Gastric cancer: Clinical practice guidelines in oncology™

Gastric cancer is rampant in several countries. Its incidence in the Western Hemisphere has been declining for more than 40 years. In the past 15 years, the incidence of proximal gastric cancer has increased in Western countries compared with non-proximal gastric cancer, which is more prevalent in Japan and other parts of the world. Diffuse histology is also more common now than intestinal type of histology. H. pylori infection, smoking, and high salt intake are risk factors for gastric cancer. Few gastric cancers are associated with inherited gastric cancer predisposition syndromes. Several advances have been made in therapeutic approaches, imaging techniques, and staging procedures. Multidisciplinary team management is essential for treating patients with gastric cancer. Patients with locoregional disease should be referred to high-volume treatment centers. Surgery is the primary treatment option for medically fit patients with resectable gastric cancer. However, in the West, surgery alone is an insufficient therapy for most patients. Subtotal gastrectomy is preferred for distal gastric cancers, whereas proximal or total gastrectomy is recommended for proximal tumors. Based on the results of recent clinical trials, perioperative chemotherapy with ECF or its modifications is recommended for medically fit patients with resectable locoregional distal esophageal, gastroesophageal junction, and gastric adenocarcinoma (category 1). Preoperative chemoradiation may also be considered for these patients (category 2B). Post-operative treatment is based on surgical margins and nodal status. All patients with unresectable disease may be treated with 5-FU-based chemoradiation. Targeted therapies in combination with chemotherapy have produced encouraging results in the treatment of patients with advanced gastric, esophageal, and gastroesophageal junction cancers. Based on the results of the ToGA trial, the NCCN panel included trastuzumab plus chemotherapy in the guidelines as a new treatment option for patients with HER2-positive advanced gastric cancer or gastroesophageal junction adenocarcinoma. The efficacy of VEGFR and EGFR inhibitors in combination with chemotherapy for patients with advanced gastric and gastroesophageal junction cancers are being evaluated in ongoing randomized phase III trials. Best supportive care is an integral part of treatment, especially in patients with metastatic and advanced gastric cancer. Patients with good performance status can be treated with chemotherapy or best supportive care, whereas best supportive care alone is the appropriate treatment for patients with poor performance status. Assessment of disease severity and related symptoms is essential to initiate appropriate palliative interventions that will prevent and relieve suffering and improve quality of life for patients and their caregivers. Treatment options used for palliation of symptoms in patients with advanced gastric cancer include endoscopic placement of self-expanding metal stents, laser surgery, or RT. The NCCN Gastric Cancer Guidelines provide an evidence-based systematic approach to the management of gastric cancer in the United States. Many new chemotherapeutic agents, targeted therapies, vaccines, gene therapy, and antiangiogenic agents are being studied in clinical trials. The panel encourages patients to participate in well-designed clinical trials to enable further advances.