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

Recent weight changes discussed and weight recorded

Alcohol intake discussed and recorded and support for reducing alcohol consumption offered if appropriate

Smoking status discussed and recorded and brief smoking cessation advice offered to smokers

Physical activity recorded

Referral to a dietitian considered

Referral to a physiotherapist or exercise physiologist considered

Education on being sun smart considered

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

Signs and symptoms recorded

Patient referred for an endoscopy if symptomatic

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient notified of support services such as Cancer Council 13 11 20

Referral options discussed with the patient and/or carer including cost implications

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

Diagnosis confirmed

Staging conducted and recorded in the patient’s medical record

Full histology obtained

Performance status and comorbidities measured and recorded

Patient discussed at an MDM and decisions provided to the patient and/or carer

Clinical trial enrolment considered

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to support services (such as Cancer Council) as required

Treatment costs discussed with the patient and/or carer

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

Intent of treatment established

Risks and benefits of treatments discussed with the patient and/or carer

Treatment plan discussed with the patient and/or carer

Treatment plan provided to the patient’s GP

Treating specialist has adequate qualifications, experience and expertise

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Early referral to palliative care considered

Advance care planning discussed with the patient and/or carer

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

Treatment and follow-up summary provided to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient-reported outcome measures recorded

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

Treatment intent, likely outcomes and side effects explained to the patient and/or carer and the patient’s GP

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Advance care planning discussed with the patient and/or carer

Patient referred to palliative care if appropriate

Routine follow-up visits scheduled

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

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to palliative care

Advance care directive in place

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.

Oesophagogastric cancer QRG

Oesophagogastric cancer QRG

Oesophagogastric cancer

Quick Reference Guide