International guidelines and high-volume center recommendations

E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)

The lack of evidence of follow-up is revealed by the fact that the most leading scientific societies and cooperative groups propose different schedules and that many centers apply a followup program dictated by past common practices in their medical center. Guidelines are generally supposed to be founded on strong evidence (therefore valid and unbiased) but to date they are based on low-level evidence or no evidence at all (Table 19.2).

The American Society of Clinical Oncology (, the Society of Surgical Oncology (, the Cancer Care Ontario (, the National Institute for Clinical Excellence (, the Cochrane Collaboration (, and the Society for the Surgery of the Alimentary Tract ( do not provide formal guidelines or recommendations for follow-up after gastrectomy for cancer. Similarly, the Japanese Gastric Cancer Association (JGCA) guidelines offer no guidelines on follow-up [17].

The National Cancer Comprehensive Network (NCCN) guidelines include for all patients a complete history and physical examination every 3–6 months for 1–2 years, every 6–12 months for 3–5 years and annually thereafter. Other investigation should be done if clinically indicated. Patients who have undergone surgical resection should be monitored and treated as indicated for vitamin B12 and iron deficiency [2].

The European Society of Medical Oncology (ESMO), the European Society of Surgical Oncology (ESSO), and the European Society of Radiotherapy and Oncology (ESTRO) guidelines state that regular follow-up may allow treatment of symptoms, psychological support, and early detection of recurrence, though there is no evidence that it improves survival outcomes. Follow-up has a role in the identification of patients for second-line chemotherapy and in clinical trials to detect symptoms of disease progression before significant clinical deterioration. Laboratory and imaging studies should be carried out when recurrence is suspected or when further chemoor radiotherapy is indicated [1].

The Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS), the British Society of Gastroenterology (BSG), and the British Association of Surgical Oncology (BASO) agree that regular review may identify early recurrence but there is no evidence for specific investigations nor that follow-up can affect overall survival. Endoscopy, cross-sectional imaging, and tumor markers have all been evaluated, but lack specificity or sensitivity [18].

The Italian Research Group for Gastric Cancer (GIRCG) has proposed three different follow-up schedules (mild, moderate, or intensive) after gastrectomy for cancer in relation with a risk score calculated for each individual patient. A logistic regression model is used for the computation of the score; the coefficient Z is calculated as Z = -3.888–0.339 (middle third) + 0.917 (upper third) + 6.266 (diffuse location) + 0.027 (age) + 1.075 (pT2) + 2.013 (pT3-T4) + 1.668 (pN1) + 3.056 (pN2) + 4.971 (pN3) – 0.848 (D2– D3 dissection). The value of parametric variables was 0 (negative) or 1 (positive), whereas age was considered as a continuous variable. For each patient, the value of the coefficient Z obtained was included in the formula: (?eZ/1 + eZ) Ч 100 which gives risk values ranging from 0 to 100% [19].

Table 19.2. International guidelines recommendations

Gastric cancer. Principles and practice (2015) T 19.2

For patients with mild risk (< 10% or patients over 80) they propose ultrasound of the abdomen and tumor marker assay every 6 months, endoscopy and chest X-ray annually, CT scan in case of clinical suspicion or increased level of tumor markers. For patients with moderate risk (between 10 and 50%): tumor markers are investigated every 3 months, abdominal ultrasound after 6 months, 18 months, 30 months, and CT scan and endoscopy annually. For patients with high risk (> 50%): tumor markers every 3 months, CT scan every 6 months, endoscopy annually.

After 5 years annual clinical monitoring, other exams if clinically indicated, any screening for second cancer (occult blood test, mammography, PSA, etc…)

To be noted that in international guidelines no nutritional or quality-of-life issues evaluation is considered.

By means of answering a questionnaire, a selected group of world-renowned experts in the field of surgical oncology were contacted via email. The main portion of the survey focused on follow-up schedules and methodologies. Most questions were yes/no or multiple choice, with several text boxes included allowing for comments from participants to provide additional information or clarification.

All respondents reported having a strategy for surveillance after surgery for gastric cancer, but there was variance in strategy.

First of all we asked about the main reason for follow-up. For almost all respondents (4/6) the primary aim of the follow-up schedule is the evaluation of complications associated with surgery and quality-of-life issues and most of them perform nutritional assessment at visits. In one institution (University Hospital of Lille, France) the primary aim is the early detection of recurrence whereas in other institutions (Jagiellonian University, Krakow, Poland) it is the collection of outcome data for treatment evaluation and/or research purposes.

In 4/6 of responders follow-up schedule is carried out by a multidisciplinary team (surgeons with medical oncologists). In two institutions the follow-up is performed by the surgical team.

No significant differences were reported in terms of follow-up frequency for different disease stages. On average, advanced gastric cancer patients are followed-up every 3 months in the first year postoperatively, as opposed to followup every 6 months for early gastric cancer during the first year postoperatively. From the second to fourth postoperative year, the patients were usually seen every 6 months. In all cases follow-up ends at 5 years after surgery.

Table 19.3 summarizes the follow-up schedules as reported by respondents. Almost all respondents considered CT scan as mandatory for detection of all type of recurrence and PET scan as optional study.

One respondent left the question blank because he did not have a systematic follow-up schedule and performs advanced imaging and/ or endoscopy during follow-up when symptoms arise or when there is clinical suspicion of recurrence.

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