Future strategies and adjuvant treatment of gastric cancer

The most recent meta-analyses of adjuvant chemotherapy in resected gastric cancer suggest that systemic treatment may achieve a small, but statistically significant and probably clinically relevant, reduction in risk of death. However, this still needs confirmation in a large, prospective, well-designed phase III study. The recent Intergroup 0116 study, conducted in USA, of combined post-operative chemoradiotherapy demonstrated significantly improved disease-free and overall 5-year survival compared with an observation-only arm. However, 54% of patients appeared to have had suboptimal surgery. The fact that adjuvant therapy reduced locoregional (and not distant) relapse suggests that its benefit may lie in compensating for inadequate dissection. Combined modality therapy was associated with moderate toxicity, but a high requirement for changes in radiation planning. Therefore, the role and feasibility of adjuvant radiotherapy needs to be confirmed in patients operated on in Western Europe. Several approaches to the development of early systemic therapy in gastric cancer are being pursued. These include the evaluation of cisplatin-based adjuvant regimens, the use of neoadjuvant treatment, the incorporation into adjuvant and neoadjuvant regimens of newer cytotoxics such as docetaxel and irinotecan, and the assessment of novel, molecularly targeted agents such as the epidermal growth factor receptor and angiogenesis inhibitors.