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.

Cancer Center Amsterdam Cancer Treatment and Quality of Life Amsterdam the Netherlands; Department of Medical Oncology Amsterdam UMC University of Amsterdam Amsterdam the Netherlands

Clinic for Hematology and Oncology Hirslanden Zurich AG Zurich Switzerland

Department of Biomedical Sciences Humanitas University Via Rita Levi Montalcini 4 Pieve Emanuele Milan 20072 Italy; Medical Oncology and Hematology Unit IRCCS Humanitas Research Hospital Humanitas Cancer Center Rozzano Milan Italy

Department of Comprehensive Cancer Care and Faculty of Medicine Masaryk University Masaryk Memorial Cancer Institute Brno Czech Republic

Department of Health Sciences Section of Clinical Pharmacology and Oncology University of Florence Florence Italy

Department of Medical Oncology Amsterdam UMC Free University Amsterdam the Netherlands; Cancer Center Amsterdam Cancer Treatment and Quality of Life Amsterdam the Netherlands

Department of Medical Oncology CUF Tejo Lisbon Portugal

Department of Medical Oncology Leiden University Medical Center Leiden the Netherlands

Department of Medical Oncology Unidade Local de Saúde de Gaia e Espinho Villa Nova de Gaia Portugal

Department of Medical Oncology University Medical Center Utrecht Utrecht University Utrecht the Netherlands

Department of Oncology Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom

Department of Oncology University Medical Centre Maribor Maribor Slovenia

Department of Radiological Oncological and Pathological Sciences Sapienza University of Rome Policlinico Umberto 1 Rome Italy

Division of Oncology Department of Medicine 1 Medical University of Vienna Vienna Austria

Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht University Utrecht the Netherlands

Medical Oncology Department Catalan Institute of Oncology Barcelona Spain

Medical Oncology department Institut du Cancer de Montpellier Montpellier France

Medical Oncology unit Ospedale del Mare Via E Russo Naples Italy

University Cancer Center Leipzig University of Leipzig Leipzig Germany

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