best supportive care.
  Discuss the benefits, risks and treatment consequences of each option with the person with oesophageal cancer and those who are important to them (as appropriate). [2018]

1.5.3.

After a person with oesophageal cancer has had treatment, assess the tumour’s response to chemotherapy or chemoradiotherapy and reconsider if surgery is an option. [2018]

First-line palliative chemotherapy for locally advanced or metastatic oesophago-gastric cancer

1.5.4.

Offer trastuzumab (in combination with cisplatin and capecitabine or 5-fluorouracil) as a treatment option to people with HER2-positive metastatic adenocarcinoma of the stomach or oesophago-gastric junction (see also NICE’s technology appraisal guidance on trastuzumab for the treatment of HER2-positive metastatic gastric cancer).

In January 2018, this was an off-label use of cisplatin. See NICE’s information on prescribing medicines. [2018]

1.5.5.

Offer first-line palliative combination chemotherapy to people with advanced oesophago-gastric cancer who have a performance status 0 to 2 and no significant comorbidities. Possible drug combinations include:

• doublet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin
• triplet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin.
  Discuss the benefits, risks and treatment consequences of each option with the person and those important to them (as appropriate).
  In January 2018, this was an off-label use of capecitabine, cisplatin, epirubicin and oxaliplatin. See NICE’s information on prescribing medicines.
  For all NICE technology appraisal guidance on first-line palliative chemotherapy, see the NICE topic pages for oesophageal cancer and stomach cancer. [2018]

Second-line palliative chemotherapy and subsequent therapy for locally advanced or metastatic oesophago-gastric cancer

1.5.6.

Consider second-line palliative chemotherapy for people with oesophago-gastric cancer. [2018]

1.5.7.

Discuss the risks, benefits and treatment consequences of second-line palliative chemotherapy for oesophago-gastric cancer with the person and those who are important to them (as appropriate). Cover:

• how different treatments can have similar effectiveness but different side effects
• how the treatments are given
• if the person has any preference for one treatment over another. [2018]

1.5.8.

Consider a clinical trial (if a suitable one is available) as an alternative to second-line chemotherapy for people with oesophago-gastric cancer.

For NICE technology appraisal guidance on second-line palliative chemotherapy and subsequent therapy, see the NICE topic pages for oesophageal cancer and stomach cancer. The point at which to use genomic biomarker-based therapy in solid tumour treatment pathways is uncertain, see the NICE topic page on genomic biomarker-based cancer treatments. [2018]

Luminal obstruction in oesophageal and oesophago-gastric junctional cancer

1.5.9.

Offer self-expanding stents to people with oesophageal and oesophago-gastric junctional cancer who need immediate relief of dysphagia. [2018]

1.5.10.

Offer self-expanding stents or radiotherapy to people with oesophageal and oesophago-gastric junctional cancer, depending on the degree of dysphagia and its impact on nutrition and quality of life, performance status and prognosis. [2018]

1.5.11.

Do not routinely offer external beam radiotherapy after stenting for people with oesophageal and oesophago-gastric junctional cancer. [2023]

1.5.12.

Consider external beam radiotherapy after stenting of oesophageal and oesophago-gastric junctional cancer for people with prolonged post-interventional bleeding or a known bleeding disorder. [2023]

Outflow obstruction in gastric cancer

1.5.13.

Offer uncovered self-expanding metal stents or palliative surgery to people with gastric cancer, depending on fitness to undergo surgery, prognosis and extent of disease. [2018]

Radical treatment

1.6.1.

Offer nutritional assessment and tailored specialist dietetic support to people with oesophago-gastric cancer before, during and after radical treatments. [2018]

1.6.2.

Offer immediate enteral or parenteral nutrition after surgery to people who are having radical surgery for oesophageal and oesophago-gastric junctional cancers. [2018]

1.6.3.

For people with oesophago-gastric cancer, follow the recommendations in NICE’s guideline on nutrition support for adults. [2018]

Palliative care

1.6.4.

Consider support from a specialist cancer-specific dietitian for people with oesophago-gastric cancer receiving palliative care. [2018]

1.6.5.

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. [2018]

1.6.6.

For people with oesophago-gastric cancer, follow the recommendations in NICE’s guideline on improving supportive and palliative care for adults with cancer. [2018]

Why this is important

The aetiology of squamous cell carcinoma (SCC) of the oesophagus is changing. Patients with SCC are now fitter, with fewer comorbidities than in previous years. Standard radical treatment for SCC of the oesophagus is usually chemoradiotherapy, which is associated with a median survival of between 12 and 18 months. Given a fitter patient population, surgery may be a therapeutic option but its effectiveness in addition to chemoradiotherapy is unknown and a randomised controlled study to investigate whether the combination improves disease-free and overall survival would provide useful information to guide future clinical practice.

Why this is important

In patients with submucosal (T1b) N0 oesophageal adenocarcinoma (OAC), the associated risk of lymph node metastases is estimated to be between 4% for sub-mucosal 1 (sm1) and up to 16% for sm3 based on retrospective surgical data. The majority of patients with a submucosal T1bN0 OAC therefore currently have major surgical resection without detecting any cancer cells in the oesophagus or lymph nodes. Oesophagectomy is also a procedure associated with significant morbidity (up to 50%) and mortality (2% to 4%).

In comparison, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are techniques that can remove the submucosa with less morbidity and mortality than surgery and, providing there is no lymph node involvement, can lead to a cure. However, compared to surgery nodal involvement can only be assessed by F-18 FDG PET-CT scanning and endoscopic ultrasound (EUS), which may lead to under-treatment of some patients with T1b disease.

A study to assess which patients should have endoscopic therapy or surgery for T1bN0 OAC would be useful, as this would help prevent both under- and over-treatment of this group of people. This could be a randomised controlled trial comparing surgery and endoscopic treatment.

Why this is important

People who have surgery for oesophago-gastric cancer have a prolonged period without adequate oral intake after surgery. Oral, enteral and parenteral nutrition support strategies are used to support people during this time. Evidence suggests that providing some form of nutrition support improves surgical outcomes. However, which of these methods is the safest and most effective has not been determined and because of this, practice in this field varies nationally. A study to identify the best method of delivering safe and effective nutritional support interventions which aim to reduce post-operative complications in this population would help guide future clinical practice.

Why this is important

People who have had surgery for oesophago-gastric cancer have nutritional difficulties as a result of problems eating, ongoing symptoms, and side effects related to the surgery. It is well recognised that they have a poor quality of life. Most patients have adjuvant treatment, however their nutritional status may negatively impact on their ability to tolerate this, meaning treatment can be stopped early or not received. Jejunostomy feeding tubes are often used to provide nutrition support after discharge from hospital after surgery.

Some small studies have shown a benefit in terms of weight preservation, but none have shown that this leads to better recovery, tolerance of treatment or quality of life. Practice in this area varies greatly, with some centres placing jejunostomy tubes and continuing enteral feeding after discharge, some placing the jejunostomy tubes and not using them routinely and others not placing jejunostomy tubes at all. Studies should aim to identify if jejunostomy placement leads to clinical benefit in adults who have had surgery for oesophago-gastric cancer.

Why this is important

There is no clearly defined follow-up protocol for people with oesophago-gastric cancer treated radically. Detection of early recurrence potentially suitable for radical treatment offers the possibility of increased survival. However, the best methods of detecting recurrence are unclear and there is no evidence to show whether early detection leads to improved overall survival. The alternative is to wait until symptoms reoccur and then reevaluate the further treatment options available. Studies examining the role of screening in this scenario would show whether routine follow-up in asymptomatic people was effective at detecting recurrence and improving overall survival.

Why the committee made the recommendations

Recommendations 1.5.9 to 1.5.12

The committee did not find any new evidence that would affect recommendations 1.5.9 and 1.5.10 and therefore did not update the recommendations made by the previous committee on the basis of the evidence they considered (see the previous full guideline from 2018).

Most of the evidence considered by the committee did not show a difference between the effectiveness of different interventions for relieving dysphagia caused by luminal obstruction of the oesophagus in people with oesophageal and oesophago-gastric junctional cancer whose condition was not being treated with curative intent. A high quality, UK-based health technology assessment provided new evidence on external beam radiotherapy (EBRT) after stenting for people with dysphagia whose condition needed palliation.

This study compared self-expanding metal stents (SEMS) alone to SEMS and adjuvant EBRT and concluded that the data could not differentiate between them for all outcomes considered in the evidence review. The committee agreed that they did not support the routine use of EBRT for people after stenting. However, the committee noted that there was some evidence of better outcomes for gastrointestinal-related bleeding. Although this was of low certainty, they agreed that from their experience EBRT helps to prevent bleeding. Therefore, they made a recommendation to consider EBRT for people with prolonged bleeding after stent insertion or a known bleeding disorder. Stopping bleeding is important to people who have incurable oesophageal and oesophago-gastric junctional cancer because it improves their quality of life. The committee made a recommendation for research about the use of EBRT to prevent bleeding because there was not enough evidence to make a strong recommendation about it.

The committee agreed that only offering EBRT after stent insertion to people with oesophageal and oesophago-gastric junctional cancer if they had prolonged bleeding or a known bleeding disorder would lead to more effective targeting of comparatively scarce EBRT services. Furthermore, it will reduce the treatment burden for people with oesophageal and oesophago-gastric junctional cancer who are not bleeding from the cancer site, or do not have a known bleeding disorder, and their carers and relatives. This is because they will not have the inconvenience of travelling for unnecessary EBRT treatment and the side effects associated with it.

The committee made a recommendation for research on the effectiveness of enteral feeding for people who have dysphagia caused by luminal obstruction as no evidence was found.

How the recommendations might affect practice

The committee agreed that the new recommendations are likely to be cost saving because they will reduce the number of people receiving EBRT after stenting, and the number of different treatments that most people receive since most people will not receive EBRT.

Resources for EBRT after stent insertion can be more effectively directed to people with incurable oesophageal and oesophago-gastric junctional cancer who have prolonged bleeding or a known bleeding disorder.

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