medwireNews: The overall survival of patients with resectable gastric cancer who have received adequate preoperative chemotherapy and surgery does not differ according to whether or not they receive postoperative chemoradiotherapy, phase III trial data show.
The CRITICS trial directly compared two standards of care in gastric cancer: perioperative chemotherapy, which is the preferred treatment method in Europe, and preoperative chemotherapy plus postoperative chemoradiotherapy, commonly used in the USA.
Edwin Jansen, from the Netherlands Cancer Institute in Amsterdam, and colleagues say their findings imply that “preoperative chemotherapy with adequate surgery can be considered the backbone of resectable gastric cancer treatment.”
They add: “This trial provides a rationale to focus on preoperative strategies and to explore further intensification of the preoperative phase in future studies.”
Between 2007 and 2015, 788 patients with stage IB–IVA resectable gastric or gastroesophageal adenocarcinoma from 56 hospitals in the Netherlands, Sweden, and Denmark were randomly assigned to receive either perioperative chemotherapy (chemotherapy group; n=393) or preoperative chemotherapy with postoperative chemoradiotherapy (chemoradiotherapy group; n=395).
Following preoperative chemotherapy, which consisted of three cycles of epirubicin, cisplatin, and capecitabine, or epirubicin, oxaliplatin, and capecitabine, 95% of patients in the chemotherapy group and 93% of those in the chemoradiotherapy group proceeded to surgery, with a potentially curative resection done in 79% and 83%, respectively.
Postoperatively, 59% of patients started chemotherapy with the same regimen as preoperatively and 62% started chemoradiotherapy, which consisted of a radiation dose of 45 Gy in 25 fractions, for 5 weeks, combined with oral capecitabine and intravenous cisplatin.
Reasons for not starting postoperative treatment were most commonly progressive or unresectable disease, treatment related toxicity, refusal or poor general health, and death.
At a median follow-up of 61.4 months, 55% of patients in the chemotherapy group and 58% of those in the chemoradiotherapy group had died. Median overall survival was not significantly different between the two groups, at 43 and 37 months, respectively.
Writing in The Lancet Oncology, Jansen and co-authors say their findings raise the question of “whether or when chemoradiotherapy adds to the efficacy of preoperative or postoperative chemotherapy.”
They add: “It is possible that because all patients in our study received preoperative chemotherapy, postoperative treatment did not further increase survival.”
In an accompanying comment, Trevor Leong, from the Peter MacCallum Cancer Centre in Melbourne, Victoria, Australia, says “[t]he results of the CRITICS trial would suggest that changing to postoperative chemoradiotherapy is of no benefit” when patients on a perioperative chemotherapy regimen have responded poorly to preoperative chemotherapy.
However, he adds that “there might be subsets of patients who might benefit more from chemoradiotherapy, and further studies planned by the investigators will investigate this question in more detail.”
Leong concludes that the initial results from the CRITICS trial indicate that chemoradiotherapy may now have only “a limited role” in patients with resectable gastric cancer, who have received preoperative chemotherapy, but that it “should still be considered for appropriate patients who have not had any preoperative therapy.”
By Laura Cowen
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