From the Guidelines
FLOT (5-Fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel) is a highly effective perioperative chemotherapy regimen for resectable gastric cancer, offering improved disease-free survival and overall survival rates compared to other regimens. The FLOT regimen, which consists of docetaxel combined with oxaliplatin and 5-FU/leucovorin, has demonstrated a prolonged median disease-free survival and median overall survival, higher pathological response rate, and R0 resection rate with a more tolerable profile compared to the ECF/ECX regimen, as shown in the FLOT4-AIO study presented at the 2017 American Society of Clinical Oncology (ASCO) annual meeting 1.
The benefits of FLOT include:
- P median disease-free survival
- Prolonged median overall survival
- Higher pathological response rate
- Higher R0 resection rate
- More tolerable profile compared to other regimens
The FLOT regimen can be considered as the new standard preoperative chemotherapy regimen for resectable gastric cancer, according to the Chinese Society of Clinical Oncology (CSCO) clinical guidelines for the diagnosis and treatment of gastric cancer 1. However, it is essential to closely monitor patients for potential toxicities, including neutropenia, diarrhea, neuropathy, and fatigue, and provide appropriate supportive care.
Key considerations for the use of FLOT in clinical practice include:
- Patient selection: FLOT is most beneficial for patients with good performance status who can tolerate the regimen's intensity
- Dose modifications: may be necessary based on individual tolerance
- Monitoring: close monitoring of blood counts, kidney and liver function, and appropriate antiemetics and potentially G-CSF support are required
- Treatment duration: typically 4 cycles before and after surgery (8 cycles total)
From the Research
Efficacy of FLOT for Resectable Gastric Cancer
The FLOT regimen, consisting of 5-Fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel, has been studied for its efficacy in treating resectable gastric cancer. Key findings include:
- Improved overall survival (OS) in patients with locally advanced gastric cancer compared to initial surgery followed by chemotherapy 2, 3
- Favorable OS results in the FLOT-first group compared to the surgery-first group, with 3-year survival rates of 58.7% and 30.9%, respectively 2
- Perioperative FLOT improved OS compared to perioperative ECF/ECX, with a median OS of 50 months vs 35 months 3
Pathological Response and Survival Outcomes
Studies have also examined the pathological response and survival outcomes of patients treated with FLOT:
- The FLOT group showed a higher pathological response rate (TRG-0) of 6.2% compared to 4.7% in the NO-FLOT arm 4
- Survival outcomes were better in the FLOT group, with a median disease-free survival of 30 months vs 22.2 months 4
- The addition of atezolizumab to perioperative FLOT improved postoperative stage and histopathologic regression, with higher complete margin-free (R0) resection rates 5
Comparison with Other Regimens
Comparisons with other regimens have been made:
- FLOT was compared to the GASTRODOC regimen, with the planned treatment more frequently completed in the neoadjuvant arm 6
- FLOT was also compared to ECF/ECX, with FLOT showing improved OS and similar adverse event rates 3
Key Findings and Implications
Key findings and implications include:
- FLOT is a safe and effective treatment for resectable gastric cancer, with improved OS and pathological response rates 2, 3, 4
- The addition of immunotherapy, such as atezolizumab, may further improve outcomes in certain patient populations 5
- Further research is needed to fully establish the efficacy and safety of FLOT in various populations, including elderly patients and those with microsatellite instability or high PD-L1 levels 4, 5