EURECCA Oesophago-Gastric Cancer Project

The results of cancer treatment across Europe show considerable variation. The EUROCARE study published in 2014 reports both overall and disease specific survival to be different in different geographical areas.¹ For example, the 5-year survival for gastric cancer is 29.6% in Southern Europe contrasting with 17.2% in the UK and Ireland. The reasons for these differences are multifactorial reflecting aetiology and demographics as well as service provision and approaches to treatment. Ensuring that all potential patients have the same outcome for their cancer irrespective of where they live is a huge challenge.

In order to understand the extent of the variation, careful evaluation of disease related data is essential. The EURECCA (acronym for European Registry of Cancer CAre) project² has been established to challenge the variations and to try to establish standards, which are intended to enhance quality and improve outcome. The use of audit techniques is the most appropriate approach but this requires consistency and validity of data recording within and between countries. Many countries have variable cancer registration with some having nationally resourced comprehensive mandatory registration and others having none at all. This can limit the reliability of data comparison but equally can set a precedent for those with less complete information to improve their processes.

EURECCA began evaluating the outcome for patients with colorectal cancer including countries with national registries and those with national audits facilitated by specialist associations.³ Following agreement on the type of data to be recorded it was possible to demonstrate detailed variation in disease presentation, approaches to diagnosis and treatment, and treatment outcome. Subsequent projects have looked at the results of treatment for elderly patients and more recently the group has established a study of new approaches to treatment of rectal cancer.

The EURECCA Oesophago-Gastric project attempted to emulate the work undertaken by the colorectal group. The initial task was to agree a dataset.⁴ Those countries with either a national registry or a national audit and those countries with established collaborative associations were asked to submit the data items that were routinely recorded. There was a wide range with the respective datasets from 60 to 702 items from 7 countries. The datasets were compared to select those items commonly recorded. An item was included if it was in the dataset of 6 of the 7 countries. As a result 46 data items were identified. These included details of demographics, presentation, treatments, pathology and initial outcomes of treatment; much of the data was surgical as these are easier metrics to record.

After establishing the dataset, a comparison of the management of oesophageal, junctional and gastric cancer was undertaken for patients treated in five countries over a twelve-month period.⁵ This again included data from national audits and registries and from large collaborative databases. A total of 4668 patients were included. There were variations in demographics across the countries with patients tending to be younger in France. In 4 countries the majority of cancers were adenocarcinoma although in France there were similar numbers of adenocarcinoma and squamous cell cancers. Disease tended to be diagnosed earlier in France and Ireland. Combinations of neoadjuvant therapies were different with chemo radiotherapy preferred in the Netherlands and Ireland for oesophageal and junctional cancers contrasting with chemotherapy in the UK and France. All countries used perioperative chemotherapy in gastric cancer but only 30% of patients received this treatment. There were similarities in R0 resection rates with 86% and 88% undergoing R0 resections for oesophageal and junctional disease and for gastric disease respectively. Operative mortality varied between 1% and 7%.

The EURECCA group has also evaluated the provision of services for patients with oesophageal and gastric cancer. A questionnaire-based study has identified both similarities and differences in the diagnosis, assessment, treatment and support for patients. Approaches to initial assessment and management were largely similar although there were differences in access to services partly reflecting established practices. In particular there was variable use of endoscopic ultrasound because of differences of opinion with regard to cross-sectional and functional imaging. There has been centralisation of surgery in most countries although gastric resection is still considered part of general surgery in some countries rather than a specialist procedure. There were qualitative differences specifically in clinical nurse specialist and dietitian provision. In addition, although most countries have multidisciplinary teams their composition and the frequency of meetings show variation. There were also significant variations in research and audit. This study attempted to determine if standardised clinical pathways could be implemented with the intention of improving the service and outcome. All countries were in favour but introduction may be limited because of the variations in the availability of resources and the way overall health services are configured.

In Spain, the EURECCA Oesophago-Gastric project begun in the Catalonian region in 2013, taking advantage of the ongoing centralisation of esophageal and gastric cancer surgery. Surgeons of all 17 authorised hospitals were asked to provide data of all oesophageal and gastric resected cancers with curative intent from 2011 to 2013. A total of 1121 patients were included, 233 esophagectomies and 888 gastrectomies. When compared with previous registries, a drastic decrease of treating hospitals was noted, with a subsequent increase of esophagectomies and gastrectomies per centre per year (from 3.4 to 7.4 and from 7.2 to 17 respectively).⁶ A decrease of postoperative morbidity and mortality was shown, along with an increase of transthoracic approaches and extended lymphadenectomies and a greater standardisation of multimodal treatments.^7,8 Esophagectomies had a higher complication rate than gastrectomies (36.4% vs 19.8%), but lower mortality (2.8% vs 6.8%). This phenomenon, known as a higher “failure to rescue” for gastrectomies, has also been noted in the Dutch EURECCA registry and is partly explained by patient selection.

The main goal of the Spanish EURECCA registry is to incorporate as many regions as possible, as long as inclusion of all local population is granted, not just a sample. In 2013, Navarra joined in, adding all 145 patients operated on from 2011 to 2013. Other regions, such as the Basque Country and the Autonomous Community of Valencia, are presently considering linking up to it.

The EURECCA project has demonstrated how collaborative approaches can be developed across countries to understand differences, which may help evaluate the variation in outcome across Europe for patients with oesophageal and gastric cancer. Further collaboration with colleagues in the European Gastric Cancer Association and the European Society for Diseases of the Esophagus (ESDE) are planned, focusing not only on audits but also on developing guidelines and standards, which are intended to improve patient experience and outcome. A big challenge is providing support and guidance for those countries where services are more limited.