Oesophago-gastric cancer: assessment and management in adults

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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