Processes of care in curative therapy for gastric cancer: A RAND/UCLA appropriateness study.

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104 Background: Processes of care in curative therapy for gastric cancer are ill-defined, have significant variations and may impact patient outcomes. Methods: A multi-disciplinary expert panel (16 physicians, 6 countries) scored 595 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1-3 were considered inappropriate, 4-6 uncertain, and 7-9 appropriate. Agreement was reached when 11 of 16 panelists scored the statement similarly. If a statement was agreed to be appropriate, it was given a necessity score in the same manner. Results: Open gastrectomy was considered appropriate for all patients and necessary for patients with N2-3 disease, while laparoscopic gastrectomy was appropriate for patients with T1-2 N0 disease. D1 lymph node dissection (LND) was considered appropriate for T1 N0 disease. For all others, D2 LND was considered appropriate and necessary. It was appropriate to assess at least 15 LN. Intraoperative pathologic assessment of the proximal margin was considered appropriate for gross margins <5 cm or T3/T4 lesions. If the margin was positive on frozen section, re-resection of the stomach or abdominal esophagus was considered appropriate for N1-3 disease and necessary for N0 disease. Curative resection was appropriate if a patient presented with perforation. Neoadjuvant chemotherapy was considered appropriate for patients who presented with T1-2 N2-3 or T3-4 N0-3 disease with minor symptoms but not with major symptoms. Adjuvant chemoradiotherapy was considered appropriate and necessary for patients with T1-2 N1-3 or T3-4 N0-3 disease. No adjuvant therapy was considered appropriate for patients with T1N0 disease. Conclusions: The above criteria have been found to be appropriate and necessary for the curative treatment of patients with gastric cancer and may be used to improve processes and quality of care.