Oesophago-gastric cancer: assessment and management in adults

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]

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]

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]

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]

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]

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

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

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

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

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

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]

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]

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

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

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]

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

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

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

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]

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

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

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]

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

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]

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]

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]

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]

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

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]

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]

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

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]

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

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]

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]

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

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

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

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

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]

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