Multimodal treatments for resectable gastric cancer: A systematic review and network meta-analysis

Different countries prefer particular types of multimodal treatments against resectable gastric cancer. Due to lacking of unified conclusions, we therefore conducted a network meta-analysis to rank all recommended strategies simultaneously and hierarchically. Record retrieval was conducted in PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, ASCO and ESMO meeting libraries from inception to September 2018. Randomized controlled trials featuring comparisons between different preferred multimodal treatments against resectable gastric cancer were eligible. The Cochrane Risk of Bias Tool was applied to assess methodological quality of included trials. Overall survival was primary endpoint. Network calculation was based on random-effects model and the relative ranking of each node was numerically indicated by P-score. All procedures were conducted according to Cochrane Handbook 5.1 and PRISMA for Network Meta-analysis (CRD42018109147). As a result, a total of 11 studies were included into our systematic review, corresponding to 7235 patients. Regarding overall survival, "PeriCT (FLOT)" (perioperative 5-FU plus leucovorin plus oxaliplatin plus docetaxel chemotherapy) topped the hierarchy (HR 1.00, P-score = 0.918), followed by "PostCT (XP)" (postoperative capecitabine plus platinum chemotherapy; HR 1.14, P-score = 0.759) and "PostCT (S-1)" (postoperative S-1 monotherapy; HR 1.16, P-score = 0.732). In subgroup analyses, "PostCT (XP)" became the top regimen for eastern population while "PeriCT (FLOT)" was the optimal node for western population. In conclusion, perioperative FLOT chemotherapy could potentially be the best multimodal treatment against resectable gastric cancer than other recommended strategies. Therefore, a global D2-lymphadenectomy randomized controlled trial comparing perioperative FLOT chemotherapy with postoperative XELOX chemotherapy should be carried out.