A New Option for Stomach Cancer Treatment

Article date: July 18, 2006

Chemo Before and After Surgery Can Improve Results for Some Patients

Summary: Some people with stomach cancer may survive longer if they get chemotherapy before and after surgery to remove the tumor, according to a recent British study in the New England Journal of Medicine. The finding gives doctors a new way to approach treatment for patients with cancer that hasn't spread to distant sites in the body.

Why it's important: Surgery can cure many stomach cancers if they are found before the cancer spreads throughout the stomach or beyond it. Unfortunately, only a fraction of stomach cancers in the United States are found at this early stage. Most are detected after the tumor has spread within the stomach and to nearby lymph nodes, or even to other parts of the abdomen. When this happens, surgery alone may no longer be enough. It is important to find other treatment strategies to help patients who cannot be cured by surgery alone.

What's already known: A study published in 2001 showed that giving chemotherapy and radiation after surgery could help patients with locally advanced (stage II or III) stomach cancer live longer. But it wasn't clear whether giving chemotherapy before surgery might also have some benefit. Researcher David Cunningham, MD, and colleagues from Britain's Royal Marsden Hospital and other institutions thought it might. They speculated that chemo before surgery would help shrink the tumor, making surgery more effective, and thought it might also kill off any stray cancer cells that may have moved beyond the stomach.

How this study was done: To test their theory, Cunningham and his collaborators recruited 503 patients with stage II or higher adenocarcinoma of the stomach or lower part of the esophagus. About half the patients (253) were randomly assigned to surgery only, while the rest (250) were assigned to get chemotherapy, too. Those patients got 3 cycles of chemo before surgery, and another 3 cycles afterward. The researchers used epirubicin, cisplatin, and fluorouracil (ECF), a drug combination commonly used for stomach cancer.

What was found: The chemotherapy did, in fact, shrink the tumors by an average of about 2 centimeters. It also appeared to reduce spread to lymph nodes. Patients who got chemotherapy tended to have less lymph node involvement than those who had surgery only. More importantly, though, the chemotherapy also improved survival and the length of time it took for the cancer to start growing again. After about 4 years of follow up, 170 people in the surgery-only group had died, compared to 149 in the chemotherapy group.

Fewer than half of the patients assigned to the chemotherapy group completed all 6 cycles of treatment. But that doesn't necessarily mean the treatment is too hard to take, said John Macdonald, MD, medical director of St. Vincent's Comprehensive Cancer Center, and chief of medical oncology at St. Vincent's Hospital-Manhattan. He wrote an editorial about the new study, and was lead author of the 2001 study showing chemo and radiation after surgery was helpful.

Most of the people who didn't finish chemotherapy quit because their cancer continued growing despite treatment, he noted. The rate of complications after surgery was similar in the patients who had chemotherapy before their operation (45.7%) and those who didn't (45.3%), as was the number of deaths within 30 days of surgery (14 in the chemo group, and 15 in the surgery-only group). Patients in both groups spent the same amount of time in the hospital after surgery (13 days).

"If the preoperative chemotherapy had damaged patients and they'd had more complications, you would see patients in the hospital for a longer period of time, which didn't appear to happen," Macdonald said.

The bottom line: This new approach to treatment is another option doctors should consider for appropriate patients, Macdonald said. Future research will need to examine whether using new chemotherapy drugs like oxaliplatin or capecitabine might get even better results. And doctors will also look at combining pre-surgery chemotherapy with post-surgery chemoradiation.

Citations: "Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer." Published in the July 6, 2006, New England Journal of Medicine (Vol. 355, No. 1: 11-20). First author: David Cunningham, MD, Royal Marsden Hospital, Surrey, UK.

"Gastric Cancer - New Therapeutic Options." Published in the July 6, 2006, New England Journal of Medicine (Vol. 355, No. 1: 76-77). Author: John S. Macdonald, MD, St. Vincent's Comprehensive Cancer Center, New York, and Aptium Oncology, Los Angeles.

Reviewed by: Members of the ACS Medical Content Staff

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