A randomized Phase III trial of etoposide, epirubicin, and cisplatin versus 5-fluorouracil, epirubicin, and cisplatin in the treatment of patients with advanced gastric carcinoma. Turkish Oncology Group

Targeted therapy for gastric cancer--current status

In patients with metastatic gastric cancer, median overall survival remains under 1 year and standard chemotherapy regimens are not able to substantially improve the prognosis of the patients. Amplification and over-expression of HER2 is reported in approximately 20% of gastric tumours, challenging the use of targeted therapies. There are several targeted therapies in different stages of clinical development with trastuzumab being the first overcoming the regulatory hurdle and getting European Medicines Agency approval. In patients with advanced gastric or gastro-oesophageal junction cancer, addition of trastuzumab to chemotherapy significantly improved overall survival compared with chemotherapy alone. Addition of trastuzumab to chemotherapy did not increase the incidence of adverse events. Other agents targeting the HER2 pathway (lapatinib) or other domains of epidermal growth factor receptor family (cetuximab) are currently being investigated for the treatment of an advanced gastric cancer.

Advanced gastric cancer--slow but steady progress

Progress in gastric cancer has been slow, but steady. Historically, patients commonly presented with significant disease related co-morbidity and received treatment of marginal benefit but unfortunately associated with significant toxicity. Today there is no universally accepted reference standard chemotherapy for this disease. However, there is reason for optimism. Meta-analyses of randomized trials have shown a benefit for first-line combination chemotherapy. Current three drug chemotherapy regimens remain toxic, though perhaps less so than previously, and can result in a small but significant survival advantage in carefully chosen patients. Incremental improvements have been observed in both treatment-related toxicity and survival after first-line therapy. More patients are candidates for chemotherapy beyond progression with first-line therapy and response rates with second-line regimens are similar to those seen in other solid tumor malignancies. Although there is no randomized data to support its use second-line treatment should be considered in appropriate patients. Even before the integration of targeted therapies in the treatment of gastric cancer, it was evident that survival for more than 2 years is possible in a subset of patients and large retrospective studies have highlighted clinicopathologic factors associated with improved survival. Presently, with the addition of targeted therapy, especially anti-angiogenic and anti-Her2 therapy, and a better understanding of the biology of the disease, perhaps a sense of optimism should indeed suppress the nihilism commonly associated with this disease.

Epirubicin, Cisplatin, and Fluorouracil (ECF) Regimen

The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparing, dispensing, and administering antineoplastic therapy and to the agents, commercially available and investigational, used to treat malignant diseases.

Chemotherapy for advanced gastric cancer: across the years for a standard of care

Chemotherapy is of crucial importance in advanced gastric cancer patients, in order to obtain palliation of symptoms and improve survival. The most extensively studied drugs as single agents are 5-fluorouracil, cisplatin, doxorubicin, epirubicin, mitomycin C and etoposide. Newer chemotherapeutic agents include the taxanes (docetaxel and paclitaxel), oral fluoropyrimidines (capecitabine and S-1), oxaliplatin and irinotecan. Randomised trials comparing monotherapy with combination regimens have consistently shown increased response rates in favour of combination regimens, whereas only marginally improved survival rates were usually found. Several combination therapies have been developed and have been examined in Phase III trials. However, in most cases, they have failed to demonstrate a survival advantage over the reference arm. There is no internationally accepted standard of care, and uncertainty remains regarding the choice of the optimal chemotherapy regimen. The objective of this article is to review the present literature available on major Phase II - III clinical trials, in which patients suffering from advanced gastric cancer were treated with cytotoxic chemotherapy.

Chemotherapy for advanced gastric or gastroesophageal cancer: defining the contributions of docetaxel

Despite continuing decline in its incidence, gastric cancer remains the fourth most commonly diagnosed malignancy and is the second leading cause of cancer death around the world. There are > 50% of patients who develop metastatic cancer, which in the majority is beyond cure and, despite many advances that have been achieved in the management of gastric cancer over the past 15 years, patient prognosis remains very poor. The need for the development of more effective therapies that are likely to further improve survival time cannot be overemphasised. A number of new active classes of agents have been identified and these include camptothecins, taxanes, platinols and oral fluoropyrimidines. This review explicitly focuses on the development of docetaxel in the treatment of advanced gastric or gastroesophageal cancer. Docetaxel, a potent taxane, is active as a single agent and in combination with other active agents. Most importantly, the final results of a pivotal randomised Phase III trial have demonstrated a higher overall response rate, longer time to progression and longer overall survival when docetaxal was added to cisplatin plus 5-fluorouracil and compared with cisplatin plus 5-fluorouracil (a reference regimen). This regimen with docetaxel, cisplatin and 5-fluorouracil is intense and proper patient selection and monitoring of the patients is recommended. Future developments will lead to the incorporation of docetaxel in regimens with improved safety profile.

Effects of natural polysaccharides on the growth and peritoneal carcinomatosis of human gastric adenocarcinoma in a nude mouse model

We have examined the effects of natural polysaccharides isolated from Phellinus gilvus (PG) in vitro and in vivo against gastric cancer. PG decreased cell proliferation and increased cell apoptosis in a dose-dependent manner in vitro. PG also led to a marked inhibition of tumor growth and significant decrease in the incidence of peritoneal carcinomatosis. Histological analysis of tumor confirmed dramatic increase in tumor cell apoptosis by PG, indicating reduced tumor cell proliferation. These data showed that polysaccharides isolated from PG significantly inhibited tumor growth and metastasis in an orthotopic model of human gastric adenocarcinoma, without detectable problematic adverse effects.

Gastric cancer

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.