Background: Failure of first-line systemic therapy is commonly observed among patients with advanced gastric cancer. Although paclitaxel plus ramucirumab has been recommended as the preferred second-line strategy, other regimens also display potentially comparable efficacies. Moreover, there is currently lacking of consensus on the systemic treatment among refractory patients. Unfortunately, despite of several previously published systematic reviews, there is still lacking of a comprehensive and hierarchical evidence that properly compares all eligible literatures simultaneously. Hence, we performed a systematic review as well as network meta-analysis in order to summarize and analyze all potential knowledge on this field. Methods: Record retrieval was conducted in PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, ASCO and ESMO meeting abstract library from inception to August 2018. Regarding survival and tolerability, randomized controlled trials featuring comparisons between different systemic treatments among previously treated patients with advanced gastric cancer were eligible for our systematic review. The quantitative network meta-analyses were additionally performed among second-line unselected patients with fluoropyrimidine-based first-line regimens and refractory unselected cases. Overall survival was the primary endpoint, while progression-free survival, objective response rate, hematological and non-hematological adverse events were selected as secondary endpoints. Hazard ratio (HR) and risk ratio (RR) with their 95% confidence interval were used for time-to-event survival and dichotomous variables respectively. Pairwise and network calculation were based on random-effects model and the relative ranking of each regimen was numerically indicated by P-score. Findings: A total of 36 studies were included into our systematic review. The demographic characteristics were comparable across the studies and the overall risk of bias was in low level. Concerning second-line unselected patients with fluoropyrimidine-based first-line regimens, PO (paclitaxel plus olaparib) (HR 1.00 (0.77-1.28), P-score=0.909) and PRa (paclitaxel plus ramucirumab) (HR 1.00, P-score=0.907) dominated the overall survival ranking while PRa additionally topped the hierarchy for progression-free survival (HR 1.00, P-score=0.983) and objective response rate (RR 1.00, P-score=0.925). Both PO and PRa displayed acceptable tolerability. As for second-line HER2 positive patients, trastuzumab-based doublets failed to surpass taxane monotherapy in survival efficacies. Among general refractory or third-line only cases, apatinib reigned the hierarchy by significantly and insignificantly surpassing placebo and nivolumab respectively, irrespective of overall and progression-free survival, while showing comparable adverse events as well. Interpretation: In conclusion, paclitaxel plus ramucirumab is the optimal regimen for second-line unselected patients with fluoropyrimidine-based first-line regimens while olaparib-based medications also have the potential to become vital alternatives against advanced gastric cancer, especially among eastern population where paclitaxel plus ramucirumab seems less effective. Paclitaxel monotherapy should be recommended as the preferred second-line regimen among HER2 positive patients who receive standard first-line treatment. Both apatinib and nivolumab could be potentially recommended as refractory regimens due to their significant superiority against placebo, however their mutual efficacies still need to be verified in further global investigations. Funding Statement: Scientific Research Training Program for Young Talents (2017); National Natural Science Foundation of China (81572413). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: All procedures were conducted according to Cochrane Handbook 5.1 and PRISMA for Network Meta-analysis (CRD42018104672).
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