Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

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.

1.1.2 Make sure the person with oesophago-gastric cancer is given information, in a format that is appropriate for them, to take away and review in their own time after you have spoken to them about their cancer and care.

1.1.3 Inform people with oesophago-gastric cancer about peer-to-peer local or national support groups for them to join if they wish.

1.1.4 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.

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.

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.

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.

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

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.

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

1.2.3 Ensure curative oesophago-gastric resections are performed in a specialist surgical unit by specialist oesophago-gastric surgeons.

1.3 Assessment after diagnosis

Determining suitability for radical treatment of histologically-confirmed oesophageal or gastro-oesophageal junctional 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 junctional tumours that are suitable for radical treatment (except for T1a tumours).

1.3.2 Do not offer endoscopic ultrasound only to distinguish between T2–T3 tumours in people with oesophageal and gastro-oesophageal junctional tumours.

1.3.3 Only offer endoscopic ultrasound to people with oesophageal and gastro-oesophageal junctional cancer when it will help guide ongoing management.

1.3.4 Only consider staging laparoscopy for people with oesophageal or gastro-oesophageal junctional cancer when it will help guide ongoing management.

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.

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

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.

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).

1.4 Radical treatment

T1N0 oesophageal cancer

1.4.1 Offer endoscopic mucosal resection for staging for people with suspected T1 oesophageal cancer.

1.4.2 Offer endoscopic eradication of remaining Barrett's mucosa for people with T1aN0 oesophageal cancer.

1.4.3 For recommendations on the treatment of Barrett's oesophagus, see the NICE guideline on Barrett's oesophagus: ablative therapy.

1.4.4 Offer radical resection for people with T1bN0 oesophageal adenocarcinoma if they are fit enough to have surgery.

1.4.5 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).

Surgical treatment of oesophageal cancer

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

Lymph node dissection in oesophageal and gastric cancer

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

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

Localised oesophageal and gastro-oesophageal junctional adenocarcinoma

1.4.9 For people with localised oesophageal and gastro-oesophageal 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.

Gastric cancer

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

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

Squamous cell carcinoma of the oesophagus

1.4.12 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).

1.5 Palliative management

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.

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).

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.

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

1.5.4 Offer trastuzumab (in combination with cisplatin[1] and capecitabine or 5-fluorouracil) as a treatment option to people with HER2-positive metastatic adenocarcinoma of the stomach or gastro-oesophageal junction (see the NICE technology appraisal guidance on trastuzumab for the treatment of HER2-positive metastatic gastric cancer).

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[2] in combination with cisplatin[1] or oxaliplatin[3]

  • triplet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin[4].

    Discuss the benefits, risks and treatment consequences of each option with the person and those important to them (as appropriate).

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

1.5.6 Consider second-line palliative chemotherapy for people with oesophago-gastric cancer.

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.

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.

Luminal obstruction in oesophageal and gastro-oesophageal junctional cancer

1.5.9 Offer self-expanding stents to people with oesophageal and gastro-oesophageal junctional cancer who need immediate relief of dysphagia.

1.5.10 Offer self-expanding stents or radiotherapy as primary treatment to people with oesophageal and gastro-oesophageal junctional cancer, depending on the degree of dysphagia and its impact on nutrition and quality of life, performance status and prognosis.

1.5.11 Consider external beam radiotherapy after stenting for people with oesophageal and gastro-oesophageal junctional cancer, for long-term disease control.

Outflow obstruction in gastric cancer

1.5.12 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.

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.

1.6.2 Offer immediate enteral or parenteral nutrition after surgery to people who are having radical surgery for oesophageal and gastro-oesophageal junctional cancers.

1.6.3 For people with oesophago-gastric cancer, follow the recommendations in the NICE guideline on nutrition support for adults.

Palliative care

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

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.

1.6.6 For people with oesophago-gastric cancer, follow the recommendations in the NICE guideline on improving supportive and palliative care for adults with cancer.

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.

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 for the detection of recurrent disease

  • routine radiological surveillance solely for the detection of recurrent disease.



[1] Although this use is common in UK clinical practice, at the time of publication (January 2018), cisplatin did not have a UK marketing authorisation for oesophageal or gastric cancer. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[2] Although this use is common in UK clinical practice, at the time of publication (January 2018), capecitabine did not have a UK marketing authorisation for oesophageal cancer. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[3] Although this use is common in UK clinical practice, at the time of publication (January 2018), oxaliplatin did not have a UK marketing authorisation for oesophageal or gastric cancer. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[4] Although this use is common in UK clinical practice, at the time of publication (January 2018), epirubicin did not have a UK marketing authorisation for oesophageal cancer. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

  • National Institute for Health and Care Excellence (NICE)