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Adjuvant and neoadjuvant treatment of gastric cancer

Craig Earle, MD, MSc, FRCPC
Harvey Mamon, MD, PhD
Section Editors
Richard M Goldberg, MD
Christopher G Willett, MD
Deputy Editor
Diane MF Savarese, MD


The incidence of gastric cancer has been declining steadily since the 1930s, yet it remains a major cause of cancer death in the United States [1]. The high mortality rate reflects the prevalence of advanced disease at presentation [2]. In population-based series of Western populations, the five-year survival rate for patients with completely resected stage I gastric cancer is approximately 70 to 75 percent, while it drops to 35 percent or less for stage II disease and beyond (table 1) [2]. These sobering results have spawned efforts to improve the treatment results for this group of patients using adjuvant (postoperative) or neoadjuvant (preoperative) therapies. (See "Surgical management of invasive gastric cancer", section on 'Prognosis'.)

The positive impact of such therapies on survival in patients with resected gastric cancer has become clearer over time, although there is no consensus as to the best approach. In many parts of the world, chemotherapy alone (either following surgery or combined preoperative and postoperative administration, as in the multinational MAGIC trial [3]) is the preferred treatment strategy. On the other hand, a large American Intergroup trial (INT0116) demonstrating a significant survival benefit for chemoradiotherapy after complete resection resulted in the adoption of this strategy in the United States, despite concerns that inadequate surgical staging (particularly the extent of lymphadenectomy) may have led to an overestimation of benefit [4]. The issues surrounding extent of lymph node dissection in gastric cancer are discussed in detail elsewhere. (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)

Another controversial issue is the management of cancers arising at the esophagogastric junction (EGJ). The classification and management of these tumors have evolved over time. In the 2010 edition of the tumor, node, metastasis (TNM) staging manual, tumors arising at the EGJ or in the cardia of the stomach (figure 1) within 5 cm of the EGJ that extend into the EGJ or esophagus (the so-called Siewert III EGJ tumors [5]) were staged and treated as esophageal (table 2) rather than stomach cancers [6]. However, tumors that arise beyond 5 cm of the EGJ, or are within 5 cm of the EGJ but without extension to the esophagus or EGJ are still classified and treated as gastric cancers. In the most recent eighth edition staging classification from 2017 [7], tumors involving the EGJ with a tumor epicenter no more than 2 cm into the proximal stomach are staged as esophageal cancers, while EGJ tumors with their epicenter located more than 2 cm into the proximal stomach are staged as stomach cancers, as are all cardia cancers not involving the EGJ. (See "Diagnosis and staging of esophageal cancer", section on 'TNM staging criteria' and "Clinical features, diagnosis, and staging of gastric cancer", section on 'TNM staging criteria'.)

This topic review will focus on adjuvant and neoadjuvant therapies for noncardia gastric cancer. The epidemiology, staging, and surgical treatment of gastric cancers and multimodality approaches for treatment of esophageal and EGJ tumors are covered separately. (See "Epidemiology of gastric cancer" and "Clinical features, diagnosis, and staging of gastric cancer" and "Surgical management of invasive gastric cancer" and "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus" and "Multimodality approaches to potentially resectable esophagogastric junction and gastric cardia adenocarcinomas".)


Complete surgical resection is a prerequisite for cure of gastric cancer. However, the poor long-term survival rates after surgery alone for patients with locally advanced gastric and esophagogastric junction (EGJ) cancer have led to the exploration of a variety of adjuvant (postoperative) and neoadjuvant (preoperative) treatment strategies incorporating chemotherapy with or without radiation therapy (RT). The survival benefit from combined modality therapy as compared with surgery alone has become clearer over time.


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Literature review current through: Mar 2017. | This topic last updated: Feb 10, 2017.
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