Among European Nations, Greater Clinical Standardization Needed for Patients With Cancer

A questionnaire issued to experts in 14 European countries that use oncology clinical pathways has identified the need for greater standardization of clinical practices for patients with esophageal and gastric cancers (OGC). 

Despite advances in technology and treatment strategies, the prognoses for patients with OGC have remained poor across multiple European countries. In studies conducted by EURECCA (European Registration of Cancer Care), results showed that only 12.4% of patients with esophageal cancer survived 5 years or longer. Additionally, a detailed review of over 6000 patients treated in 5 different countries revealed wide ranging variations in therapeutic and surgical approach. 

To correct this variation, many institutions have implemented clinical pathways in an attempt to articulate best treatment strategies for different clinical problems. Clinical pathways are most often created using national guidelines developed from evidence-based data and must account for the entirety of the patient’s journey through treatment.

Researchers from EURECCA conducted a study with the aim of describing and analyzing clinical pathways across Europe to determine service differences for patients with OGC. To do so, the team created a survey with questions pertaining to how patients proceeded through care, including disease presentation, diagnostic approaches, staging, multidisciplinary treatment planning, treatment strategy, and follow-up.

The questionnaire was circulated to representatives of countries participating in the EURECCA Upper Gastrointestinal Group. Of the 14 countries invited to complete the questionnaire, 10 (71.4%) responded: Italy, Poland, Sweden, Ireland, The Netherlands, Spain, Germany, Denmark, France and UK. All surveys were completed in full with no missing data. In terms of presentation and diagnosis, most countries reported that patients presented with symptoms to their family doctor, although, in Spain, 40% presented directly to a gastroenterologist because he or she was present at the primary care facility. None reported utilizing screening programs. Time to diagnostic endoscopy did vary somewhat, occurring between 1 and 3 weeks in Ireland, Sweden, Italy, and Poland; within less than 1 week in Denmark; and after more than 3 weeks in Poland and The Netherlands. 

Most countries used computed tomography (CT) to stage OGC, which was done between 1 and 3 weeks after diagnosis, except in Ireland (less than 1 week) and Poland (more than 3 weeks). For all tumor types, staging and interventional techniques were usually completed within 3 weeks, although it took longer in Germany, Italy, and Poland. 

To treat OGC, all countries reported that they were either using or in the process of developing strategies in line with national guidelines for OGC. Multidisciplinary teams that included surgeons, medical and clinical oncologists, and a gastroenterologist or endoscopist were also in place in all countries except Poland. The UK representative also reported including a dietitian in their teams. All countries also had multidisciplinary team meetings at least once per week to review patients’ charts and determine treatment paths.

Follow-up practices were perhaps the most different among all countries. In Ireland, Spain, Poland, and the UK, patients were typically seen within 3 weeks of discharge following surgery. All other countries reported that follow-ups took place after 3 weeks. Subsequent follow-up was then reported as being between 3 and 6 months. 

Researchers, led by William H Allum, MD, Royal Marsden NHS Foundation Trust, London, UK, concluded that their survey results revealed a need for greater standardization of services for the treatment of OGC. To do this, leaders will need to work together to create standardized management guidelines that take into account the resources and professional expertise specific to each individual country. EURECCA will look to develop these clinical pathways in future studies.—Sean McGuire

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Messager M, de Steur W, Boelens PG, et al. Description and analysis of clinical pathways for oesophago-gastric adenocarcinoma, in 10 European countries (the EURECCA Upper GI Group – European Registration of Cancer Care). [published online February 6, 2016]. Eur J Surg Oncol. 2016. doi: 10.1016/j.ejso.2016.01.001.