Double Dutch.

Top Line: Following neoadjuvant chemo and surgery for gastric cancer, is adjuvant chemo or concurrent chemoradiation better?
The Study: Eagerly awaited results of the CRITICS trial are finally here. The design was pretty straightforward--a mash-up of the MAGIC (perioperative ECF) and MacDonald (chemoradiation after R0 resection) regimens, which both improved overall survival. So if each are good, wouldn’t both be better? Inclusion was broad: stages IB-IVA gastric and siewert II-III esophagogastric junction tumors. All 788 enrollees received preop epirubicin + cisplatin or oxaliplatin + capecitabine or 5FU (ECF) x 3. About 80% of enrollees underwent curative resection, 80% of whom had a D1 resection. Operative outcomes weren’t stellar: 10% had positive margins, only 6% had a complete tumor response, and >50% had involved nodes at surgery. Three-quarters of resected patients went on to randomized adjuvant therapy of ECF x 3 versus radiation to 45 Gy with concurrent CF. In the end, only 48% of enrollees completed all adjuvant therapy. And after all that...drum roll please...there was no difference between groups: Median overall survival (OS) was 3-3.5 years, rates of OS at 5 years were 40%, and patterns of failure were almost identical. Put another way, both arms were equally bad. The takeaway is adjuvant chemoradiation should probably only be used if you forgot neoadjuvant therapy.
Bottom Line: The combo of neoadjuvant chemo and adjuvant radiation did not improve disease control or survival compared to perioperative chemo in patients with gastric cancer. By the way, periop chemo should include a taxane. | Cats, Lancet Oncol 2018


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