Oesophagogastric cancer
Quick Reference Guide
The optimal care pathways describe the standard of care that should be available to all cancer patients treated in Australia. The pathways support patients and carers, health systems, health professionals and services, and encourage consistent optimal treatment and supportive care at each stage of a patient’s journey. Seven key principles underpin the guidance provided in the pathways: patient-centred care; safe and quality care; multidisciplinary care; supportive care; care coordination; communication; and research and clinical trials.
This quick reference guide provides a summary of the Optimal care pathway for people with oesophagogastric cancer.
Please note that not all patients will follow every step of the pathway.
Support: Assess supportive care needs at every step of the pathway and refer to appropriate health professionals or organisations.
Prevention
Stopping smoking will reduce the risk of oesophagogastric cancer.
Risk factors
There are very few people at high risk. People with the following risk factors are at increased risk:
Oesophageal adenocarcinoma |
Male gender, obesity, gastro-oesophageal reflux, Barrett’s oesophagus, tobacco smoking, alcohol consumption and increasing age |
Oesophageal squamous cell carcinoma |
Heavy alcohol consumption, tobacco smoking, increasing age, caustic injury and achalasia |
Gastric cancer |
Increasing age, Helicobacter pylori bacteria, previous partial gastrectomy (especially more than 20 years ago), tobacco smoking, pernicious anaemia and family history of gastric cancer |
* Most common risk factors are bolded.
Early detection
Being aware of the risk factors and who is at high risk can guide monitoring and referral to a specialist.
Careful monitoring of Barrett’s oesophagus may lead to early detection.
Screening recommendations
There are no formal population-based screening programs for oesophagogastric cancer in Australia.
Checklist
Signs and symptoms
- Dysphagia (difficulty swallowing)
- Persistent epigastric pain/dyspepsia
- Pain on swallowing
- Food bolus obstruction
- Unexplained weight loss or anorexia
- Haematemesis (vomiting blood) or melena
- Early satiety
- Unexplained nausea/abdominal bloating or anaemia.
Symptoms (red flag) requiring urgent consultation
- New onset or rapidly progressive dysphagia
- Progressive/new epigastric pain persisting for more than 2 weeks.
General practitioner investigations
The patient’s GP should take a thorough medical history to check for any risk factors and symptoms (e.g. bleeding or dysphagia) that suggest upper gastrointestinal (GI) cancer.
Immediately refer all patients with significant (red flag) symptoms for an endoscopy.
Referral
Where there is a confirmed diagnosis or high level of suspicion, patients should see an upper GI surgeon with expertise in oesophagogastric cancer who is an active participant in an upper GI cancer multidisciplinary team within 2 weeks of GP referral.
The specialist may need to urgently refer the patient to allied health practitioners (particularly a dietitian) before a multidisciplinary meeting (MDM).
Referral options
At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.
Communication
The GP’s responsibilities include:
- explaining to the patient and/or carer who they are being referred to and why
- supporting the patient and/or carer while waiting for specialist appointments
- informing the patient and/or carer that they can contact Cancer Council on 13 11 20.
Checklist
Timeframe
Patients with concerning (red flag) symptoms of oesophagogastric cancer should see their GP within 2 weeks.
If oesophagogastric cancer is suspected, refer patients to a specialist for an endoscopy within 2 weeks of GP referral.
Diagnosis and staging
An expert histopathologist should review the biopsy material from the endoscopy before the MDM.
Staging for oesophageal cancer may involve:
- CT scan of the neck, thorax, abdomen and pelvis
- endoscopic ultrasound
- PET scan
- endoscopic resection.
Staging for oesophagogastric junction cancer may involve:
- CT scan of the neck, thorax, abdomen and pelvis
- endoscopic ultrasound
- staging laparoscopy
- PET scan
- endoscopic resection.
Staging for gastric cancer may involve:
- CT scan of the neck, thorax, abdomen and pelvis
- endoscopic resection
- staging laparoscopy.
Genetic testing
Environmental factors are important in causing gastric cancer; inherited factors (i.e. genes) usually play a minor role.
Occasionally gastric cancers are due to an inherited cancer predisposition.
Treatment planning
Discuss all newly diagnosed patients at an MDM within 4 weeks of GP referral.
Research and clinical trials
Consider enrolment where available and appropriate. Search for a trial.
Communication
The lead clinician’s (1) responsibilities include:
- discussing a timeframe for diagnosis and treatment options with the patient and/or carer
- explaining the role of the multidisciplinary team in treatment planning and ongoing care
- encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
- providing appropriate information and referral to support services as required
- communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from MDMs.
1: Lead clinician – the clinician who is responsible for managing patient care.
The lead clinician may change over time depending on the stage of the care pathway and where care is being provided.
Checklist
Timeframe
Staging work-up needs to be complete for presentation at the MDM within 2 weeks of diagnosis and within 4 weeks of GP referral.
Establish intent of treatment
- Curative
- Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
- Symptom palliation.
Treatment options
Given the poor prognosis of this cancer at present, for many patients, treatment is often given with palliative rather than curative intent. Early specialist palliative care may be required.
Endoscopic treatments are suitable for high-grade dysplasia and selected cases of early cancer.
Surgery
Surgical resection offers the best long-term survival chance in patients with locally advanced oesophageal or gastric cancer.
Palliative oesophageal resection for metastatic cancer is not recommended.
Radiation therapy may be indicated for oesophageal or oesophagogastric junction cancer as part of:
- neoadjuvant therapy before surgery
- definitive chemoradiation (unresectable locally advanced disease)
- symptom palliation.
Radiation therapy may be indicated for gastric cancer as part of:
- postoperative care in combination with chemotherapy in selected patients who have undergone a gastrectomy for locally advanced gastric cancer
- symptom palliation before or after chemotherapy.
Systemic therapy may be indicated for:
- locally advanced disease (pre- or postoperatively or as primary treatment)
- inoperable locally advanced oesophageal or gastro-oesophageal cancer.
Palliative care
Review by a specialist palliative care team is essential. Early referral to palliative care can improve quality of life and in some cases may prolong survival. Referral should be based on need, not prognosis.
For more, visit the Palliative Care Australia website.
Communication
The lead clinician and team’s responsibilities include:
- discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
- discussing advance care planning with the patient and/or carer where appropriate
- helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.
Checklist
Timeframe
Begin treatment within 2 weeks of the MDM.
Provide a treatment and follow-up summary to the patient, carer and GP outlining:
- the diagnosis, including tests performed and results
- tumour characteristics
- treatment received (types and date)
- current toxicities (severity, management and expected outcomes)
- interventions and treatment plans from other health professionals
- potential long-term and late effects of treatment and care of these
- supportive care services provided
- a follow-up schedule, including tests required and timing
- contact information for key healthcare providers who can offer support for lifestyle modification
- a process for rapid re-entry to medical services for suspected recurrence.
Communication
The lead clinician’s responsibilities include:
- explaining the treatment summary and follow-up care plan to the patient and/or carer
- informing the patient and/or carer about secondary prevention and healthy living
- discussing the follow-up care plan with the patient’s GP
Checklist
Detection
Most residual or recurrent disease will be detected via routine follow-up or by the patient presenting with symptoms.
Treatment
Evaluate each patient for referral to the original multidisciplinary team is appropriate. For most patients, treatment is often given with palliative rather than curative intent.
Advance care planning
Advance care planning is important for all patients but especially those with advanced disease. It allows them to plan for their future health and personal care by thinking about their values and preferences. This can guide future treatment if the patient is unable to speak for themselves.
Survivorship and palliative care
Review by a specialist palliative care team is essential. Survivorship and palliative care should be addressed and offered early. Early referral to palliative care can improve quality of life and in some cases may prolong survival. Referral should be based on need, not prognosis.
Communication
The lead clinician and team’s responsibilities include:
- explaining the treatment intent, likely outcomes and side effects to the patient and/or carer and the patient’s GP.
Checklist
Palliative care
Consider a referral to palliative care. Ensure an advance care directive is in place.
Communication
The lead clinician’s responsibilities include:
- being open about the prognosis and discussing palliative care options with the patient
- establishing transition plans to ensure the patient’s needs and goals are considered in the appropriate environment.
Checklist
Visit our guides to best cancer care webpage for consumer guides. Visit our OCP webpage for the optimal care pathway and instructions on how to import these guides into your GP software.