News

Gastric cancer is a highly fatal malignancy, and surgery alone often does not provide a cure, even for relatively early stages of disease. Various approaches have been adopted around the world to improve surgical outcomes; however, there currently is no global consensus with regard to the extent of surgery or the timing and choice of chemotherapy and radiation. The journal Oncology recently featured a review of current and new approaches to resectable gastric cancer, and Manish Shah, M.D. provided some contextual commentary. Read the full piece here.

What Options Beyond Surgery Are Available for Gastric Cancer Patients?

It has long been established that patients with locally advanced, resectable gastric cancer benefit from additional therapy beyond surgery alone. Given the different disease subtypes that exist, and the global heterogeneity of the disease, the options available for adjuvant therapy are numerous, including perioperative chemotherapy (as in the MAGIC trial), postoperative chemoradiotherapy (chemoRT) (Intergroup 0116 study), and postoperative chemotherapy (the ACTS-GC and CLASSIC studies).

Why We Need to ‘Think Outside the Box’ Going Forward

The excitement generated by the successes of the studies just mentioned is tempered by the fact that survival benefits have been marginal (eg, 10% to 15%). In the West, the majority of patients diagnosed with advanced gastric cancer will still die of their disease. We next have tried combination strategies that are permutations of the treatment strategies mentioned above: eg, adding epirubicin, cisplatin, and capecitabine (ECX) to postoperative chemoRT (CALGB 80101 study), comparing postoperative chemoRT vs chemotherapy (ARTIST trial), and most recently, combining preoperative chemotherapy with postoperative chemoRT as compared with perioperative chemotherapy alone (CRITICS trial).

These studies have been negative, however, and underscore the need for a new approach. This review highlights new strategies currently being pursued, including intensification of chemotherapy, targeting of human epidermal growth factor receptor 2–positive disease, and use of preoperative chemoRT. Although each of these strategies may move the bar, it remains clear that novel treatment options are sorely needed. We need something new, something different, some type of disruptive technology. Is this new technology immuno-oncology? Or the use of positron emission tomography scans to identify early failures so that salvage strategies might be pursued early (ClinicalTrials.gov identifier: NCT02485834)? YES! Either of these novel strategies might be the disruptive approach that we need, and I encourage everyone to participate in the studies of these strategies that are now open. It is clear that moving the bar and improving outcomes for gastric cancer patients in the adjuvant setting have been challenging, and without quickly completing well-designed clinical trials, it will be even more difficult to make substantial and clinically meaningful progress.