The effectiveness of intravenous 5-fluorouracil-containing chemotherapy after curative resection for gastric carcinoma: A systematic review of published randomized controlled trials

Adjuvant Chemoradiotherapy for Gastric Cancer: Efficacy and Cost-Effectiveness Analysis

Purpose: The benefit of adjuvant chemotherapy (CT) for localized gastric cancer (GC) after D2-gastrectomy has been clearly demonstrated. However, adjuvant chemoradiotherapy (CRT) remains controversial. This study aimed to assess the efficacy and cost-effectiveness of treatment for GC after D2-gastrectomy. Materials and methods: Stage IB-IIICGC patients who had received adjuvant CRT or CT, or who had just been observed after D2-gastrectomy were retrospectively selected. Therapeutic strategy after surgery, disease-free survival (DFS), overall survival (OS), adverse events and costs were recorded retrospectively. A Markov model was developed to simulate the process of GC after D2-gastrectomy. Health outcomes were measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratio (ICER) was regarded as the primary outcome. Results: A total of 254 patients were selected. Three year OS and DFS were 83.02 and 64.15% in the adjuvant CRT group, 74.19 and 63.54% in the adjuvant CT group, and 45.45 and 43.35% in the observation group. Total grade 3 or 4 toxicity was higher in the CRT group than in the CT group (54.72% vs. 37.10%, p < 0.05). The ICER of the CT and CRT groups vs. the observation group were $10,571.55 and $11,467.41/QALY, respectively. The probability of CT, CRT and observation being cost-effective were 28.9, 37.9, and 33.2%, respectively, when a willingness-to-pay threshold (WTP) of $25,648.45/QALY was used. Conclusions: Adjuvant CRT was associated with improved OS and DFS compared with adjuvant CT and postoperative observation. Both adjuvant CRT and CT are likely to be cost effective compared with postoperative observation. However, adjuvant CRT was the optimal choice for a WTP threshold of $25,648.45/QALY.

Docetaxel, cisplatin, and 5-fluorouracil compared with epirubicin, cisplatin, and 5-fluorouracil regimen for advanced gastric cancer: A systematic review and meta-analysis

BACKGROUND

As the first-line regimens for the treatment of advanced gastric cancer, both docetaxel, cisplatin, and 5-fluorouracil (DCF) and epirubicin, cisplatin, and 5-fluorouracil (ECF) regimens are commonly used in clinical practice, but there is still controversy about which is better.

AIM

To compare the efficacy and safety of DCF and ECF regimens by conducting this meta-analysis.

METHODS

Computer searches in PubMed, EMBASE, Ovid MEDLINE, Science Direct, Web of Science, The Cochrane Library and Scopus were performed to find the clinical studies of all comparisons between DCF and ECF regimens. We used progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), and adverse effects (AEs) as endpoints for analysis.

RESULTS

Our meta-analysis included seven qualified studies involving a total of 598 patients. The pooled hazard ratios between the DCF and ECF groups were comparable in PFS (95%CI: 0.58-1.46, P = 0.73), OS (95%CI: 0.65-1.10, P = 0.21), and total AEs (95%CI: 0.93-1.29, P = 0.30). The DCF group was significantly better than the ECF group in terms of ORR (95%CI: 1.13-1.75, P = 0.002) and DCR (95%CI: 1.03-1.41, P = 0.02). However, the incidence rate of grade 3-4 AEs was also greater in the DCF group than in the ECF group (95%CI: 1.16-1.88, P = 0.002), especially for neutropenia and febrile neutropenia.

CONCLUSION

With better ORR and DCR values, the DCF regimen seems to be more suitable for advanced gastric cancer than the ECF regimen. However, the higher rate of AEs in the DCF group still needs to be noticed.

Decreased FOXP3+ and GARP+ Tregs to neoadjuvant chemotherapy associated with favorable prognosis in advanced gastric cancer

Neoadjuvant chemotherapy (NACT) has been an increasingly used therapeutic strategy to improve the outcome of advanced gastric cancer (GC) over the past few decades. Lymphocytic infiltration has been reported to be associated with response to NACT, but the immune cell subpopulation and its prognosis contributing to response in GC have not been clarified yet. In the current study, the tumor infiltration of FOXP3+ and GARP+ regulatory T-cells (Tregs, marked by FOXP3 and GARP) response to NACT in advanced GC and their correlation with prognosis were evaluated. The infiltration of FOXP3+ and GARP+ Tregs in 102 patients with advanced GC who were treated with or without NACT was measured using immunohistochemical method. The infiltration of FOXP3+ and GARP+ Tregs was significantly decreased in the NACT group than in the non-NACT group (P=0.023 and P=0.012, respectively) and significantly associated with tumor, node, metastasis stage (P=0.019 and P=0.011, respectively). There was no significant difference in patient’s overall survival between the NACT and non-NACT groups (P=0.166); however, patients in the NACT group with decreased infiltration of FOXP3+ and GARP+ Tregs had longer overall survival (P=0.002 and P<0.001, respectively). Univariate and multivariate analyses indicated that the infiltration of GARP+ Tregs and lymph node metastasis were independent prognostic factors (P=0.038 and P=0.013, respectively). The results demonstrated that NACT could decrease the infiltration of FOXP3+ and GARP+ Tregs, and that the infiltration of GARP+ Tregs may serve as a new prognostic factor of human GC response to NACT.

Efficacy of S-1 vs capecitabine for the treatment of gastric cancer: A meta-analysis

AIM: To rationally evaluate the effect of S-1 vs capecitabine for the treatment of gastric cancer.

METHODS: MEDLINE, EMBASE, Cochrane Controlled Trials Register, Google Scholar, and China Journal Full Text Database were accessed to collect clinical randomized controlled trials regarding the effect of S-1 vs capecitabine for the treatment of gastric cancer patients. Statistical analysis was performed by meta-analysis. Four randomized controlled trials met the inclusion criteria.

RESULTS: Compared with capecitabine regimens, the 1-year survival rate in gastric cancer patients was 0.80 (95%CI: 0.52-1.21, P = 0.29). The overall response rate of S-1 vs capecitabine was 0.94 (95%CI: 0.59-1.51, P = 0.93). Compared with capecitabine regimens, the most frequent hematologic toxicities were neutropenia (OR = 0.99, 95%CI: 0.65-1.49, P = 0.94) and thrombocytopenia (OR = 0.72, 95%CI: 0.31-1.67, P = 0.44). The most frequent non-hematologic toxicities included nausea (OR = 0.85, 95%CI: 0.56-1.28, P = 0.43) and hand-foot syndrome (OR = 0.16, 95%CI: 0.10-0.27, P < 0.00001).

CONCLUSION: The existing studies suggest that S-1 is not more effective than capecitabine in the treatment of gastric cancer patients, but does exhibit less toxicity with regard to hand-foot syndrome.

Perioperative chemotherapy in locally advanced gastric cancer

Gastric cancer is one of the most common cancers and a main cause of cancer-related death worldwide, since the majority of patients suffering of this malignancy are usually faced with a poor prognosis due to diagnosis at later stages. In order to improve treatment outcomes, the association of surgery with chemo and/or radiotherapy (multimodal therapy) has become the standard treatment for locally advanced stages. However, despite several treatment options currently available for management of these tumors, perioperative chemotherapy has been mainly accepted for the comprehensive therapeutic strategy including an appropriated D2-gastrectomy. This manuscript presents a (nonsystematic) critical review about the use of perioperative chemotherapy, with a special focus on the drugs delivery.

Docetaxel, cisplatin and fluorouracil (DCF) regimen compared with non-taxane-containing palliative chemotherapy for gastric carcinoma: a systematic review and meta-analysis

BACKGROUND

Gastric carcinoma (GC) is one of the highest cancer-mortality diseases with a high incidence rate in Asia. For surgically unfit but medically fit patients, palliative chemotherapy is the main treatment. The chemotherapy regimen of docetaxel, cisplatin and 5-fluorouracil (DCF) has been used to treat the advanced stage or metastatic GC. It is necessary to compare effectiveness and toxicities of DCF regimen with non-taxane-containing palliative chemotherapy for GC.

METHODS

PubMed, EmBase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure databases were searched to select relative randomized controlled trials (RCTs) comparing DCF to non-taxane-containing chemotherapy for patients with palliatively resected, unresectable, recurrent or metastatic GC. Primary outcome measures were 1-year and 2-year overall survival (OS) rates. Secondary outcome measures were median survival time (MST), median time to progression (TTP), response rate and toxicities.

RESULTS

Twelve RCTs were eligible and 1089 patients were analyzed totally (549 in DCF and 540 in control). DCF regimen increased partial response rate (38.8% vs 27.9%, p = 0.0003) and reduced progressive disease rate (18.9% vs 33.3%, p = 0.0005) compared to control regimen. Significant improvement of 2-year OS rate was found in DCF regimen (RR = 2.03, p = 0.006), but not of 1-year OS rate (RR = 1.22, p = 0.08). MST was significantly prolonged by DCF regimen (p = 0.039), but not median TTP (p = 0.054). Both 1-year OS rate and median TTP had a trend of prolongation by DCF regimen. Chemotherapy-related mortality was comparable (RR = 1.23, p = 0.49) in both regimens. In grade I-IV toxicities, DCF regimen showed a major raise of febrile neutropenia (RR = 2.33, p<0.0001) and minor raises of leucopenia (RR = 1.25, p<0.00001), neutropenia (RR = 1.19, p<0.00001), and diarrhea (RR = 1.59, p<0.00001), while in other toxicities there were no significant differences.

CONCLUSION

DCF regimen has better response than non-taxane containing regimen and could potentially improve the survival outcomes. The chemotherapy-related toxicity of DCF regimen is acceptable to some extent.

Neoadjuvant or adjuvant therapy for resectable gastric cancer: a systematic review and practice guideline for North America

BACKGROUND

Gastric cancer is a global health problem accounting for 10% of all new cancer cases and 12% of all cancer deaths worldwide. Many clinical trials and meta-analyses have explored the value of neoadjuvant or adjuvant chemotherapy and radiation therapy in gastric cancer; however, these studies have produced conflicting results. The purpose of this guidance document was to determine whether patients with resectable gastric cancer should receive neoadjuvant or adjuvant therapy in addition to surgery. Outcomes of interest were overall survival, disease-free survival, and adverse events.

METHODS

A systematic review was undertaken to inform recommendations regarding neoadjuvant and adjuvant therapy in resectable gastric cancer in Ontario, Canada. MEDLINE and EMBASE databases, as well as American Society of Clinical Oncology (ASCO) annual meeting proceedings and American Society for Therapeutic Radiology and Oncology (ASTRO) proceedings were systematically searched from 2002 to 2010. Oral fluoropyrimidine trials were excluded owing to the unavailability of these agents in North America.

RESULTS

Overall, 22 randomized controlled trials (RCTs), 13 meta-analyses, and two secondary analyses were included. The systematic review informed the development of a clinical practice guideline with the following recommendations. Postoperative 5-fluorouracil-based chemoradiotherapy based on the Macdonald approach or perioperative ECF (epirubicin, cisplatin, fluorouracil) chemotherapy based on the Cunningham/MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) approach are both acceptable standards of care in North America. Choice of treatment should be made on a case-by-case basis. Adjuvant chemotherapy is a reasonable option for those patients for whom the Macdonald and MAGIC protocols are contraindicated. All patients with resectable gastric cancer should undergo a pretreatment multidisciplinary assessment to determine the best plan of care.

CONCLUSIONS

Overall survival in patients with resectable gastric cancer is significantly improved with the use of either postoperative chemoradiation (Macdonald approach) or perioperative ECF (MAGIC protocol).

[Recent advances in the treatment of gastric cancer]

Gastric cancer is the 9th most common malignancy in Hungary, being the 4th most frequent cause of death among all cancers. The traditional treatment approaches did not turn out to be effective against advanced gastric cancer. On the other hand, due to better understanding of the underlying molecular biology of tumors, targeted therapeutics emerge resulting in longer survival times. Dank M. Recent advances in the treatment of gastric cancer.

Radiation exposures of cancer patients from medical X-rays: how relevant are they for individual patients and population exposure?

X-ray procedures have a substantial impact not only on patient care but also on man-made radiation exposure. Since a reliable risk-benefit analysis of medical X-rays can only be performed for diagnosis-related groups of patients, we determined specific exposure data for patients with the ten most common types of cancer. For all patients with the considered cancers undergoing medical X-ray procedures in a maximum-care hospital between 2000 and 2005, patient- and examination-specific data were retrieved from the hospital/radiology information system. From this data, the cumulative 5-year effective dose was estimated for each patient as well as the mean annual effective dose per patient and the mean patient observation time for each cancer site. In total, 151,439 radiographic, fluoroscopic, and CT procedures, carried out in 15,866 cancer patients (age, 62+/-13 years), were evaluated. The mean 5-year cumulative dose varied between 8.6 mSv (prostate cancer) and 68.8 mSv (pancreas cancer). Due to an increasing use of CT scans, the mean annual effective dose per patient increased from 13.6 to 18.2 mSv during the 6-year period. Combining the results obtained in this study for a particular hospital with cancer incidence data for Germany, we estimated that cancer patients having X-ray studies constitute at least 1% of the population but receive more than 10% of the total effective dose related to all medical X-ray procedures performed nationwide per year. A large fraction of this dose is radiobiologically ineffective due to the reduced life expectancy of cancer patients.

Cost-effectiveness analysis of chemotherapy for advanced gastric cancer in China

AIM: To assess the economics of various chemotherapeutic regimens for advanced gastric cancer (AGC), and to select the best cost-effective regimen for the common Chinese patients.

METHODS: Data source used in this study was the Chinese Biomedical Disk Database. Patients were diagnosed as AGC and any regimen was eligible. Outcome measures included median survival time (MST) and percentage of complete and partial response (CR+PR). Economic statistics was per capita direct medical cost (DMC) of a single cycle. TreeAge Pro Healthcare 2007 software was used to carry out cost-effectiveness and incremental cost-effectiveness analysis. Sensitivity analyses were applied by altering willingness-to-pay and annual discount rate, and also re-analyzed by excluding the studies with apparent heterogeneity.

RESULTS: Seven retrospective economics studies on 760 patients were included. 5-fluorouracil-based regimens were universal, and also some new agents were involved, such as docetaxel, paclitaxel, and oxaliplatin. By processing analysis, we could recommend etoposide, leucovorin and 5-fluorouracil (ELF) regimen as preference, with a DMC/MST ratio of 2543 RBM/11.7 mo and a DMC/CR+PR ratio of 2543 RMB/53.3%. Uracil-tegafur, etoposide and cisplatin (FEP) or 5-fluorouracil, adrimycin/epirubin and mitomycin (FAM) regimens could be regarded as optional first-line chemotherapy for AGC in common Chinese patients. With no regard for willingness-to-pay, the docetaxel, cisplatin and 5-fluorouracil (DCF) regimen could be chosen as either a first- or a second-line chemotherapy, with a DMC/CR+PR ratio of 9979 RMB/56.3%.

CONCLUSION: 5-fluorouracil regimens are still considered the mainstream for AGC, while new agents such as taxanes are optional. More randomized clinical trials are required before any mandatory recommendation of certain regimens for patients with AGC in China is made.