Comparison of perioperative chemotherapy with adjuvant chemoradiotherapy for resectable gastric cancer: findings from a population-based study

Comparison of Perioperative Chemotherapy versus Postoperative Chemoradiotherapy for Operable Stomach Cancer: A Western Canadian Province Experience

Background: The standard approaches for resectable stomach cancer are postoperative chemoradiotherapy (PCR) or perioperative chemotherapy (PC). Limited evidence is available regarding the superiority of one of the two approaches. We aimed to compare the survival of patients with operable stomach cancer who were treated with PC or PCR. Methods: In this retrospective cohort study, patients with operable stomach cancer diagnosed between 2005–2015 in the province of Saskatchewan were identified and, based on type of treatment, were placed into PCR and PC groups. A Cox proportional multivariate analysis was performed to assess independent prognostic variables, including survival advantage of PC over PCR. Results: A total of 88 eligible patients with a median age of 66 (56–71) and a male to female ratio of 1:0.44 were identified. Seventy-three (83%) patients had pathologically node positive disease. Sixty-seven (76%) patients received PCR, while 21 (24%) patients received PC. The median overall survival of the whole group was 34 months, with 38 months (95% CI 24.6–51.3) in the PCR group vs. 30 months (14.3–45.7) in the PC group (p = 0.29). Median relapse-free survival was 34 months (20.7–47.3) in the PCR group vs. 23 months (6.7–39.3) in the PC group (p = 0.20). Toxicities were comparable. On multivariate analysis, T ≥ 3 tumor (HR, 3.57 (1.39–8.56)), neutrophil to lymphocyte ratio (LNR) > 2.8 (HR, 1.85 (1.05–3.25)), and positive resection margins (HR, 1.89 (1.06–3.37)) were independently correlated with inferior survival. Conclusions: This well-designed population based cohort study suggests a lack of survival benefit of PC over PCR. Both treatment options remain viable approaches for resectable stomach cancer.

Lack of National Adoption of Evidence-Based Treatment for Resectable Gastric Adenocarcinoma

BACKGROUND

Level 1 evidence for multimodal treatment of resectable gastric adenocarcinoma from the Intergroup 0116 (2001) and MAGIC (2006) trials demonstrated survival benefit of adjuvant chemoradiation (CRT) and perioperative chemotherapy, respectively. We evaluated the adoption of evidence-based treatment in the post-MAGIC era and its impact on survival.

METHODS

A total of 7058 patients with resectable gastric adenocarcinoma undergoing definitive surgical resection between 2004 and 2015 were analyzed using the National Cancer Database.

RESULTS

Over the study period, the proportion of patients receiving adjuvant CRT decreased from 19.1% to 9.1%, while perioperative chemotherapy increased from 1.9% to 28.6%. Utilization of perioperative chemotherapy surpassed adjuvant CRT in 2011. Evidence-based treatment (either perioperative chemotherapy or adjuvant CRT) had better overall survival (OS) than other treatments for clinical stage II-III patients (p < 0.05). On multivariate analysis of the whole study period, evidence-based treatments were associated with better OS (HR 0.67 [0.60-0.74], p < 0.05). Only 360/1262 (28.5%) patients in the perioperative chemotherapy group completed postoperative therapy, which was associated with improved OS (p < 0.05). For clinical stage III patients (n = 2402), only 806 (33.6%) received evidence-based treatment, while 487 (22.2%) underwent surgery alone. On multivariate analysis of these patients between 2010 and 2015, both perioperative chemotherapy (HR 0.49 [0.35-0.68]) and adjuvant CRT (HR 0.31 [0.21-0.44]) were associated with better OS than surgery alone (p < 0.05).

CONCLUSIONS

Since the INT-0116 and MAGIC trials, utilization of evidence-based treatments for resectable gastric adenocarcinoma has increased, with perioperative chemotherapy surpassing adjuvant CRT as the preferred practice. However, overall utilization of these regimens remains quite low nationally despite association with improved OS.

Longitudinal Analysis of Quality-of-Life Recovery After Gastrectomy for Cancer

OBJECTIVE

The purpose of this study was to identify factors associated with quality-of-life recovery after gastrectomy.

METHODS

Patients anticipated to undergo gastric cancer resection were invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and STO22 surveys in the preoperative setting and at 0-1.5 months (early), > 1.5-6 months (intermediate), and > 6-18 months (late) following resection. Quality-of-life recovery was measured as paired differences between pre- and postoperative results. Multivariable linear regression identified factors associated with preoperative quality of life and degree of change following resection.

RESULTS

Across 393 participants, response rates at the intermediate and late postoperative time points were 58% (n = 228) and 71% (n = 277), respectively. Relative to baseline, median global health scale decreased in the early (- 15.1 pts, p < 0.001) and intermediate (- 3.6 pts, p = 0.02) time points, but recovered by the late time point (+ 1.2 pts, p = 0.411). Relative to distal/subtotal gastrectomy, proximal/total gastrectomy was associated with worse recovery in both the early and late time points. Surgical complications were associated with worse early recovery. Patients who presented with locally advanced tumors (T3-T4) had lower preoperative quality-of-life scores, and more readily recovered to baseline after surgery. A minimally invasive approach was not associated with postoperative recovery.

CONCLUSIONS

Most patients recover to baseline within 1 year following major gastrectomy, and recovery is easier with more limited resections. Patients with locally advanced tumors tend to have poorer baseline quality of life, which may improve following resection.

Indications for adjuvant chemotherapy in patients with pT1N1M0 gastric cancer: a single-center experience

PURPOSE

Whether adjuvant chemotherapy (AC) has a survival benefit for all patients with pathological stage pT1N1M0 (Stage IB) gastric cancer (GC) remains controversial.

METHODS

All patients with surgically resected, histologically confirmed pT1N1M0 GC between January 2011 and December 2017 at the National Cancer Center, China, were retrospectively reviewed.

RESULTS

A total of 179 patients with pT1N1M0 were identified. Survival analysis showed that both overall survival (OS) and cause-specific survival (CSS) were significantly different between patients treated with and without AC (p < 0.01). Independent risk factors for reduced OS identified in the Cox regression analysis in patients with pT1N1M0 cancer were sex (male sex, hazard ratio [HR] 2.470, 95% confidence interval [CI] 1.294-4.718), examined lymph nodes (EN) (EN ≤ 15, HR 2.402; 95% CI 1.329-4.341), and AC (treated without AC, HR 2.554; 95% CI 1.393-4.681), which were also independent risk factors for reduced CSS. We divided patients with pT1N1M0 into three risk categories (high, moderate, and low) according to two significant prognostic factors (sex and EN) and found that both OS and CSS were significantly different between the three risk groups (p < 0.05).

CONCLUSION

An additional survival benefit related to AC is expected for selected pT1N1M0 patients. Male patients with EN ≤ 15 may be particularly appropriate candidates for AC.

Response to Neoadjuvant Treatment is Influenced by Grade in Gastric Cancer

Neoadjuvant therapy is commonly used in the management of gastric cancer. Primary tumor response to treatment correlates with prognosis. Published studies have compared efficacy of neoadjuvant therapy based on stage but not grade. The objective of this study was to determine the change in staging of gastric cancer after neoadjuvant therapy and resection based on grade. A retrospective analysis of gastric cancer patients treated at our institution between 2005 and 2017 was performed. Patient demographics, tumor characteristics, clinical and pathological stage, and microscopic treatment response were analyzed based on grade. Of the 269 patients identified during this period, 82 patients underwent definitive surgical resection, of which 38 patients received neoadjuvant therapy (low grade (grades 1 and 2), n = 17; high grade (grade 3), n = 18; and unknown grade, n = 3). Pathologic downstaging was observed in 52.9 per cent (9/17) of low-grade tumors compared with 22.2 per cent (4/18) of high-grade tumors. Majority of high-grade tumors (77.8%, 14/18) had either upstaging or unchanged stage. High-grade gastric cancers often lack response to neoadjuvant therapy. Novel targeted therapies based on biologic behavior should be evaluated and incorporated into neoadjuvant treatment. Neoadjuvant studies should stratify patients based on grade and report response by grade.

Quality of Life After Curative Resection for Gastric Cancer: Survey Metrics and Implications of Surgical Technique

Gastric cancer is one of the most common cancers worldwide, and radical gastrectomy is an integral component of curative therapy. With improvements in perioperative morbidity and mortality, attention has turned to short- and long-term post-gastrectomy quality of life (QoL). This article reviews the common psychometric surveys and preference-based measures used among patients following gastrectomy. It also provides an overview of studies that address associations between surgical decision-making and postoperative health-related QoL. Further attention is focused on reported associations between technical aspects of the operation, such as extent of gastric resection, minimally-invasive approach, pouch-based conduits, enteric reconstruction, and postoperative QoL. While there are several randomized studies that include QoL outcomes, much remains to be explored. The relationship between symptom profiles and preference-based measures of health state utility is an area in need of further research.

Implication of lymph node staging in migration and different treatment strategies for stage T2N0M0 and T1N1M0 resected gastric cancer: a SEER population analysis

PURPOSE

The purpose of this study was to explore the differences between stage T2N0M0 and stage T1N1M0 gastric cancer (GC) and to identify the necessity of adjuvant treatment (AT) for these stages.

METHODS

Between years 2004 and 2015, 1971 stage IB GC patients who underwent radical surgery were recruited using the Surveillance, Epidemiology and End Results database. We conducted univariate/multivariate analyses, the propensity score matching and evaluated gastric cancer-specific survival (GCSS) and overall survival (OS) with the log-rank test.

RESULTS

T1N1M0 had a significantly worse survival than T2N0M0 in both GCSS and OS before and after the propensity score matching. Examined lymph nodes (ELN) ≤ 15 and T1N1M0 were independent risk factors for worse GCSS and OS in stage IB GC. The absence of adjuvant chemotherapy (CT) was an independent risk factor for worse GCSS and OS in T1N1M0 but not in T2N0M0. AT demonstrated similar GCSS and OS with surgery alone (SA) for T2N0M0 but better survival for T1N1M0. Compared to CT and adjuvant chemoradiotherapy (CRT) group, SA demonstrated significantly worse GCSS and OS for T1N1M0. There was no significant difference between CT and CRT in both T2N0M0 and T1N1M0 stages. T2N0M0 had a better survival than T1N1M0 in ELN ≤ 15 subgroup. However, similar survival was demonstrated in ELN > 15 subgroup.

CONCLUSIONS

T2N0M0 GC has a better survival rate than T1N1M0 GC when ELN are ≤ 15. Moreover, T2N0M0 GC may not benefit from AT. T1N1M0 GC requires CT but not adjuvant radiotherapy.