Oesophago-gastric cancer: assessment and management in adults

  • NICE guideline
  • NG83
  • Published: 
  • Last updated: 
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Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Health professionals should follow our general guidelines for people delivering care:

1.1 Information and support

1.1.1

Offer all people with oesophago-gastric cancer access to an oesophago-gastric clinical nurse specialist through the person's multidisciplinary team. [2018]

1.1.2

Provide psychosocial support to the person with oesophago-gastric cancer and those important to them (as appropriate). Cover:

  • the potential impact on family life, changing roles and relationships

  • uncertainty about the disease course and prognosis

  • concerns over heredity of cancer, recovery and recurrence

  • where they can get further support. [2018]

Radical treatment

1.1.3

Provide information about possible treatment options, such as surgery, radiotherapy or systemic anticancer therapy, 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. [2018]

Palliative management

1.1.4

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, and

  • dietary changes, and how to manage these and access specialist dietetic support. [2018]

1.1.5

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]

1.2 Organisation of services

1.2.1

Review the treatment of people with confirmed oesophago-gastric cancer in a multidisciplinary meeting that includes an oncologist and specialist radiologist with an interest in oesophago-gastric cancer. [2018]

1.2.2

Review the treatment of people with confirmed localised, non-metastatic oesophago-gastric cancer in a specialist oesophago-gastric cancer multidisciplinary meeting. [2018]

1.2.3

Ensure curative oesophago-gastric resections are done in a specialist surgical unit by specialist oesophago-gastric surgeons. [2018]

1.3 Assessment after diagnosis

Histologically‑confirmed oesophageal or gastro-oesophageal junction cancer after endoscopy and whole-body CT scan diagnosis

1.3.1

Offer F-18 FDG PET-CT to people with oesophageal and gastro-oesophageal junction 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 gastro-oesophageal junction tumours. [2018]

1.3.3

Offer endoscopic ultrasound to people with oesophageal and gastro-oesophageal junction cancer only if it will help guide ongoing management. [2018]

1.3.4

Consider staging laparoscopy for people with oesophageal or gastro-oesophageal junction cancer only if it will help guide ongoing management. [2018]

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

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

1.3.7

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

HER2 testing

1.3.8

Offer HER2 testing to people with advanced (locally advanced unresectable, advanced or metastatic) oesophago-gastric adenocarcinoma. [2018]

1.4 Radical treatment

Other treatment options may also be available for oesophago-gastric cancer. See the NHS England Cancer Drug Fund list.

Oesophageal and gastro-oesophageal junction cancer

T1N0 oesophageal cancer
1.4.1

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

Squamous cell carcinoma of the oesophagus
1.4.2

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 each option with the person and those who are important to them (as appropriate). [2018]

1.4.3

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

  • radical chemoradiotherapy or

  • chemoradiotherapy before surgical resection. [2018]

Oesophageal and gastro-oesophageal junction adenocarcinoma
1.4.5

For people with localised oesophageal and gastro-oesophageal junction adenocarcinoma (excluding T1N0 tumours) who are going to have surgical resection, offer:

  • chemotherapy, before or before and after surgery or

  • chemoradiotherapy, before surgery.

    Encourage people to join relevant clinical trials, if available. [2018]

Surgical treatment for oesophageal cancer
Lymph node dissection for oesophageal cancer
1.4.7

Consider two‑field lymph node dissection when performing a curative oesophagectomy for people with oesophageal cancer. [2018]

Adjuvant treatment for residual disease after complete resection of oesophageal or gastro-oesophageal junction cancer

Gastric cancer

1.4.9

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

1.4.10

Consider a D2 lymph node dissection when performing a curative gastrectomy for people with gastric cancer. [2018]

1.4.11

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

Peritoneal carcinomatosis

For people with peritoneal carcinomatosis, see NICE's HealthTech guidance on cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy, which recommends that this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.

1.5 Palliative management

Other treatment options may also be available for oesophago-gastric cancer. See the NHS England Cancer Drug Fund list.

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 1 or more of:

  • systemic anticancer therapy

  • local tumour treatment, including stenting or palliative radiotherapy

  • best supportive care. [2018]

1.5.3

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

Systemic anticancer therapy for untreated advanced oesophago-gastric cancer

1.5.4

Offer palliative combination chemotherapy to people with untreated advanced oesophago-gastric cancer who have a performance status of 0 to 2 and no significant comorbidities. Possible treatment 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.

    Capecitabine in combination with a platinum-based regimen is recommended as an option for untreated inoperable advanced gastric cancer. For full details, see NICE's technology appraisal guidance on capecitabine (TA191, 2010).

Oesophageal cancer
1.5.5

Pembrolizumab with platinum- and fluoropyrimidine-based chemotherapy is recommended as an option for untreated locally advanced unresectable or metastatic carcinoma of the oesophagus in adults whose tumours express PD‑L1 with a combined positive score (CPS) of 10 or more. For full details, see NICE's technology appraisal guidance on pembrolizumab (TA737, 2024).

1.5.6

Nivolumab with fluoropyrimidine-based and platinum-based combination chemotherapy is recommended as an option for untreated unresectable advanced, recurrent, or metastatic oesophageal squamous cell carcinoma in adults whose tumours express PD‑L1 at a level of 1% or more. It is recommended only if pembrolizumab plus chemotherapy is not suitable. For full details, see NICE's technology appraisal guidance on nivolumab (TA865, 2023).

1.5.7

Nivolumab with platinum- and fluoropyrimidine-based chemotherapy is recommended as an option for untreated HER2‑negative, advanced or metastatic oesophageal adenocarcinoma in adults whose tumours express PD‑L1 with a CPS of 5 or more. For full details, see NICE's technology appraisal guidance on nivolumab (TA857, 2023).

Gastric and gastro-oesophageal junction cancer
1.5.8

Pembrolizumab with platinum- and fluoropyrimidine-based chemotherapy is recommended as an option for untreated locally advanced unresectable or metastatic HER2‑negative gastric or gastro-oesophageal junction adenocarcinoma in adults whose tumours express PD‑L1 with a CPS of 1 or more. For full details, see NICE's technology appraisal guidance on pembrolizumab (TA997, 2024).

1.5.9

Nivolumab with platinum- and fluoropyrimidine-based chemotherapy is recommended as an option for untreated HER2‑negative, advanced or metastatic gastric or gastro-oesophageal junction adenocarcinoma in adults whose tumours express PD‑L1 with a CPS of 5 or more. For full details, see NICE's technology appraisal guidance on nivolumab (TA857, 2023).

1.5.10

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 gastro-oesophageal junction. [2018]

Trastuzumab in combination with cisplatin and capecitabine or 5-fluorouracil is recommended as an option for untreated HER2-positive metastatic adenocarcinoma of the stomach or gastro-oesophageal junction. For full details, see NICE's technology appraisal guidance on trastuzumab (TA208, 2010).

1.5.11

Zolbetuximab with fluoropyrimidine- and platinum-based chemotherapy is not recommended for untreated, locally advanced, unresectable or metastatic, claudin-18.2-positive, HER2-negative, gastric or gastro-oesophageal junction adenocarcinoma in adults. For full details, see NICE's technology appraisal guidance on zolbetuximab (TA1046, 2025).

1.5.12

Pembrolizumab with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy is not recommended for untreated locally advanced unresectable or metastatic HER2-positive gastric or gastro-oesophageal junction adenocarcinoma in adults whose tumours express PD-L1 with a CPS of 1 or more. For full details, see NICE's technology appraisal guidance on pembrolizumab (TA983, 2024).

Systemic anticancer therapy for previously treated advanced oesophago-gastric cancer

1.5.13

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

1.5.14

Consider a clinical trial (if a suitable one is available) for people with advanced oesophago-gastric cancer.

Oesophageal cancer
Gastric and gastro-oesophageal junction cancer
1.5.16

Pembrolizumab is recommended as an option for treating unresectable or metastatic gastric cancer with high microsatellite instability (MSI) or mismatch repair (MMR) deficiency that has progressed during or after 1 therapy. It should be stopped at 2 years of uninterrupted treatment, or earlier if the cancer progresses. For full details, see NICE's technology appraisal guidance on pembrolizumab (TA914, 2023).

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours

Luminal obstruction in oesophageal or gastro-oesophageal junction cancer

1.5.20

Offer self-expanding stents to people with oesophageal or gastro-oesophageal junction cancer who need immediate relief of dysphagia. [2018]

1.5.21

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

1.5.22

Do not routinely offer external beam radiotherapy after stenting for people with oesophageal or gastro-oesophageal junction cancer. [2023]

1.5.23

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on luminal obstruction in oesophageal and gastro-oesophageal junction cancer.

Full details of the evidence and the committee's discussion are in evidence review A: management of luminal obstruction in adults with oesophageal cancer not amenable to treatment with curative intent.

Outflow obstruction in gastric cancer

1.5.24

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

1.6 Nutritional support

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 gastro-oesophageal junction cancers. [2018]

Palliative care

1.6.4

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

1.7 Follow-up

1.7.1

For people who have no symptoms or evidence of residual disease after treatment for oesophago‑gastric cancer with curative intent:

  • provide information about the symptoms of recurrent disease, and what to do if they develop these symptoms

  • offer rapid access to the oesophago-gastric multidisciplinary team for review, if symptoms develop. [2018]

1.7.2

For people who have no symptoms or evidence of residual disease after treatment for oesophago‑gastric cancer with curative intent, do not offer:

  • routine clinical follow up solely to detect recurrent disease

  • routine radiological surveillance solely to detect recurrent disease. [2018]