Variations among 5 European countries for curative treatment of resectable oesophageal and gastric cancer: A survey from the EURECCA Upper GI Group (EUropean REgistration of Cancer CAre)

doi:10.1016/j.ejso.2015.09.017

European Journal of Surgical Oncology (EJSO)

Volume 42, Issue 1, January 2016, Pages 116-122

https://doi.org/10.1016/j.ejso.2015.09.017 Get rights and content

Abstract

Introduction

EURECCA (EUropean REgistration of Cancer CAre) is a network aiming to improve cancer care by auditing outcome. EURECCA initiated an international survey to share and compare patient outcome for oesophagogastric cancer. The present study assessed how a uniform dataset could be introduced for oesophagogastric cancer in Europe.

Methods

Participating countries presented data using common data items describing patients', disease, strategies, and outcome characteristics. Patients treated with curative surgery for squamous cell carcinoma (SCC) or adenocarcinoma (ACA) were included.

Results

United Kingdom, the Netherlands, France, Spain and Ireland participated. There were differences in data source ranging from national registries to large collaborative groups. 4668 oesophagogastric cancer cases over a 12 months period were included. The predominant histological type was ACA. Disease stage tended to be earlier in France and Ireland. In oesophageal and junctional cancers neoadjuvant chemoradiotherapy was preferred in the Netherlands and Ireland contrasting with chemotherapy in the UK and France. All countries used perioperative chemotherapy in gastric cancer but 1/3 of patients received this treatment. The mean R0 resection rate was 86% for oesophageal and junctional resections and 88% for gastric resections. Postoperative mortality varied from 1% to 7%.

Conclusion

This European survey shown that implementing a uniform treatment and outcome data format of oesophagogastric cancer is feasible. It identified differences in disease presentation, treatment approaches and outcome, which need to be investigated, especially by increasing the number of participating countries. Future comparisons will facilitate developments in treatment for the benefit of patient outcomes.

Introduction

Overall survival for patients with gastric and oesophageal cancer has shown little improvement over the last 20 years. For gastric cancer the recent EUROCARE-5 study has shown a slight improvement in 5-year survival from 23.3% in 1999–2001 to 25.1% in 2005–2007.¹ This study also highlighted significant geographical differences across Europe with highest survival in southern and central Europe and lowest survival in Eastern Europe, the UK and Ireland. The overall 5-year survival for oesophageal cancer also remains poor at 12%. The main reason for the poor outcome is the late stage at diagnosis for both cancer sites. However, geographical differences may reflect differences in patterns of treatment.

Most population-based studies provide a broad overview, but may lack more detailed information on staging and treatment necessary to intervene and improve patterns of care. Prospective cancer audits maintained in real-time provide very valuable tools for improvement as it happens. Dikken et al. combined information from four countries using either national registry data or national audit outcomes.² Although the databases were not complete, reflecting intra-country variations in data recording, there were considerable variations in treatment practices and outcomes particularly for surgical resection rates and postoperative mortality. This study highlighted the need to develop a much larger collaborative approach to be able to compare and contrast current approaches to oesophageal and gastric cancer and search for the best care for this specific patient group.

In colorectal cancer, the EURECCA initiative has demonstrated how to establish an audit across European countries.³ Following this model the EURECCA Upper GI project was established and a common dataset was developed using existing data items recorded in 7 countries.⁴ This study reports the results of comparison of these data items in the initial 5 countries collaborating in the project.

Section snippets

Materials and methods

Five countries (Netherlands, France, Spain, UK and Ireland) have collected data on patients with oesophageal and gastric cancer treated with curative intent over a 1-year period (2011–2012). Inclusion criteria were patients with SCC and ACA of the oesophagus, oesophago-gastric junction and stomach who underwent curative treatment including surgery. Each country submitted data using a dataset of 46 items identified as common to all data sources.⁴ Briefly, this dataset involved collection of

Epidemiology

During the 12 months period, 4668 cases have been recorded across the 5 countries, 2666 oesophageal and GOJ (gastro-oesophageal junction) tumours and 2002 gastric cancers (Table 1). The majority of these were planned for resection although a small number from the Netherlands and Ireland planned for non-surgical treatments have been included. The proportion of oesophageal and junctional cancers predominated in all countries except Spain where there were more gastric cancers.

The majority were

Discussion

The aim of the EURECCA project is to improve the quality and reduce the variation of cancer care by data registration, feedback, forming plans for improvement and sharing knowledge of performance and science. This study is the first, descriptive comparison of current practice in the management of oesophageal and gastric cancer in a number of European countries. It reflects activity in a recent period (2011–12) and demonstrates how a collaborative international project can be established

Conflict of interest

The authors declare no conflict of interest.

Funding

The 2013 Annual Grant for international mobility from the AFC (French Association of Surgery) was part of the salary of MM.

Acknowledgements

The authors would like to thank all the participating countries and participants of the EURECCA Upper GI Group for their input and providing the results from the 10th International Gastric Cancer Congress (IGCC) presentations, in Verona, Italy, and the organizing committee of the 10th IGCC congress. The authors would also like to thank. Georgina Chadwick and Oliver Groene from the UK National OG Cancer Audit for their help.

References (9)

R. De Angelis et al.
Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE–5-a population-based study
Lancet Oncol
(2014)
W.O. de Steur et al.
Common data items in seven European oesophagogastric cancer surgery registries: towards a European upper GI cancer audit (EURECCA Upper GI)
Eur J Surg Oncol
(2014)
J.L. Dikken et al.
Differences in outcomes of oesophageal and gastric cancer surgery across Europe
Br J Surg
(2013)
W. van Gijn et al.
Improving quality of cancer care through surgical audit
Eur J Surg Oncol
(2010)

There are more references available in the full text version of this article.

Cited by (49)

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide
2023, The Lancet Oncology
The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.
Internal audit of oncological results in gastric cancer surgery
2022, Cirugia Espanola
No hay apenas información nacional sobre los resultados oncológicos de la cirugía del cáncer gástrico, por lo que se utilizan cifras foráneas, que pueden ser absolutamente distintas de las locales. El objetivo de nuestro trabajo es analizar estos resultados en los pacientes intervenidos en nuestro centro.
Se analizan los resultados de supervivencia de 134 pacientes intervenidos por cáncer gástrico con intención curativa desde 2004 hasta junio de 2016.
El 76,8% de los pacientes (103/134) tenían estadios clínicos avanzados (≥ ii), se realizó laparoscopia de estadificación en el 67% de los mismos (69/103), linfadenectomía extensa (≥ LD1+) en el 89,3% (92/103), y recibieron QT perioperatoria el 76,7% (79/103). La distribución final por estadios patológicos 0, i, ii, iii y iv fue del 8,2; 20,2; 26,1; 37,3 y 8,2%, respectivamente. La mediana de seguimiento fue de 87 meses. La mediana de SG fue de 68 meses y la SG a uno, 3 y 5 años fue del 81,2, 62 y 53,8%, respectivamente. La SG a 5 años según el estadio patológico fue del 100% para el estadio 0, del 88,4% para el estadio i, del 62,5% para el estadio ii, del 23,6% para el estadio iii y del 17% para el estadio iv.
Nuestras tasas de supervivencia se encuentran en los rangos altos de la literatura occidental. No se han podido comparar con resultados nacionales debido al déficit de información sobre resultados oncológicos en la cirugía del cáncer gástrico en nuestro entorno más cercano.
National information on the oncological results of gastric cancer surgery is scarce, so foreign figures are used, which may completely differ from local ones. The aim of our study is to analyse these results in the patients operated on in our centre.
Survival results of 134 patients that underwent gastric cancer surgery with curative intent from 2004 to June 2016 were analysed.
A percentage of 76.8 of the patients (103/134) presented in advanced clinical stages (≥ ii). Staging laparoscopy was performed in 67% of them (69/103), an extensive lymphadenectomy (≥ LD1+) was carried out in 89.3% of patients (92/103), and 76.7% (79/103) received perioperative chemotherapy. The distribution by pathological stage 0, i, ii, iii and iv was 8.2, 20.2, 26.1, 37.3, and 8.2%, respectively. Median follow-up was 87 months. Median OS was 68 months and one-, 3- and 5-year OS were 81.2, 62, and 53.8%, respectively. The 5-year OS according to pathological staging was 100% for stage 0, 88.4% for stage i, 62.5% for stage ii, 23.6% for stage iii and 17% for stage iv.
Our survival rates are in the high ranges of western literature. These results could not be compared with national ones due to the lack of information regarding oncological outcomes in gastric cancer surgery in our closest environment.
Evaluation of data quality in the Spanish EURECCA Esophagogastric Cancer Registry
2021, European Journal of Surgical Oncology
Citation Excerpt :
In order to compare the current practice in a number of European countries, a consensus about a uniform dataset was reached and data were collected from five national and/or regional participating registries [9]. However, differences in disease presentation, treatment approaches and outcomes between countries have been recognized [10,11]. In Spain, outcomes of esophagogastric cancer surgery are scarce and most information comes from administrative databases [12].
Although the number of nationwide clinical registries in upper gastrointestinal cancer is increasing, few of them perform regular clinical audits. The Spanish EURECCA Esophagogastric Cancer Registry (SEEGCR) was launched in 2013. The aim of this study was to assess the reliability of the data in terms of completeness and accuracy.
Patients who were registered (2014–2017) in the online SEEGCR and underwent esophagectomy or gastrectomy with curative intent were selected for auditing. Independent teams of surgeons visited each center between July 2018 and December 2019 and checked the reliability of data entered into the registry. Completeness was established by comparing the cases reported in the registry with those provided by the Medical Documentation Service of each center. Twenty percent of randomly selected cases per hospital were checked during on-site visits for testing the accuracy of data (27 items per patient file). Correlation between the quality of the data and the hospital volume was also assessed.
Some 1839 patients from 19 centers were included in the registry. The mean completeness rate in the whole series was 97.8% (range 82.8–100%). For the accuracy, 462 (25.1%) cases were checked. Out of 12,312 items, 10,905 were available for verification, resulting in a perfect agreement of 95% (87.1–98.7%). There were 509 (4.7%) incorrect and 35 (0.3%) missing entries. No correlation between hospital volume and the rate of completeness and accuracy was observed.
Our results indicate that the SEEGCR contains reliable data.
Improved postoperative outcomes and reduced transfusion rates after implementation of a Patient Blood Management program in gastric cancer surgery
2021, European Journal of Surgical Oncology
Citation Excerpt :
Of 147 patients with Hb ≤ 12 g/dL and/or serum ferritin ≤300 mg/L, 77 (52.4%) received i.v. iron therapy, which was administered ≥7 days before surgery in 63 (81.8%) and using ferric carboxymaltose in 62 (80.5%). Median time interval between diagnosis and gastric cancer resection did not change, neither in patients receiving neoadjuvant therapy (141 [131–151] days before the PBM program vs. 136 [118–152] days after the PBM program; p = ns) nor in those not receiving neoadjuvant therapy (28 [17–37] days vs. 33 [22–56] days; p = ns). Transfusion with RBCT was administered in 81 occasions, being justified by the PBM protocol in 67 (82.7%) because of Hb < 7 g/dL in 19, Hb 7–9 g/dL with risk factors and/or symptoms of anemia in 41, and Hb > 9 g/dL with suspicion of active bleeding in 7.
Gastric cancer patients are often transfused with red blood cells, with negative impact on postoperative course. This multicenter prospective interventional cohort study aimed to determine whether implementation of a Patient Blood Management (PBM) program, was associated with a decrease in transfusion rate and improvements in clinical outcomes in gastric cancer surgery.
We compared transfusion practices and clinical outcomes in patients undergoing elective gastric cancer resection before and after implementing a PBM program, including strategies to detect and treat anemia and restrictive transfusion practice (2014–2018). Primary outcome was transfusion rate (TR). Secondary outcomes were complications, reoperations, length of stay, readmissions, 90-day mortality and failure-to-rescue. Differences were adjusted by confounding factors.
Some 789 patients were included (496 pre- and 293 post-PBM). TR decreased from 39.1% to 27.0% (adjusted difference −9.1, 95% CI -15.2 to −2.9), being reduction particularly significant in patients with anemia, ASA score 3–4, locally advanced tumors, undergoing open surgery and total gastrectomy. Infectious complications diminished from 25% to 16.4% (−6.1, 95%CI -11.5 to −0.7), reoperations from 8.1% to 6.1% (−2.2, 95%CI -5.1 to +0.6), median length of stay from 11 [IQR 8–18] to 8 [7–12] days (p < 0.001), hospital readmission from 14.1% to 8.9% (−5.4, 95%CI -9.6 to −1.1), mortality from 7.9% to 4.8% (−2.4, 95%CI -4.7 to −0.01), and failure-to rescue from 62.7% to 32.7% (−23.1, 95%CI -37.7 to −8.5).
Implementation of a PBM program was associated with a reduction in transfusion rate and improvement in postoperative outcomes in gastric cancer patients undergoing curative resection.
A rare case of caecal volvulus post gastrectomy for gastric cancer
2020, International Journal of Surgery Case Reports
Surgery for gastric cancer is associated with a high morbidity and mortality rate. Postoperative complications are not uncommon in this setting and an understanding of risk factors and patient profile can impact clinical outcomes.
We present a rare event where a 64 year old patient post gastrectomy for a T1 gastric carcinoma developed a caecal volvulus leading to critical instability. This demonstrates how two events can occur in time leading to critical instability. Exploratory laparotomy revealed a caecal volvulus that had obstructed the jejunostomy site. She had a right hemicolectomy and the jejunostomy was unkinked. This is the first documented case report of this type in the literature.
Surgical resection remains the cornerstone therapy for gastric cancer. Postoperative complications are not uncommon in this setting where risk factors impact clinical outcomes. The importance of risk factors has been demonstrated in patients who underwent gastrectomy. We present a rare event where a patient post gastrectomy develops a caecal volvulus demonstrating how two events can occur in time leading to critical instability.
Post operative complications are not uncommon in gastrectomies. Although common things occur commonly, one must consider rare events when a patient significantly deteriorates.
Standardizing the treatment of oesophagogastric junction tumours: Centralization, registries and surgical training
2019, Cirugia Espanola
El tratamiento quirúrgico de los adenocarcinomas de la unión esofagogástrica se basa en gastrectomías totales o esofaguectomías oncológicas, procedimientos de alta complejidad y considerable morbimortalidad. Los datos obtenidos del análisis de registros quirúrgicos poblacionales muestran una elevada variabilidad en el enfoque terapéutico y los resultados entre diferentes centros hospitalarios y zonas geográficas. Una de las principales medidas destinadas a reducir esta variabilidad, mejorando los resultados globales, es la centralización de la enfermedad en centros de referencia, proceso que debe basarse en el cumplimiento de unos estándares de calidad e ir acompañada de la armonización de protocolos terapéuticos. La cirugía mínimamente invasiva puede disminuir la morbilidad postoperatoria sin comprometer la supervivencia, pero es técnicamente más demandante que la cirugía abierta. Los programas de formación quirúrgica tutelada permiten incorporar la cirugía mínimamente invasiva a la práctica de los equipos quirúrgicos sin que la curva de aprendizaje condicione la morbimortalidad ni la radicalidad oncológica.
Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams’ training curves without affecting morbidity, mortality or oncologic radicality.

View all citing articles on Scopus

View full text

Variations among 5 European countries for curative treatment of resectable oesophageal and gastric cancer: A survey from the EURECCA Upper GI Group (EUropean REgistration of Cancer CAre)

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Epidemiology

Discussion

Conflict of interest

Funding

Acknowledgements

Lancet Oncol

Eur J Surg Oncol

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

Br J Surg

Improving quality of cancer care through surgical audit

Eur J Surg Oncol