Abstract
To clarify the effect of neoadjuvant chemotherapy (NAC) on the survival outcomes of operable gastric cancers, we searched PubMed, Embase, and Cochrane Library for randomized clinical trials published until June 2014 that compared NAC-containing strategies with NAC-free strategies in patients with adenocarcinoma of the stomach or the esophagogastric junction, who had undergone potentially curative resection. The adjusted pooled hazard ratio (HR) for overall survival (OS) was insignificant when comparing the NAC-containing arm with the NAC-free arm. Subgroup analysis showed that the OS of the treatment arm that involved both adjuvant chemotherapy (AC) and NAC was significantly improved over the control arm (AC only) (HR = 0.48, 95% CI: 0.35–0.67; P < 0.001). While NAC alone plus surgery did not show any survival benefit over surgery alone. Perioperative chemotherapy (PC) also showed a significant increase in PFS and a significant reduction in distant metastasis compared to surgery alone. Therefore, in patients with resectable gastric cancer, NAC alone is not enough and AC alone is not good enough to definitely improve their OS. Collectively, PC combined with surgery could maximize the survival benefit for patients with resectable gastric cancer.
Highlights
Cancer based on the US Intergroup-0116 trial[4]
Would Neoadjuvant chemotherapy (NAC) alone have survival benefits for operable gastric cancer patients, or should it be combined with adjuvant chemotherapy (AC)? Or is AC itself sufficient to improve the survival in gastric cancer patients and NAC is not useful? How do we look upon the use of NAC in Asia where the highest incidence of gastric cancer, skillful operative technique, and good adjuvant treatment strategies coexist? The key question is that we still don’t know if perioperative chemotherapy (PC) exactly has an extra advantage than AC in the treatment of operable gastric cancers
Results regarding overall survival (OS) and progression-free survival (PFS) were expressed as hazard ratio (HR) with 95% CIs, which were used directly or estimated from the Kaplan-Meier survival curves or by the indirect method described by Parmer and colleagues[13]
Summary
Cancer based on the US Intergroup-0116 trial[4]. In parts of Europe, perioperative chemotherapy (PC) is regarded as the standard treatment on the basis of the MAGIC trial[3]. Most clinical trials or meta-analyses have shown that NAC can improve the R0 resection rate in patients with locally advanced gastric cancer, but the results regarding long-term efficacy such as overall survival (OS) and progression-free survival (PFS) have been inconsistent[9,10,11,12]. The key question is that we still don’t know if PC exactly has an extra advantage than AC in the treatment of operable gastric cancers To address these questions, we performed an updated meta-analysis involving 2,093 patients from 14 different trials between 1966 and June, 2014, comparing NAC-containing strategies with NAC-free strategies, mainly in terms of OS of patients with resectable gastric cancer, estimated by HR and 95% CI
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