Adjuvant and neoadjuvant treatment of gastric cancer
- Craig Earle, MD, MSc, FRCPC
Craig Earle, MD, MSc, FRCPC
- Director, Health Services Research Program
- Cancer Care Center and the Ontario Institute for Cancer Research
- Harvey Mamon, MD, PhD
Harvey Mamon, MD, PhD
- Associate Professor of Radiation Oncology
- Harvard Medical School
- Section Editors
- Richard M Goldberg, MD
Richard M Goldberg, MD
- Section Editor — Gastrointestinal Cancer
- Director of the West Virginia University Cancer Institute and the Mary Babb Randolph Cancer Center
- Professor of Medicine
- Laurence S. & Jean J. DeLynn Chair of Oncology
- Christopher G Willett, MD
Christopher G Willett, MD
- Section Editor — Radiation Therapy
- Duke University Medical School
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 . The high mortality rate reflects the prevalence of advanced disease at presentation. 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, and it drops to 35 percent or less for stage IIB disease and beyond (table 1 and figure 1). (See "Surgical management of invasive gastric cancer", section on 'Prognosis'.)
Efforts to improve treatment results beyond those obtained with surgery alone have included adjuvant (postoperative) and neoadjuvant (preoperative) strategies. 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.
This topic review will focus on adjuvant and neoadjuvant therapies for noncardia gastric cancer. The epidemiology, staging, and surgical treatment of invasive gastric cancers, the management of early gastric cancer (an adenocarcinoma that is restricted to the mucosa or submucosa, irrespective of lymph node metastasis [T1, any N]), and multimodality approaches for treatment of invasive thoracic esophageal cancers and cancers arising in the esophagogastric junction (EGJ) and proximal stomach (cardia) 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 "Early gastric cancer: Treatment, natural history, and prognosis" 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".)
OVERVIEW OF THE THERAPEUTIC APPROACH
●For patients with potentially resectable noncardia gastric cancer, randomized trials and meta-analyses indicate a significant survival benefit over surgery alone for a number of approaches, including adjuvant chemoradiotherapy, perioperative (preoperative plus postoperative) chemotherapy (as was used in the MAGIC trial ), and adjuvant chemotherapy. Few trials have directly compared these approaches, and the optimal way to integrate combined modality therapy has not been definitively established. A major problem, at least in the United States, is that patients with gastric cancer are commonly taken to the operating room prior to consultation with medical or radiation oncologists. Multidisciplinary preoperative evaluation is preferable.
●Enrollment in available clinical trials is preferred. If protocol treatment is not available or is declined, the following represents our general approach:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- OVERVIEW OF THE THERAPEUTIC APPROACH
- APPROACH TO PATIENTS NOT YET RESECTED
- Neoadjuvant/perioperative chemotherapy
- - MAGIC trial
- - French FNCLCC/FFCD trial
- - EORTC trial 40954
- - Meta-analysis
- - Choice of regimen and patient selection
- Non-epirubicin-containing regimens
- - FLOT
- Neoadjuvant chemoradiotherapy
- Postoperative management of poor responders
- PATIENTS WITH INITIAL POTENTIALLY CURATIVE RESECTION
- Pathologic T3N0 or node-positive disease
- - Adjuvant chemoradiotherapy
- Intergroup 0116
- CALGB 80101
- ARTIST trial
- - Adjuvant chemotherapy
- - Meta-analyses
- Choice of regimen
- - Japanese S-1 trial
- - CLASSIC trial
- - Chemotherapy versus chemoradiotherapy
- - Timing of adjuvant therapy
- Pathologic T2N0 disease
- INITIALLY LOCALLY UNRESECTABLE NONMETASTATIC DISEASE
- ONGOING RESEARCH
- POSTTREATMENT CANCER SURVEILLANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS