Download Appropriateness Score Necessity Score Scenario: Preoperative

Appropriateness Score
Scenario: Preoperative Evaluation
Patients should be staged by CT abdomen/pelvis
preoperatively.
PET scan is not routinely indicated for gastric cancer
staging.
With the exception of early gastric cancer or metastatic
disease, diagnostic laparoscopy should be performed before
initiating treatment.
Scenario: Multi-disciplinary Care
Multidisciplinary decision-making, after staging, but
before treatment initiation, is recommended for care of
gastric cancer patients.
A multidisciplinary team which may include surgeons,
medical oncologists, radiation oncologists, radiologists,
pathologists, gastroenterologists, nurses, social
workers, palliative care specialists and dieticians is
preferred to care for gastric cancer patients.
In locally advanced gastric cancer, (>T2, N0, M0 AJCC 7),
patients should be considered for adjunctive therapies
such as peri-operative chemotherapy or post-operative
chemoradiation.
Linitis plastica is a particularly aggressive cancer, and a
multi-disciplinary approach is essential to management.
Patients with diffuse gastric cancer and familial history, or
patients <45 years (with diffuse gastric cancer) should be
referred for genetic assessment.
Scenario: Treatment Decision-making
Select T1aN0 lesions should be considered for endoscopic
removal.
In the metastatic setting, non-surgical management
options are preferred in patients without major
symptoms.
In patients with metastatic disease, surgery should only
be considered for palliation of major symptoms.
Scenario: Surgical Technique
In curative-intent resections, consideration of intra-operative
assessment of margin status by frozen section is important.
A D1 lymph node dissection is preferred in patients with early
gastric cancer or significant co-morbidities.
A D2 lymph node dissection is preferred for curative intent
resection in advanced, non-metastatic gastric cancer.
At least 16 lymph nodes should be assessed for
adequate staging of curative-resected gastric cancer.
A Roux-en-Y reconstruction is the preferred reconstruction
for a total gastrectomy.
Scenario: Provider Considerations
It is preferred that gastric cancer surgery be performed
by a surgeon experienced in gastric cancer
management.
It is preferred that non-emergent curative intent resections
are performed by surgeons with an annual volume of gastric
cancer resections >6 cases/yr.
Necessity Score
Median
Dev
A/I/D
Median
Dev
A/I/D
9
0.1
A
8
0.5
A
8
0.8
A
7
0.9
A
8
0.8
A
7
1.1
I
Median
Dev
A/I/D
Median
Dev
A/I/D
9
0.3
A
7.5
1.4
A
9
0.3
A
7
0.9
A
9
0.3
A
8
0.5
A
9
0.4
A
7.5
1.3
I
8
0.7
A
7
0.7
I
Median
Dev
A/I/D
Median
Dev
A/I/D
9
0.5
A
7
1.3
I
8.5
0.6
A
7.5
1.1
A
8
0.7
A
7
0.9
A
Median
Dev
A/I/D
Median
Dev
A/I/D
9
0.4
A
7
0.9
I
8.5
0.6
A
6.5
1.3
I
8.5
0.6
A
7
1.4
I
9
0.4
A
7
1.3
A
9
0.5
A
8
1
I
Median
Dev
A/I/D
Median
Dev
A/I/D
9
0.2
A
8
1.6
A
8
0.9
A
6
1.3
I
Laparoscopic resections should be performed by
surgeons who are experienced in both advanced
laparoscopic surgery and gastric cancer management.
9
0.1
A
8
0.6
A
Gastric cancer surgery should be performed in a center
with sufficient support to prevent or manage
complications (e.g. Interventional radiology, anesthesia,
level 1 ICU).
9
0.2
A
8
0.6
A
It is preferred that non-emergent curative intent resections
are performed in hospitals with an annual volume of gastric
cancer resections >15 cases/yr.
8
0.9
A
6.5
1.3
I
Appendix 1: Twenty-two tenets created by the expert panel. Median appropriateness and necessity scores are
reported on a scale of 1 to 9. Results in bold indicate agreement on necessity. Dev= Mean absolute deviation from
the median; A=agreement that a procedure is either appropriate or necessary. I=Indeterminate. D=Disagreement.
CT: computed tomography. PET: positron emission tomography.