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Supplements The Current and Future Management of Gastric Cancer
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Gastric Cancer: Local and Global Burden
Lynne Lederman, PhD
Gastric Cancer Therapy: Recognizing and Managing Fragmentation of Care and Evidence Gaps
Michael R. Page, PharmD, RPh; and Shriya Patel, PharmD
The Current and Future Management of Gastric Cancer With David H. Ilson, MD, PhD
David H. Ilson, MD, PhD

Gastric Cancer: Local and Global Burden

Lynne Lederman, PhD
Modern Perspectives on Treatment
The modern recommended approach to treatment of gastric cancer considers the clinical and pathologic stage of the disease, the patient’s fitness for surgery, and the presence of an actionable biomarker, human epidermal growth factor receptor 2 (HER2) overexpression, which may respond to anti-HER2 monoclonal antibodies.8

Surgery remains the primary treatment for patients with early-stage gastric cancer. Clinical staging determines the extent of the disease before surgery, and the goal is complete resection with adequate margins. No consensus exists on the best type of resection (subtotal vs total gastrectomy) or the extent of lymph node dissection.7

In East Asia, treatment consists of gastrectomy with D2 lymph node resection (ie, removal of involved proximal or distal part of the stomach, or entire stomach, including the greater and lesser omental lymph nodes, plus removal of all the nodes along the left gastric artery, common hepatic artery, celiac artery, splenic hilum, and splenic artery). In Western countries, although extended lymph node dissection of distant lymph nodes allows accurate staging, it is associated with increased survival in some, but not all, clinical studies. D2 lymph node dissection is recommended, but not required. There is agreement that removal of 15 or more lymph nodes aids in staging.7

Newer surgical approaches that reduce morbidity compared with open surgery include laparoscopic resection and endoscopic therapies, including endoscopic mucosal resection and endoscopic submucosal dissection. Laparoscopic resection requires further study. The endoscopic approaches are major advances in the treatment of early-stage gastric cancer, and are therefore less applicable in the United States, where gastric cancers tend to be diagnosed in advanced stages.7

Radiation therapy has been used both presurgically and post surgically for patients with more advanced gastric cancer, and it may provide some benefit, including reduction of locoregional recurrence and higher resection rates, particularly if used in combination with chemotherapy (as chemoradiation) in resectable gastric cancer, either preoperatively or perioperatively.7,8 Chemoradiation or chemotherapy is recommended for patients with surgically unresectable gastric cancer and for those who are not surgical candidates. Unresectable gastric cancers may become surgically resectable after treatment.8

Currently, chemotherapy regimens for gastric cancer are fluoropyrimidine-based (eg, fluorouracil or capecitabine) or taxane-based. Postoperative treatment is determined by the stage, the completeness of the resection, the presence or absence of positive lymph nodes, and whether chemotherapy was received preoperatively. Patients who experience locoregional recurrence may be offered surgery; those with unresectable locoregional recurrence and those with metastatic disease at diagnosis or after initial therapy may be offered palliative management. For those with good performance status, palliative management may include systemic therapy, enrollment in a clinical trial, or palliative or best supportive care. Those with poor performance status should be offered palliative or best supportive care.8

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