Appropriateness Scores Research Articles

A RAND/UCLA Appropriateness Study of the Management of Familial Gastric Cancer

Hereditary diffuse gastric cancer (HDGC) represents a minority of gastric cancer (GC) cases. The goal of this study is to use a RAND/University of California Los Angeles (UCLA) appropriateness methodology to examine indications for genetic referral, CDH1 testing, and consideration of prophylactic total gastrectomy (PTG). A multidisciplinary expert panel of 16 physicians from six countries scored 47 scenarios. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) of 1-3 were considered inappropriate, 4-6 uncertain, and 7-9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed upon were subsequently scored for necessity. The panel felt that patients with family history of diffuse gastric cancer (DGC), lobular breast cancer, or multiple family members with GC should be referred for genetic assessment and multidisciplinary decision-making. The panel felt that it is appropriate for patients with DGC to have CDH1 mutation testing in a family with (1) ≥2 cases of GC, with at least one case of DGC diagnosed before age of 50 years; (2) ≥3 cases of GC diagnosed at any age, one or more of which is DGC; (3) a patient diagnosed with DGC and lobular breast carcinoma; or (4) patients diagnosed with DGC under age of 35 years. The panel felt that PTG should be offered to CDH1 mutation carriers 20 years or older. Identification of genetic mutations in patients at risk for hereditary GC is important, and criteria for testing are suggested.

A RAND/UCLA appropriateness study of the management of familial gastric cancer.

16 Background: Hereditary diffuse gastric cancer (HDGC) makes up 0.1-0.3% of all gastric cancers. Management of patients with HDGC is inconsistent and there is disagreement regarding management. Methods: A multi-disciplinary expert panel of 16 physicians from 6 countries scored 47 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) 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 (NS) in the same manner. AS and NS are reported if agreement was met. Results: Gastric cancer (GC) patients with a family history of diffuse gastric cancer (DGC), lobular breast cancer or multiple family members with GC should be referred for genetics assessment and multidisciplinary decision-making (AS 8.0). It is appropriate for patients with DGC to have CDH1 mutation testing in a family with: (1) two or more cases of GC, with at least one case of DGC diagnosed before the age of 50 (AS 8.0); (2) three or more cases of GC diagnosed at any age, one or more of which is DGC (AS 8.0); (3) a patient diagnosed with DGC and lobular breast cancer (AS 8.0); or (4) a patient diagnosed with DGC under the age of 35 (AS 7.0, NS 5.0). A prophylactic total gastrectomy should be offered to CDH1 mutation carriers 20 years or older (AS 7.0). Conclusions: The Gastric Cancer Processes of Care panelists have outlined high risk patients in whom CDH1 mutation status should be determined, and cases in which a prophylactic gastrectomy is appropriate.

What studies are appropriate and necessary for staging gastric cancer? Results of a RAND/UCLA expert panel.

15 Background: The approach for staging gastric cancer (GC) patients has not been well defined, resulting in widespread heterogeneity in the application of pre-operative staging modalities. Methods: A multi-disciplinary expert panel of 16 physicians from 6 countries scored 84 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) from 1-3 were considered inappropriate, 4-6 uncertain, and 7-9, appropriate. Agreement was reached when 11 of 16 panelists scored the scenario similarly. If a scenario was agreed to be appropriate, it was given a necessity score (NS) in the same manner. AS and NS are reported if agreed upon. Results: TNM staging should be determined pre-operatively (AS 7.0-9.0; NS 7.0-9.0). Pre-operative radiological assessment should include a computed tomography (CT)−abdomen, CT−pelvis, and should be performed with a multi−detector CT scanner with 5 mm slices (AS 8.0−9.0; NS 7.0−9.0). A CT Chest may be performed (AS 7.5). The utility of a chest radiograph was indeterminate. All patients should have a pre-operative esophagogastroduodenoscopy (EGD). The endoscopist should biopsy the tumor; document its size, description, location, distance from the GE junction, and any GE junction, esophageal or duodenal involvement. If the EGD report is unclear, the surgeon should repeat it to confirm tumor location (AS 7.5-9.0, NS 7.0−9.0). Endoscopic ultrasound is appropriate prior to endoscopic resection, but not surgical resection (AS 9.0). Diagnostic laparoscopy (DL) should be performed prior to resection of cT3,4 lesions, or multi−visceral resections. DL should include visual inspection of the stomach, diaphragm, liver, and ovaries (AS 8.0−9.0, NS 7.0−9.0). Conclusions: The Gastric Cancer Processes of Care expert panel has made recommendations regarding pre−operative staging modalities in an effort to standardize work up. Standardization could lead to more accurate staging and allocation towards optimal stage−specific treatments.

What care is appropriate and necessary for metastatic gastric cancer patients? Results of a RAND/UCLA expert panel.

70 Background: Most gastric cancer patients present with advanced stage disease precluding curative surgical treatment. The utility of surgical and non-surgical options for non-curative, advanced disease is debated and the appropriate treatment strategy unclear. Methods: A multi-disciplinary expert panel of 16 physicians from 6 countries, scored 47 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) 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 then given a necessity score (NS) in the same manner. Results: Surgical resection and bypass were agreed to be inappropriate in patients with minor symptoms and visible carcinomatosis, liver metastases or more than one site of metastatic disease for cardia and distal lesions (AS 1.0-3.5). The expert panel disagreed on the role for surgical resection in patients who were cytology positive only (AS 4-6). The role of resection for patients with major symptoms if they had visible carcinomatosis, liver metastases or more than one site of metastatic disease (AS 2-5) was indeterminate. Patients with distal tumours and major symptoms and multiple liver metastases or more than one site of metastatic disease were considered indeterminate for surgical resection (AS 2). Best supportive care was agreed to be appropriate for patients with minor symptoms and multiple liver metastases or more than one site of metastatic disease (AS 8, NS 5-6). Conclusions: The role of surgery in metastatic gastric cancer treatment decision-making is not supported by experts for the majority of scenarios. Continued uncertainty in appropriate and necessary treatment decision-making for advanced patients with a minimal burden metastatic disease exists and underscores the need for randomized controlled trials.