4.2.4 Systemic therapy

For locally advanced oesophageal or gastric cancer, neoadjuvant chemotherapy with or without radiation therapy followed by surgery is recommended.

For locally advanced oesophageal or gastric cancer, perioperative chemotherapy or neoadjuvant chemoradiation followed by surgery are reasonable approaches.

For locally advanced gastric cancer, perioperative chemotherapy in patients undergoing surgery is the current standard of care. In select cases where patients have had upfront curative surgical resection, adjuvant chemotherapy or adjuvant chemoradiation can be considered.

For inoperable locally advanced oesophageal or gastro-oesophageal cancer, concurrent definitive chemoradiation is the current standard of care.

For patients with metastatic or inoperable locally advanced disease for palliative intent, systemic therapy alone is recommended:

  • chemotherapy plus trastuzumab for patients with HER2-positive advanced/metastatic adenocarcinoma of the stomach
  • chemotherapy alone in HER2-ve oesophageal/gastro-oesophageal or gastric cancer.

Current evidence supports using palliative radiation and chemotherapy sequentially rather than concurrently and is dictated by the predominant symptom requiring palliation as a priority.

Timeframes for starting treatment

Treatment should begin within two weeks of the MDM.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access