Stomach cancer medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]
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Overview
The optimal therapy for stomach cancer depends on the stage at diagnosis.
Medical therapy
The current goal of chemotherapy is to delay the manifestation of disease-related symptoms and to prolong survival. Some patients with advanced disease survive more than 5 years by chemotherapy alone.
Chemotherapy is the treatmentof choice for unresectable/ recurrent gastric cancer. The median survival time achieved by chemotherapy for unresectable/ recurrent gastric cancer is 6–13 months.
Principles of indication
Chemotherapy is indicated for patients with unresectable or recurrent disease
After non-curative R2 resection
patients with unresectable T4b disease
extensive nodal disease
hepatic metastases
peritoneal dissemination or other M1 disease.
Methodology
Response to the treatment should be evaluated by examinations that may include CT, endoscopy and contrast radiography, followed by comparison with the baseline data.
Tumor shrinkage should be evaluated by response criteria of the Japanese Classification of Gastric Carcinoma or Response Evaluation Criteria in mSolid Tumors (RECIST) to decide on whether or not to continue with the treatment.
3. When continuation of the treatment is deemed oncologically feasible, the drug dosage and administration schedule should be reconsidered taking into account the adverse events observed in the previous cycle of treatment. Attention should also be paid to cumulative adverse events such as skin manifestations, taste disturbance and neurotoxicity.
4. Chemotherapy for individuals exposed or infected tonhepatitis B virus should be screened, monitored and treated
These drugs are to be used alone or in combination, adhering to the dose and schedule employed when being evaluated in clinical trials.
The following drugs are used in chemotherapy for gastric
cancer:
fluorouracil (5FU)
tegafur-gimestat-otastat potassium (S-1)
capecitabine
cisplatin
irinotecan
docetaxel
paclitaxel
trastuzumab
Ramucirumab and oxaliplatin
Postoperative adjuvant chemotherapy
Postoperative adjuvant chemotherapy is delivered with an intention to reduce recurrence by controlling residual tumor cells following curative resection.
Various regimens had been tested in numerous clinical trials in Japan without producing solid evidence in support of adjuvant chemotherapy until the efficacy of S-1 was proven in the ACTS-GC trial [29, 30], a study that secured the place of postoperative chemotherapy with S-1 as a standard of care (recommendation category 1).
After this, the feasibility of several combinations of anticancer drug with S-1 was explored in the postoperative setting [31, 32], and some of the combinations are currently under evaluation in phase III trials. On the other hand, other phase III evidence in support of postoperative chemotherapy was established in 2012 by the CLASSIC trial conducted mainly in Korea [33], in which significant prolongation of recurrence-free survival was shown with a combination of capecitabine and oxaliplatin.
Survival benefit of postoperative adjuvant chemotherapy by combination of S-1 and another cytotoxic drug, including oxaliplatin, will have to be proven by a randomized trial with S-1 monotherapy as a control.
Indications
The patients eligible for the ACTS-GC trial were those
with a tumor of pathological stage II, IIIA or IIIB,
excluding those classified as stage II due to pT1/pN2�pN3
status, as defined by the previous 13th edition of the
Japanese Classification of Gastric Carcinoma (2nd English
edition), who had undergone R0 gastrectomy with CD2
lymphadenectomy. The eligibility for postoperative adjuvant
chemotherapy will remain the same in the current
version of the treatment guidelines.
Chemotherapy
Drugs Approved for Stomach (Gastric) Cancer
- Adrucil (Fluorouracil)
- Cyramza (Ramucirumab)
- Docetaxel
- Doxorubicin Hydrochloride
- Efudex (Fluorouracil)
- Fluoroplex (Fluorouracil)
- Herceptin
- Mitomycin C
- Mitozytrex (Mitomycin C)
- Mutamycin (Mitomycin C)
- Ramucirumab
- Taxotere (Docetaxel)
- Trastuzumab
Drug Combinations Used in Stomach (Gastric) Cancer
- FU-LV
- TPF
- XELIRI[1]
Radiation Therapy
Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for palliation of incurable disease
Chemoradiation Therapy
Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both. Chemoradiation given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Chemoradiation given before surgery, to shrink the tumor (neoadjuvant therapy), is being studied.[2]
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibody therapy is a type of targeted therapy used in the treatment of gastric cancer.
Monoclonal antibody therapy uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. For stage IV gastric cancer and gastric cancer that has recurred, a monoclonal antibody such as trastuzumab may be given to block the effect of the growth factor protein HER2, which sends growth signals to gastric cancer cells.[3]