Can Surgical Treatment Results in Gastric Cancer Be Improved?

Patients with gastric cancer have a poor prognosis. Surgery is the only treatment modality offering hope for cure. However, even after curative surgery, the five-year survival rate is still about 30%. Even though the incidence of early gastric cancer is up to 40% of all cases (surgically curable) in Japan, in Western countries most of the patients are diagnosed at an advanced stage, when curative surgery is no longer possible. Most patients die of locoregional recurrence or distant metastasis. Therefore, every attempt should be made to increase early diagnosis and to find additional prognostic factors which can be determined preoperatively. Operations with extended lymphadenectomy are associated with higher morbidity and mortality rates, while a possible survival benefit is not proven in Western countries. The five-year survival results of two large prospectively randomized, controlled trials (the Dutch Gastric Cancer Trial and the British Medical Research Council Trial) comparing limited lymphadenectomy (D1) to extended lymphadenectomy (D2) are still being awaited. In light of increased morbidity and mortality rates associated with extended lymphadenectomy, the limits of surgical possibilities for the treatment of gastric cancer seem to be reached. Adjuvant radiotherapy and chemotherapy are demonstrated to not give an additional survival advantage compared to surgery only. Development of more active combination chemotherapy regimens and results in locally advanced gastric cancer are encouraging. Therefore, to evaluate the place of preoperative chemotherapy in potentially operable gastric cancer, two randomized trials have been initiated in the Netherlands and Great Britain. Gastric cancer should be considered a malignancy which requires a multidisciplinary approach of a specialized team consisting of committed specialists. New treatment modalities should only be applied to patients in clinical trial settings with dedicated clinicians.