gastric cancer debate adjuvant chemoradiotherapy

Gastric Cancer Debate:Adjuvant Chemo-radiotherapyMohamed Abdulla M.D.Prof. of Clinical OncologyCairo University

Intercontinental City Stars Hotel and TowerWednesday, 28/10/2015

Member of Advisory Board, Consultant, and Speaker for:• Amgen, Astellas, AstraZeneca, Hoffman la Roche, Janssen

Cilag, Merck Serono, Novartis, Pfizer• The content of this presentation does not relate to any product

of a commercial interest

Speaker Disclosures:

Basic Facts:• Decreasing incidence over past decades.• 2nd – 3rd cause of cancer related deaths.• Surgical resection is the cornerstone in curative

management loco-regional failures (40 – 65%).• The 10 – Year OAS for all stages is only around 20%.• Wide Ethnic & Geographic variations between Asian

and other countries.

Landry et al. Patterns of failure following curative resection of gastric cancer. Int J Ra- diat Oncol Biol Phys 1990;191:1357-62. Jemal etal. Cancer Statistics, 2010. CA Cancer J Clin 2010. [Epub ahead of print]

Recurrence After Surgery:

Wong et al. J Gastrointest Oncol 2015;6(1):89-107

Can we go better?

Advanced Disease

R0 – D2Resection

NeoadjuvantPerioperative

AdjuvantPostoperative

40 - 65% LR

Radiation Therapy

Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48

Intergroup 0116 Adjuvant Trial:

556 Patients(T1-4 N0-1)

Surgery (D1 or Less)

Observation

CRT

S = 27 msS + CRT = 36 msP = 0.005

S = 19 msS + CRT = 30 msP < 0.001

Macdonald et al. N Engl J Med, Vol. 345, No. 10 · September 6, 2001

Updated Analysis of SOWG – Directed Intergroup 01116 Trial

Smalley et al. J Clin Oncol. 2012 30:2327-2333.

ARTIST Trial:458 Patients

Non-Metastatic Gastric Cancer

D2 ResectionXP X 6

XP/XRT/XP

Lee at al. J Clin Oncol. 2012 30:268-273

ARTIST Trial: 7 – Year Updated Analysis:

Park et al. J Clin Oncol. 2015.33:3130-3136

XP XRT PLR 13% 7% 0.0033

DFS (LNs +) 72% 76% 0.004

Postoperative Radiation Therapy:• Positive LNs.• Intestinal (Non Diffuse) histopathology.

Who Benefits of Adjuvant Radiation Therapy?

Who Benefits of Adjuvant Radiation Therapy?

OAS DFS

Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013

Who Benefits of Adjuvant Radiation Therapy?

Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013

OAS By Nodal Dissection

20% in OAS & DFS

Who Benefits of Adjuvant Radiation Therapy?

Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013

Radiation Therapy Incomplete Nodal Dissection

Intestinal Type

Positive Nodal Disease

Multi-Modal Treatment of GC:

Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48

Multimodal Treatment is Superior to Single Modality (Surgery).

Geographic Practice Variations:

Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48

USA European Japanese

Adjuvant CRT Neoadjuvant CT Adjuvant CT

Int. 0116 MAGIC D2 Resection S1 Adjuvant

Take Home Message:

• Clinical trials are crucial.• Radiation therapy is appealing in

improving local control and DFS among patients with LNs +ve.

• Postoperative CRT would be preferred for non-cardia lesions.

• 5-Fu/LV/RT according to Int. 0116 is preferred.