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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.