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. 2025 Mar 11:218:115278.
doi: 10.1016/j.ejca.2025.115278. Epub 2025 Feb 1.

Optimal timing for initiating first-line palliative systemic therapy in asymptomatic metastatic esophagogastric cancer: Insights from a European Delphi study

Denice Kamp  1 , Anne M May  1 , Antoine Adenis  2 , Andreia Capela  3 , Sarah Derks  4 , Francesca De Felice  5 , Nina Fokter Dovnik  6 , Cinta Hierro  7 , Aysegul Ilhan-Mutlu  8 , Florian Lordick  9 , Radka Lordick Obermannova  10 , Angelica Petrillo  11 , Alberto Puccini  12 , Ana Raimundo  13 , Giandomenico Roviello  14 , Alexander Siebenhüner  15 , Marije Slingerland  16 , Elizabeth C Smyth  17 , Hanneke W M van Laarhoven  18 , Nadia Haj Mohammad  19
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Free article

Optimal timing for initiating first-line palliative systemic therapy in asymptomatic metastatic esophagogastric cancer: Insights from a European Delphi study

Denice Kamp et al. Eur J Cancer. .
Free article

Abstract

Background: The enhanced application of imaging techniques is resulting in the diagnosis of more patients with asymptomatic metastatic esophagogastric cancer (mEGC). We conducted a Delphi study to gather insights from European experts on the optimal timing for initiating palliative systemic therapy for these patients.

Methods: An online survey featured 14 scenarios where physicians chose their preferred timing for initiating systemic therapy: immediate(<3 weeks) or deferred. The standard scenario was a 65-year-old male, WHO/ECOG 0 with asymptomatic mEGC, 2 metastases in each lung, HER2 -, PDL1-CPS 2. In every subsequent case, one characteristic was modified. To investigate the fortitude of the physicians' preference for an immediate start, scenarios also included a patient who was motivated to start but preferred to defer if the physician deemed it judicious. Consensus was defined as ≥ 75 % agreement; scenarios without consensus were re-evaluated in Delphi round 2.

Results: Thirty-nine physicians participated in the first round, and 33 in the second round. Consensus to start treatment immediately was reached in 12 (86 %) scenarios. When patients preferred to defer, the consensus was to still advise to start palliative systemic treatment immediately in half (n = 7) of the scenarios. Only 2 scenarios (pre-existent WHO/ECOG 2 or 78 years old) reached the consensus that treatment could be deferred.

Conclusions: In asymptomatic mEGC, immediate start of treatment is preferred by European experts. Consensus was established that treatment can be deferred for patients who prefer deferral and either have a pre-existent WHO/ECOG performance status of 2 or are of advanced age.

Keywords: Chemotherapy; Delphi Technique; Esophageal cancer; Gastric cancer; Metastasis; Palliative medicine.

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Conflict of interest statement

Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A. Adenis: Financial Interests, Personal, Advisory Board: AstraZeneca, Bayer, BMS, MSD; Non-Financial Interests, Institutional, Principal Investigator: AstraZeneca, Bayer, BMS, MSD; Non-Financial Interests, Institutional, Funding: Bayer; Financial Interests, Personal, Invited Speaker: BMS, MSD, Novartis. S. Derks: Financial Interests, Institutional, Advisory Board: BMS; Financial Interests, Institutional, Invited Speaker: BMS, Servier; Financial Interests, Institutional, Funding, sponsoring investigator initiated study: Incyte. C. Hierro: Financial Interests, Personal, Invited Speaker: MSD, Lilly; Financial Interests, Personal, Research Grant, Principal Investigator of Merck Research Grant in Personalized Medicine 2020: Merck; Non-Financial Interests, Principal Investigator, Clinical Trial: BMS, Zymeworks, ALX Oncology, AstraZeneca; Other, Travel fees: BMS, Amgen, Roche, Merck. A. Ilhan-Mutlu: Financial Interests, Personal, Advisory Board: MSD, Servier, Daiichi Sankyo, BMS, Astellas; Financial Interests, Personal, Invited Speaker: Eli Lily, Servier, BMS, MSD, Astellas, Daiichi Sankyo; Financial Interests, Personal, Other, Consulting: Astellas, MSD, Amgen, AstraZeneca; Financial Interests, Personal, Other, Travel support: BMS, Roche, Eli Lilly, Daiichi Sankyo. F. Lordick: Financial Interests, Personal, Advisory Board: Amgen, Astellas, BMS, Bayer, BeiGene, Eli Lilly, MSD, Novartis, Roche, Daiichi Sankyo, PAGE; Financial Interests, Personal, Invited Speaker: AstraZeneca, BMS, Deutscher Ärzteverlag, Eli Lilly, Imedex, Incyte, Iomedico, MSD, MedUpdate, Medscape, Merck Serono, Roche, Servier, Springer-Nature, StreamedUp!, Daiichi Sankyo, Novartis, Art Tempi; Financial Interests, Personal, Expert Testimony: BioNTech, Elsevier; Financial Interests, Institutional, Research Grant: BMS, Gilead. R. Obermannova: Financial Interests, Personal, Advisory Board: BMS, AstraZeneca; Non-Financial Interests, Leadership Role, Czech Clinical Trials Network in Oncology: CZECRINonco; Non-Financial Interests, Leadership Role, Visegrad 4 educational grant for clinical trials staff: Visegrad Funds. A. Petrillo: Financial Interests, Personal, Invited Speaker: Eli Lilly, BSM, Amgen; Financial Interests, Personal, Expert Testimony: Servier; Financial Interests, Personal, Invited Speaker, Master in Management e Organizzazione dei Servizi Farmaceutici: University of Salerno; Financial Interests, Personal, Advisory Board: Bayer; Financial Interests, Institutional, Other, participation in the profit trials Keynote-937 and MK7902–012: MSD; Financial Interests, Institutional, Other, Participation in the profit trial RegoPembro: Bayer; Financial Interests, Institutional, Other, Participation in the profit trials Mo42541, Imbrave251 and Amethista: Roche; Financial Interests, Personal and Institutional, Invited Speaker: MSD; Non-Financial Interests, Principal Investigator, Principal investigator for the no-profit phase II Together trial, promoted by: GISCAD; Non-Financial Interests, Member: AIOM, Women4Oncology, ASCO; Non-Financial Interests, Member, gastrointestinal group: EORTC; Non-Financial Interests, Leadership Role, Young oncologists representative (regional commission: Campania), 2021–2023 and 2023–2025: AIOM; Non-Financial Interests, Leadership Role, Administrator of an international network of oncologists and other cancer specialists with the aim to enhance access to the best education possibilities in oncology through an evidence-based and value-driven approach, especially for colleagues from low and middle-income countries: Oncollege; Non-Financial Interests, Member, Gruppo Oncologico Italia Meridionale: GOIM; Other, access to attend some courses/congresses online: Servier; Other, grant to attend some courses/congresses online: Eli Lilly, MSD; Other, grant to attend some courses/congresses: Merck Serono. A.C. Raimundo: Financial Interests, Personal, Invited Speaker, Symposium: Merck Serono; Financial Interests, Personal, Advisory Board, Advisory Board and Symposium: MSD; Financial Interests, Personal, Advisory Board, Advisory Board and scientific reunion: BMS; Financial Interests, Personal, Advisory Board, Advisory Board and symposium: Servier; Financial Interests, Institutional, Invited Speaker: MSD, BMS, Bayer, Roche. M. Slingerland: Financial Interests, Institutional, Advisory Board: BMS, Lilly, AstraZeneca. E. Smyth: Financial Interests, Personal, Invited Speaker: Amgen, Bristol Myers Squibb, Imedex, Merck, Novartis, Prova Education, Servier, TouchIME, Elsevier, Peervoice, Cor2Ed, Daiichi Sankyo, MSD, Suzhou Liangihui Network Technology Company Ltd.; Financial Interests, Personal, Other, TSC: Amgen; Financial Interests, Personal, Advisory Board: Astellas, AstraZeneca, Bristol Myers Squibb, My Personal Therapeutics, Novartis, Roche, Servier, Zymeworks, Viracta, Boehringer Ingelheim, AbbVie, Natera; Financial Interests, Personal, Other, IDMC: BeiGene, Zymeworks; Financial Interests, Personal, Expert Testimony: Bristol Myers Squibb; Financial Interests, Personal, Other, IDMC chair: Everest Clinical Research; Financial Interests, Personal, Other, IDMC Chair: Jazz Pharmaceuticals; Financial Interests, Personal, Officer: EORTC GI Clinical Trials Group; Financial Interests, Institutional, Invited Speaker: Daiichi Sankyo, Roche, AstraZeneca, Merus, Basilea, MSD, Amgen, Mirati; Financial Interests, Institutional, Research Grant: Bristol Myers Squibb, AstraZeneca; Non-Financial Interests, Leadership Role, Trustee: UK & Ireland Oesophagogastric Group (UKIOG). H.W.M. van Laarhoven: Financial Interests, Institutional, Invited Speaker: Astellas, BeiGene, Benecke, BMS, Daiichi Sankyo, JAAP, Medtlaks, Novartis, Springer, Travel Congress Management BV, Auristone; Financial Interests, Institutional, Advisory Board: Amphera, Anocca, Astellas, AstraZeneca, BeiGene, Boehringer Ingelheim, Daiichi Sankyo, Dragonfly, MSD, Servier; Financial Interests, Institutional, Other, Advices on protocol development: Myeloid; Financial Interests, Institutional, Other, Selection of articles for Framingham: Framingham; Financial Interests, Institutional, Research Grant, LyRICX study: Servier; Financial Interests, Institutional, Research Grant, TAPESTRY study: Merck; Financial Interests, Institutional, Research Grant, AUSPICIOUS study: Incyte; Financial Interests, Institutional, Research Grant, LOAD study: ORCA; Financial Interests, Institutional, Invited Speaker, DESTINY-GASTRIC03: AstraZeneca; Non-Financial Interests, Leadership Role, Chair upper GI Faculty: ESMO; Non-Financial Interests, Institutional, Product Samples, For all clinical study mentioned, study medication is provided: See 'research funding'. N. Haj Mohammad: Financial Interests, Institutional, Research Grant: Servier; Financial Interests, Institutional, Invited Speaker: Servier; Financial Interests, Institutional, Advisory Board: BMS, Merck, Lilly, AstraZeneca. All other authors have declared no conflicts of interest. The other authors declare no potential competing interests.