A Retrospective Comparison of Trastuzumab Plus Cisplatin and Trastuzumab Plus Capecitabine in Elderly HER2-Positive Advanced Gastric Cancer Patients

Recent Advances in Systemic Treatments for HER-2 Positive Advanced Gastric Cancer

Gastric cancer (GC) is the fifth most common cancer worldwide. Despite recent improvements in treatment quality and options, advanced gastric cancer remains one of the hardest to cure cancers, with a median overall survival (OS) of 10–12 months and a 5-year OS of approximately 5–20%. There is an unmet need for further efforts to palliate disease-related symptoms, improve quality of life, increase tumor response rate, and prolong progression free and overall survival while balancing the toxicities of therapy. The most common type of GC is adenocarcinoma, which demonstrates morphological, biological, and clinical heterogeneity. A plethora of genomic alterations and the activation of numerous molecular pathways including human epidermal growth receptor 2 (HER2), epidermal growth factor receptor (EGFR), fibroblast growth factor receptor-2 (FGFR2), mesenchymal epidermal transforming factor receptor (MET), and the phosphatidylinositol 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) are responsible for the complex heterogeneity of GC. Efforts to validate the therapeutic effects of inhibiting some of these aberrantly expressed pathways have failed to lead to a clinically meaningful outcome apart from the overexpression/amplification of the HER2 gene, inhibition of which has had a significant impact on clinical practice. The only available biomarkers to guide the effective treatment of patients with advanced GC are HER2 overexpression, MSI/PD-L1 status, and FGFR alterations. Various anti-HER2 agents have been evaluated after the success of the ToGA trial, but none led to a significant enough clinical improvement to be considered a viable alternative for HER2-targeted therapy in advanced GC until the global Keynote-811 trial, which added pembrolizumab to trastuzumab in combination with chemotherapy. This combination demonstrated a survival advantage for the first time in the 11 years since ToGA. Trastuzumab deruxtecan (T-DXd) was also found to be effective in patients who had already received >2 previous lines of treatment. Despite these promising avenues, the optimal management of HER-2 positive GC still requires further development.

Review of Survival, Safety, and Clinical Outcomes in HER2+ Metastatic Gastric Cancer Following the Administration of Trastuzumab

BACKGROUND

Therapies targeting human epidermal growth factor receptor 2 (HER2) have become a focus for improving treatment outcomes in patients with gastric cancer. This literature review sought to assesses clinical outcomes, including safety, survival, and treatment outcomes, of patients who received trastuzumab for the treatment of HER2+ metastatic gastric cancer.

METHODS

Searches were conducted in PubMed and Embase to identify observational research studies investigating the clinical outcomes of trastuzumab and combination therapies for the treatment of HER2+ metastatic gastric cancer, published January 1, 2014-August 22, 2019. Article screening was a two-phase process, and the results of each screening level were documented in accordance with PRISMA.

RESULTS

Twenty articles met the selection criteria for data extraction. Studies focused on treatment patterns or survival, safety, and clinical outcomes, as well as the natural history of disease. In the combined HER2+ patient populations included in this review, tumors were located in the stomach (33.7%), gastroesophageal junction (GEJ, 14.2%), unspecific GEJ or stomach (50.3%), or esophagus (1.9%). Studies observed increases in both overall survival and progression-free survival with the use of trastuzumab-based chemotherapy compared with chemotherapy treatment alone. Additionally, trastuzumab-based chemotherapy appeared to improve survival and clinical outcomes regardless of the presence of multi-organ metastases or tumor location.

CONCLUSIONS

Trastuzumab-treated patients have longer survival times than those not treated with trastuzumab and tolerate treatment well, with few serious adverse events. New treatments for second- and subsequent-line therapies would increase regimen options.

MINI-ABSTRACT

The treatment patterns and clinical outcomes observed in this literature review suggest patients treated with trastuzumab have longer survival times compared with chemotherapy treatment alone and tolerate treatment.

Preoperative neoadjuvant chemotherapy on surgical condition and oncogene expression in advanced gastric cancer

Objective

To evaluate the effect of preoperative neoadjuvant chemotherapy regimen of XELOX (capecitabine combined with oxaliplatin) on surgical condition and oncogene expression in advanced gastric cancer.

Methods

From January 2015 to July 2016, 124 patients with advanced gastric cancer who were admitted to our hospital were selected. Random number table method was used to divide them into an observation group and a control group, 62 each group. The observation group received two courses of neoadjuvant chemotherapy (XELOX) before operation, and the control group received surgery. The operation condition, expression of oncogenes in gastric cancer lesions, occurrence of adverse reactions and the long-term prognosis were compared between the two groups.

Results

The R0 resection rate of the observation group was significantly higher than that of the control group, and the difference was statistically significant (P<0.05). The operation time of the observation group was shorter than that of the control group, the amount of intraoperative bleeding and the amount of postoperative drainage of the observation group were less than that of the control group, and the differences were statistically significant (P<0.05). The mRNA expression of gastrokine 1, multiple tumor suppressor protein, Wilms tumor gene on the X chromosome (WTX gene) and gene of phosphate and tension homology deleted on chromosome ten (PTEN gene) in the observation group after treatment was significantly higher than that in the control group before treatment, and the increase amplitude of the observation group was more obvious than that of the control group (P<0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P>0.05). In terms of long-term prognosis, the disease-free survival time and average survival time of the observation group during the two-year follow-up period were significantly better than those of the control group, and the recurrence rate of the observation group was significantly lower than that of the control group; the differences were statistically significant (P<0.05).

Conclusion

Preoperative XELOX for advanced gastric cancer patients can effectively increase the proportion of radical surgery, reduce the risk of surgery, and significantly regulate the expression of oncogene, thus improving the long-term prognosis of patients.

Comparing cytotoxic backbones for first-line trastuzumab-containing regimens in human epidermal growth factor receptor 2-positive advanced oesophagogastric cancer: A meta-analysis

According to the Trastuzumab for Gastric Cancer (ToGA) study, trastuzumab plus cisplatin and capecitabine/5-fluorouracil (5-FU) is standard first-line treatment for human epidermal growth factor receptor 2 (HER2)-positive advanced oesophagogastric cancer. We examined the relative efficacy and safety of alternative trastuzumab-based cytotoxic backbone regimens compared to the standard ToGA regimen using meta-analysis. We searched Medline, EMBASE, CENTRAL and ASCO and ESMO up to March 2017 for studies investigating alternative first-line trastuzumab-based regimens for HER2-positive oesophagogastric cancer, defined as high protein expression IHC3+ or IHC2+ and gene amplification by in situ hybridisation. We compared primary outcome overall survival (OS) of alternative trastuzumab-based regimens to the ToGA regimen. Hazard ratios (HRs) and 95% confidence intervals (95%CI) were calculated by extraction of the published Kaplan-Meier curves. Incidence counts and toxicity sample-sizes were extracted for adverse events and compared using single-arm proportion meta-analysis in R. Fifteen studies (N = 557 patients) were included. OS was significantly longer with regimen trastuzumab plus doublet oxaliplatin and capecitabine/5-FU (median OS = 20.7 months) versus ToGA (16.0 months, HR = 0.75, 95% CI = 0.59-0.99) and was less toxic. Trastuzumab plus doublet cisplatin and S-1 showed no OS difference versus ToGA, but showed a different toxicity profile, including less hand-foot syndrome. Trastuzumab plus cisplatin or capecitabine as singlet backbone showed significantly worse survival and more toxicity versus ToGA regimen. Trastuzumab with triplet cytotoxic backbones or with bevacizumab and doublet cytotoxic backbone showed no survival benefit and more toxicity. In conclusion, trastuzumab plus doublet cytotoxic backbone containing oxaliplatin is preferable over the ToGA regimen with cisplatin. S-1 can substitute capecitabine or 5-FU when specific toxicities are encountered.

Clinical significance of expression of proliferating cell nuclear antigen and E-cadherin in gastric carcinoma

AIM

to investigate the expression of proliferating cell nuclear antigen (PCNA) and E-cadherin in gastric carcinoma and to analyze their clinical significance.

METHODS

A total of 146 patients were selected for this study, including 38 patients with intestinal metaplasia, 42 with dysplasia, and 66 with primary gastric cancer. In addition, 40 patients with normal gastric tissues were selected as controls. The expression of PCNA and E-cadherin was detected by immunohistochemistry. Differences in PCNA and the E-cadherin labeling indexes among normal gastric mucosa, intestinal metaplasia, dysplasia, and gastric carcinoma were compared. Subjects with normal gastric tissues were assigned to a normal group, while gastric cancer patients were assigned to a gastric cancer group. The difference in PCNA and E-cadherin expression between these two groups was compared. The relationship between expression of PCNA and E-cadherin and clinicopathological features was also explored in gastric cancer patients. Furthermore, prognosis-related factors, as well as the expression of PCNA and E-cadherin, were analyzed in patients with gastric cancer to determine the 3-year survival of these patients.

RESULTS

The difference in PCNA and the E-cadherin labeling indexes among normal gastric mucosa, intestinal metaplasia, dysplasia, and gastric carcinoma was statistically significant (P < 0.05). During the transition of normal gastric mucosa to gastric cancer, the PCNA labeling index gradually increased, while the E-cadherin labeling index gradually decreased (P < 0.05). The PCNA labeling index was significantly higher and the E-cadherin labeling index was significantly lower in gastric cancer than in dysplasia (P < 0.05). The expression of PCNA was significantly higher in the gastric cancer group than in the normal group, but E-cadherin was weaker (P < 0.05). There was a negative correlation between the expression of PCNA and E-cadherin in gastric carcinoma (r = -0.741, P = 0.000). PCNA expression differed significantly between gastric cancer patients with and without lymph node metastasis and between patients at different T stages. E-cadherin expression also differed significantly between gastric cancer patients with and without lymph node metastasis (P < 0.05). High T stage and positive PCNA expression were risk factors for the prognosis of patients with gastric cancer (RR > 1), while the positive expression of E-cadherin was a protective factor (RR < 1). The sensitivity, specificity, and accuracy of PCNA positivity in predicting the 3-year survival of patients with gastric cancer were 93.33%, 38.89%, and 0.64, respectively; while these values for E-cadherin negativity were 80.0%, 41.67%, and 0.59, respectively. When PCNA positivity and E-cadherin negativity were combined, the sensitivity, specificity, and accuracy were 66.67%, 66.67%, and 0.67, respectively.

CONCLUSION

Combined detection of PCNA and E-cadherin can improve the accuracy of assessing the prognosis of patients with gastric cancer.

The role of antiangiogenic agents in the treatment of gastric cancer: A systematic review and meta-analysis

BACKGROUND

The survival of advanced gastric cancer (GC) is dismal, and effects of antiangiogenic agents remain inconclusive. The purpose of this study is to assess combination of chemotherapy with antiangiogenic therapy versus traditional chemotherapy.

METHODS

To achieve the goal of scientific rigor, statistics from both referenced works and experiments were analyzed. We carefully searched for the referenced works by retrieving, as well as analyzing, literature databases for information on antiangiogenic therapy compared to other therapeutic approaches used to treat GC patients. Two groups were defined in the experiment: experimental and control groups. The experimental group was treated with antiangiogenic drug, and the control group was treated with standard chemotherapy or placebo.

RESULTS

The study included a total of 3240 participants. Overall, there was significant improvement in overall survival (hazard ratio [HR] = 0.78, 95% confidence interval [CI]: 0.67-0.91, P = 0.002), progression-free survival (HR 0.65, 95% CI: 0.52-0.81, P = 0.0002), objective response rate (risk ratio [RR] = 1.58, 95% CI: 1.33-1.88, P < 0.00001), and disease control rate (RR 2.44, 95% CI: 1.57-3.78, P < 0.0001) in the group with antiangiogenic drug versus the group with standard chemotherapy or placebo. Moreover, this new treatment approach showed tolerable toxicity.

CONCLUSION

This study confirms the superior efficacy of combination therapy with antiangiogenic agents in comparison to traditional chemotherapy regimens for patients with GC. Moreover, this new treatment approach showed tolerable toxicity. This meta-analysis provides important information for clinicians who are interested in using antiangiogenic therapies to treat GC patients.