National Comprehensive Cancer Network

Cancers originating in the esophagus, gastroesophageal (GE) junctions, and stomach constitute a major health problem around the world. The incidence of gastric cancer, however, has been declining globally since World War II and it is one of the least common cancers in North America. By some estimates, it is the fourth most common cancer worldwide. In 2009, an estimated 21,130 new cases will be diagnosed and 10,620 will eventually die of their disease in United States. The NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer provide an evidence-based systematic approach to the management of gastric cancer in the United States. Many new chemotherapeutic agents, targeted therapies, vaccines, gene therapy, and antiangiogenic agents are being studied in clinical trials. The panel encourages patients to participate in well-designed clinical trials to enable further advances.

Distress Management

In the United States, a total of 1,479,350 new cancer cases and 562,340 deaths from cancer were estimated to occur in 2009. All patients experience some level of distress associated with diagnosis and treatment of cancer at all stages of the disease. Although surveys have found that 20% to 40% of patients with newly diagnosed and recurrent cancer show a significant level of distress, fewer than 10% are actually identified and referred for psychosocial help. Many cancer patients are unable to receive the psychological care they need because of underrecognition of their psychological needs by the primary oncology team and lack of knowledge of community resources. Furthermore, because psychological issues are stigmatized even in the context of coping with cancer, patients often do not tell their physicians about their distress, and physicians often do not inquire about the psychological concerns of their patients. Recognition of patient distress has become more difficult as cancer care has shifted to the ambulatory setting, where visits are often short and rushed. A major milestone in the improvement of psychosocial care was made when the NCCN established a panel to develop clinical practice guidelines for managing patient distress.

Special Feature

SupportScreen: A Model for Improving Patient Outcomes
Matthew Loscalzo, MSW; Karen Clark, MS; Jeff Dillehunt; Redmond Rinehart; Rex Strowbridge; and Daniel Smith

As demands on physician time mount, and patients and families increasingly expect accommodation and understanding of their personal situations, health care providers must boost efficiency and minimize the expense of their clinic processes and draw on connections with community resources. Third-party payors are also expecting that the biopsychosocial needs of patients and families be addressed as an essential part of cancer care. It is widely recognized that health care has lagged far behind other industries in using technology to improve efficiency, and slow adoption of this technology means that critical information about the biopsychosocial needs of patients fails to reach the right professionals in a timely way. The authors’ team developed a new touch screen automated program called SupportScreen, which is an inexpensive patient-friendly automated process that identifies, triages, and provides educational information all in real time. SupportScreen covers the entire process of biopsychosocial screening, from initiation of patient responses to the generation of referrals and provision of educational information.

Featured Articles

Multimodality Approaches to Localized Gastric Cancer
Prajnan Das, MD, MS, MPH; Yixing Jiang, MD, PhD; Jeffrey H. Lee, MD; Manoop S. Bhutani, MD; William A. Ross, MD; Paul F. Mansfield, MD; and Jaffer A. Ajani, MD

Most patients with localized gastric cancer require multimodality therapy. Surgery is the primary treatment for localized gastric cancer, although controversy exists about the optimal extent of lymphadenectomy in these patients. Recent studies have evaluated the role of laparoscopic surgery and endoscopic mucosal resection in selected patients. Multimodality treatment options for these patients include postoperative chemoradiation and perioperative chemotherapy. The Intergroup 0116 trial showed that patients treated with surgery and postoperative chemoradiation had significantly higher overall survival compared with those treated with surgery alone. The MAGIC trial showed that patients treated with perioperative epirubicin, cisplatin, and 5-fluorouracil had significantly higher overall survival than those treated with surgery alone. Other recent trials have evaluated the roles of preoperative chemoradiation and adjuvant chemotherapy. Multidisciplinary evaluation plays a crucial role in the management of these patients.

Advancements in Radiation Techniques for Gastric Cancer
Matthew D. Callister, MD, and Leonard L. Gunderson, MD

All but the earliest cases of nonmetastatic gastric cancer represent a therapeutic challenge given the high propensity of these patients to develop locoregional and distant relapse. Neoadjuvant or adjuvant strategies that include chemoradiotherapy or chemotherapy have been associated with not only significant toxicity but also improvement in patient survival. Technologic advances in the planning and delivery of radiotherapy (RT) have enabled significant progress in the accuracy and conformality of radiation treatment. Four-dimensional CT and image-guided RT improve the accuracy of radiation treatment. Three-dimensional RT and intensity-modulated RT allow increased conformality of radiation dose distribution, sparing of normal organs, and providing opportunity for dose escalation. Initial clinical experience with these technologies shows favorable tolerance and outcomes.

Gastric Cancer: A Primer on the Epidemiology and Biology of the Disease and an Overview of the Medical Management of Advanced Disease
Manish A. Shah, MD, and David P. Kelsen, MD

Gastric cancer is a cause of significant morbidity and cancer-related mortality worldwide. Despite recent advances in targeted therapy and understanding of the biology and development of the malignancy, progress in the treatment of gastric cancer has been limited. Most newly diagnosed patients will present with incurable disease, and have a median survival of less than 1 year. Although the disease has widespread ethnic and epidemiologic differences, medical management of gastric cancer does not distinguish among the various disease subtypes. The recent report of the ToGA phase III study validated HER2 as a molecular target in this disease, supporting the concept that a greater understanding of the biology of gastric cancer subsets may improve treatment selection and overall outcome of individual patients. This article summarizes the epidemiology and ethnic variation of this disease to crystalize subtypes of gastric cancer in the context of current and future medical management of advanced disease.

Short Screening Tools for Cancer-Related Distress: A Review and Diagnostic Validity Meta-Analysis
Alex J. Mitchell, MSc, MRCPsych

Clinicians are increasingly seeking efficient methods to identify distress in cancer settings, using short screening tools with fewer than 14 items that take less than 5 minutes to complete. This article examines the value of these tools for identifying cancer-related distress, defined by semi-structured interview. Current evidence suggests that the methods involving 2 verbal questions have superior efficiency for identifying distress and therefore may be a suitable for initial assessment of distress in busy clinical settings.

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National Comprehensive Cancer Network

NCCN Guidelines® & Clinical Resources

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 8, Number 4: April 2010

NCCN Clinical Practice Guidelines in Oncology™

Special Feature

Featured Articles

NCCN Guidelines^® & Clinical Resources