• Savtaj S Brar, Alyson L Mahar, Lucy K Helyer, Carol Swallow, Calvin Law, Lawrence Paszat, Rajini Seevaratnam, Roberta Cardoso, Robin McLeod, Matthew Dixon, Lavanya Yohanathan, Laercio G Lourenco, Alina Bocicariu, Tanios Bekaii-Saab, Ian Chau, Neal Church, Daniel Coit, Christopher H Crane, Craig Earle, Paul Mansfield, Norman Marcon, Thomas Miner, Sung Hoon Noh, Geoff Porter, Mitchell C Posner, Vivek Prachand, Takeshi Sano, Cornelis van de Velde, Sandra Wong, and Natalie G Coburn.
• Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
• JAMA Surg. 2014 Jan 1; 149 (1): 18-25.

ImportanceThere is growing interest in reducing the variations and deficiencies in the multidisciplinary management of gastric cancer.ObjectiveTo define optimal treatment strategies for gastric adenocarcinoma (GC).Design, Setting, And ParticipantsRAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries.InterventionsGastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care.Main Outcomes And MeasuresPanelists scored 416 scenarios regarding treatment scenarios for appropriateness from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Agreement was reached when 12 of 16 panelists scored the scenario similarly. Appropriate scenarios agreed on were subsequently scored for necessity.ResultsFor patients with T1N0 disease, surgery alone was considered appropriate, while there was no agreement over surgery alone for patients T2N0 disease. Perioperative chemotherapy was appropriate for patients who had T1-2N2-3 or T3-4 GC without major symptoms. Adjuvant chemoradiotherapy was classified as appropriate for T1-2N1-3 or T3-4 proximal GC and necessary for T1-2N2-3 or T3-4 distal GC. There was no agreement regarding surveillance imaging and endoscopy following gastrectomy. Surveillance endoscopy was deemed to be appropriate after endoscopic resection. For patients with metastatic GC, surgical resection was considered inappropriate for those with no major symptoms, unless the disease was limited to positive cytology alone, in which case there was disagreement.Conclusions And RelevancePatients with GC being treated with curative intent should be considered for multimodal treatment. For patients with incurable disease, surgical interventions should be considered only for the management of major bleeding or obstruction.

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