Chemotherapy of advanced gastric cancer: present status, future prospects

The chemotherapy of gastric carcinoma is at an important point in its evolution. Multiple studies with a variety of agents have demonstrated that combination chemotherapy appears to be superior to single-agent chemotherapy in regard to response rate but not survival rate. The typical single agent results in response rates of 20% or less, whereas the typical combination chemotherapy regimen results in response rates of 30% to 50%. The FAM (5-fluorouracil [5-FU], doxorubicin, mitomycin C) chemotherapy regimen, widely used during the last 10 years, produces partial responses (PRs) in 35% of patients. However, the overall complete response (CR) rate is only 2%. Long-term survival of patients with disseminated malignancy is only achieved when treatments produce CR of disease. Because available combination chemotherapy approaches to gastric cancer only produce PRs, it is not surprising that there has been no impact on patient survival from these approaches. There are several newer approaches that hold promise in the treatment of gastric cancer. For example, the role of cisplatin in gastric cancer has not been completely defined. A recent study of FAP (5-FU, doxorubicin, cisplatin) has reported a 50% response rate with a significant number of CRs. The FAP regimen needs further exploration. The drug triazinate appears to have activity in gastric cancer, and in combination with mitomycin C produces a 28% response rate in patients who had failed chemotherapy regimens containing fluorinated pyrimidine. Thus, the efficacy of this drug needs further exploration in stomach cancer therapy. There is no clear definition of the future role of hepatic arterial infusion in gastric cancer. There is no question that, in colon cancer, response rates with fluorinated pyrimidine alone or fluorinated pyrimidine with mitomycin C are in the range of 50% when hepatic arterial infusion is used. This approach needs to be explored in gastric cancer. Finally, the use of intraperitoneal (IP) therapy in patients with minimal disease should be explored, because a common form of relapse in carcinoma of the stomach is IP dissemination.