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Swathikan Chidambaram and others, Identifying a core symptom set triggering radiological and endoscopic investigations for suspected recurrent esophago-gastric cancer: a modified Delphi consensus process, Diseases of the Esophagus, Volume 36, Issue 1, January 2023, doac038,

Identifying a core symptom set triggering radiological and endoscopic investigations for suspected recurrent esophago-gastric cancer : a modified Delphi consensus process

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Author: Chidambaram, Swathikan1; Patel, Nikhil M.1; Sounderajah, Viknesh1;
Organizations: 1Department of Surgery and Cancer, Imperial College London, London, UK
2Department of Surgical Oncology, Veneto Institute of Oncology-IRCCS, Padova, Italy
3Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV-IRCCS Padua, Italy
4Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich, UK
5Department of Upper Gastrointestinal Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
6Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
7Department of Thoracic Surgery and Upper Gastrointestinal Surgery, McGill University, Montréal, Canada
8Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
9Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
10Department of General Surgery, University of Mainz, Mainz, Germany
11Digestive Surgery, CHU of Bordeaux, Bordeaux, France
12Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
13Section of Gastrointestinal Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
14Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
15Department of Surgery, Oulu University Hospital, University of Oulu, Oulo, Finland
16Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
17Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
18Department of Thoracic Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
19Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
20Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
21Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
22Department of Surgery, San Raffaele Hospital, Milan, Italy
23Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
24Upper GI and Soft Tissue Unit, Academy of Surgery, Princess Alexandra Hospital, Faculty of Medicine, University of Queens- land, Brisbane, Australia
25Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
26Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
27Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
28Department of Surgery, Flinders Medical Center, Adelaide, Australia
29Department of Esophagogastric Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
30Department of Upper GI Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 0.8 MB)
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Language: English
Published: John Wiley & Sons, 2022
Publish Date: 2023-08-09


Background: There is currently a lack of evidence-based guidelines regarding surveillance for recurrence after esophageal and gastric (OG) cancer surgical resection, and which symptoms should prompt endoscopic or radiological investigations for recurrence. The aim of this study was to develop a core symptom set using a modified Delphi consensus process that should guide clinicians to carry out investigations to look for suspected recurrent OG cancer in previously asymptomatic patients.

Methods: A web-based survey of 42 questions was sent to surgeons performing OG cancer resections at high volume centers. The first section evaluated the structure of follow-up and the second, determinants of follow-up. Two rounds of a modified Delphi consensus process and a further consensus workshop were used to determine symptoms warranting further investigations. Symptoms with a 75% consensus agreement as suggestive of recurrent cancer were included in the core symptom set.

Results: 27 surgeons completed the questionnaires. A total of 70.3% of centers reported standardized surveillance protocols, whereas 3.7% of surgeons did not undertake any surveillance in asymptomatic patients after OG cancer resection. In asymptomatic patients, 40.1% and 25.9% of centers performed routine imaging and endoscopy, respectively. The core set that reached consensus, consisted of eight symptoms that warranted further investigations included; dysphagia to solid food, dysphagia to liquids, vomiting, abdominal pain, chest pain, regurgitation of foods, unexpected weight loss and progressive hoarseness of voice.

Conclusion: There is global variation in monitoring patients after OG cancer resection. Eight symptoms were identified by the consensus process as important in prompting radiological or endoscopic investigation for suspected recurrent malignancy. Further randomized controlled trials are necessary to link surveillance strategies to survival outcomes and evaluate prognostic value.

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Series: Diseases of the esophagus
ISSN: 1120-8694
ISSN-E: 1442-2050
ISSN-L: 1120-8694
Volume: 36
Issue: 1
Article number: doac038
DOI: 10.1093/dote/doac038
Type of Publication: A1 Journal article – refereed
Field of Science: 3126 Surgery, anesthesiology, intensive care, radiology
Copyright information: © The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.