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Gastric Cancer Therapy: Recognizing and Managing Fragmentation of Care and Evidence Gaps
Michael R. Page, PharmD, RPh; and Shriya Patel, PharmD
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Gastric Cancer Therapy: Recognizing and Managing Fragmentation of Care and Evidence Gaps

Michael R. Page, PharmD, RPh; and Shriya Patel, PharmD
Gastric cancer is the fifth most common type of malignancy and the third leading cause of cancer-related death worldwide.1 Although gastric cancer is less common in the United States than abroad, there remains a notable lack of standardization of care across all lines of therapy, but particularly in later-line gastric cancer treatment.2,3 Response to treatment may be highly individualized, varying even between patients with the same stage of cancer. Unfortunately, because gastric cancer is managed with a variety of therapeutic strategies, the standard of care in later-line treatment is not well characterized, and there is a need for further research to establish more comprehensive and standardized treatment strategies.3

For patients with advanced or metastatic disease or for patients receiving postoperative therapy, National Comprehensive Cancer Network (NCCN) guidelines currently recommend platinum-based therapies, such as cisplatin or oxaliplatin, plus fluoropyrimidine therapies, such as fluorouracil or capecitabine.2,4 Fifteen and 8 other discrete regimens for first- and second-line treatment of gastric cancer, respectively, are also recommended by NCCN.4 Although NCCN categorizes some treatments as preferred and classifies other treatments as alternative therapeutic options, there still remains a wide variety of choices for treatment.4

For patients with metastatic adenocarcinoma with human epidermal growth factor receptor 2 (HER2) overexpression, trastuzumab should be added in combination with a first-line chemotherapy regimen. However, importantly, NCCN recommends against administration of trastuzumab in patients receiving anthracyclines.4 With combination drug regimens, 2-drug combination regimens are generally preferred over 3-drug combination regimens, as 2-drug combinations usually have lower rates of toxicity. However, 3-drug combination regimens may be used in patients with good performance status who can be regularly examined for adverse events.4

In 2016, a study conducted by Hess et al examined chemotherapy treatment patterns, costs, and outcomes of gastric cancer patients across the United States. Their results indicated that the approach to care after disease progression or recurrence is not rigorously evidence-based. Uncertainties in the existing evidence have led to large variations in treatment patterns across providers.2
Hess and colleagues retrospectively analyzed data collected from electronic medical records (EMRs) and administrative claims.2 Data from the latter included records from hospital inpatient admissions, outpatient medical claims, professional claims, service and facility files, length of stay in institutional settings, copayment amounts, and pharmacy claims. EMR data were drawn from therapeutic regimens (drug molecule, generic drug name, dose, date of administration, length of therapy) and gastric/gastroesophageal-related surgical procedures.2

Patients included in the study were aged 18 years or older with recent diagnosis of gastric cancer between 2004 and 2012; excluded were patients who had any signs of cancer up to 6 months prior to initial diagnosis or who had gastrointestinal stromal tumor.2



 
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