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Adjuvant and neoadjuvant treatment of gastric cancer

Authors
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

INTRODUCTION

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. 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 [2]), 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:

                                
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Literature review current through: Nov 2017. | This topic last updated: Nov 27, 2017.
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