A three-pronged approach to eradicate stomach cancer offers new hope to patients, showing the potential to save lives and change the way doctors treat this disease, according to a report in the Sept. 6 issue of the New England Journal of Medicine (Vol. 345, No. 10: 725-730).

With cancer of the stomach or gastroesophageal junction, surgical removal of cancerous tissue cures patients less than 40% of the time, according to the researchers. Past studies showed that chemotherapy after surgery did not increase survival rates, the authors write. But they report a significant increase in survival by using the combination of chemotherapy and radiation therapy after surgery.

“The good news is very significant improvement in both disease-free and overall survival,” says lead author John S. Macdonald, MD, chief of medical oncology at St. Vincent’s Comprehensive Cancer Center in New York City.

“The US standard of care is certainly changing to include the chemoradiation postoperatively as we defined it in this study,” Macdonald tells ACS News Today. “Before this study the standard was surgery alone,” he says.

“I believe the data are strong enough to alter the standard procedure in patients with stomach cancer,” says Neal J. Meropol, MD, a medical oncologist and director of the Gastrointestinal Cancer Program at Fox Chase Cancer Center in Philadelphia.

In this study, 556 participants across the country enrolled through medical oncologists such as Meropol. These patients all had “curative” surgery in which all visible cancer was removed, according to the report.

Participants were then randomly assigned to two groups: about half received no further treatment — which has been the standard of care in such cases. The other half received a specific course of chemotherapy, as well as radiotherapy, as an “adjuvant,” or complementary therapy, according to the protocol of the study.

The median survival rate (meaning one half of the patients were alive and one half had died) was higher in the group that received this chemoradiotherapy combination after surgery: the median survival in the surgery-only group was 27 months; whereas, the median survival was 36 months for the patients who had surgery followed by chemoradiotherapy, the authors write.

The relapse-free period (the period of time extending from immediately following surgery until the first tumor recurrence was found) was higher as well. The median duration of time in which patients had no relapse was 30 months in the chemoradiotherapy group, compared to 19 months in the surgery-only group, the authors report.

The results of this study apply only to patients in whom all visible signs of cancer can be removed surgically, Meropol says. “In most [stomach cancer] patients, that is not the case,” he says.

The improvement in survival rates in the patients who received adjuvant chemoradiotherapy emphasizes that even in cases where surgery appears successful a high risk of relapse remains, notes Meropol.

“The implication is that even people who appear to be cured by surgery have a high risk of harboring microscopic deposits of cancer that continue to grow. The purpose of adjuvant therapy is to eradicate these microscopic deposits to improve the cure rate for this disease,” Meropol says.

Previous studies had found that adjuvant chemotherapy after surgery did not result in higher rates of survival, according to the article. But in 1991, the authors began this study which included patients and physicians from many different locations to look at the combination of chemotherapy and radiotherapy after surgery in which all visible cancer was removed.

“As far as the surgery goes, it is important that a surgeon be experienced in the resection of the stomach for cancer,” Macdonald notes. “More extensive lymph node dissection is generally considered important because it allows more precise staging.

“Radiation technique is important and the radiation therapist should have experience in postoperative radiation of resected gastric cancer,” Macdonald says. The study also emphasizes that adequate nutrition is important.

Meropol notes that in this study, the treatment plan for each patient’s radiotherapy was reviewed by the study team before treatment could begin. In 35% of the cases, the initial plan for radiotherapy was found to have minor or major deviations from the protocol set up by the researchers and needed to be changed before the therapy was administered to patients.

“The importance of radiation therapy quality control cannot be overstated,” Meropol says. “Radiation therapy administered to the upper abdomen has the potential to cause severe side effects if not administered properly.”

“Therefore, it is essential that patients receive their adjuvant therapy from radiation oncologists and medical oncologists who are familiar with treatment of the upper abdomen,” Meropol concludes.