What are the treatment options for gastric cancer?

From the Guidelines

Gastric cancer treatment should prioritize a multidisciplinary approach, with surgical resection and perioperative chemotherapy being the cornerstone of treatment for localized disease, and combination chemotherapy and targeted therapy for advanced or metastatic disease, as recommended by the most recent guidelines 1. The primary treatment for gastric cancer involves surgical resection (gastrectomy) to remove the tumor and surrounding lymph nodes, with the extent depending on cancer location and stage.

• For localized disease, perioperative chemotherapy regimens like FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel) given for 4 cycles before and after surgery improve survival, as per the latest guidelines 1.
• Alternative regimens include FOLFOX (fluorouracil, leucovorin, oxaliplatin) or CAPOX (capecitabine plus oxaliplatin).
• For advanced or metastatic disease, combination chemotherapy with regimens such as FOLFOX, DCF (docetaxel, cisplatin, fluorouracil), or trastuzumab plus chemotherapy for HER2-positive tumors is recommended, with ramucirumab and pembrolizumab being options for second-line or subsequent therapy 1.
• Immunotherapy with pembrolizumab may benefit patients with PD-L1 positive tumors, and nivolumab combined with chemotherapy is recommended as first-line therapy for tumors with PD-L1 expression levels by CPS of $5 1.
• Radiation therapy is often combined with chemotherapy, particularly in locally advanced cases or when margins are positive after surgery. Treatment decisions should be individualized based on cancer stage, patient's performance status, and molecular characteristics of the tumor, as gastric cancer's aggressive nature requires prompt and comprehensive management to improve survival outcomes, as emphasized in the latest guidelines 1.

From the FDA Drug Label

1. 4 Gastric Adenocarcinoma Docetaxel Injection in combination with cisplatin and fluorouracil is indicated for the treatment of patients with advanced gastric adenocarcinoma, including adenocarcinoma of the gastroesophageal junction, who have not received prior chemotherapy for advanced disease.

The recommended dose of Docetaxel Injection is 75 mg/m2 as a 1 hour intravenous infusion, followed by cisplatin 75 mg/m2, as a 1 to 3 hour intravenous infusion (both on day 1 only), followed by fluorouracil 750 mg/m2 per day given as a 24-hour continuous intravenous infusion for 5 days, starting at the end of the cisplatin infusion Treatment is repeated every three weeks.

1. 1 Gastric Cancer REGARD The efficacy of CYRAMZA was evaluated in REGARD (NCT00917384), a multinational, randomized, double-blind, multicenter study in patients with locally advanced or metastatic gastric cancer (including adenocarcinoma of the GEJ) who previously received platinum- or fluoropyrimidine-containing chemotherapy

RAINBOW The efficacy of CYRAMZA was evaluated in RAINBOW (NCT01170663), a multinational, randomized, double-blind study in patients with locally advanced or metastatic gastric cancer (including adenocarcinoma of the GEJ) who previously received platinum- and fluoropyrimidine-containing chemotherapy

Gastric Cancer Treatment Options:

• First-line treatment: Docetaxel in combination with cisplatin and fluorouracil is indicated for the treatment of patients with advanced gastric adenocarcinoma who have not received prior chemotherapy for advanced disease 2.
• Second-line treatment: Ramucirumab (CYRAMZA) is indicated for the treatment of patients with locally advanced or metastatic gastric cancer who have previously received platinum- or fluoropyrimidine-containing chemotherapy 3. Key Points:
• Docetaxel is used in combination with cisplatin and fluorouracil for first-line treatment of advanced gastric adenocarcinoma.
• Ramucirumab (CYRAMZA) is used as a single agent or in combination with paclitaxel for second-line treatment of locally advanced or metastatic gastric cancer.

From the Research

Gastric Cancer Treatment Overview

• Gastric cancer is a complex disease that requires a thorough multidisciplinary approach for appropriate management 4.
• The main treatment for early gastric cancer is endoscopic resection, while non-early operable gastric cancer is treated with surgery, which should include D2 lymphadenectomy 5.
• Perioperative or adjuvant chemotherapy improves survival in patients with stage 1B or higher cancers 5.

Surgical Management

• The optimal extent of lymph node dissection for gastric cancer appears to have settled in favor of D2 dissection 6.
• Minimally invasive gastric and gastroesophageal resections are performed routinely in most centers, affording faster recovery and equivalent oncologic outcomes 6.
• Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers 6.

Chemotherapy and Targeted Therapies

• Advanced gastric cancer is treated with sequential lines of chemotherapy, starting with a platinum and fluoropyrimidine doublet in the first line 5.
• Targeted therapies licensed to treat gastric cancer include trastuzumab (HER2-positive patients first line), ramucirumab (anti-angiogenic second line), and nivolumab or pembrolizumab (anti-PD-1 third line) 5.
• Triplet chemotherapy for resectable gastric cancer is now accepted and could represent a plateau of standard cytotoxic chemotherapy for localized disease 7.

Staging and Diagnosis

• Staging laparoscopy before initiation of treatment or before surgical resection has improved staging accuracy and can drastically inform treatment decisions 6.
• A staging CT of the chest and abdomen should always be performed, and diagnostic laparoscopy should be performed in patients at risk for stage IV disease 8.
• At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer 8.