The Benefits of Neoadjuvant Chemotherapy
- One of the key strategies that might be recommended for patients with gastric cancer is something called neoadjuvant chemotherapy, which involves giving chemotherapy before surgery.
- The goal is to improve outcomes for those with locally advanced gastric cancer.
- By targeting the cancer cells beforehand, the treatment may help make surgery more effective and reduce the risk of the cancer coming back.
- The neoadjuvant chemotherapy may involve getting chemo every other week four to six times before surgery, followed by additional chemotherapy after surgery.
- It’s also important to keep in mind that while chemotherapy can be challenging, it can also be a powerful tool in your fight against cancer.
“We notice that it’s easier for patients to receive chemotherapy before surgery [rather than after]. So some cancer centers around the U.S. try to offer more chemotherapy before surgery,” Dr. Alan Lima Pereira, a medical oncologist at Moffitt Cancer Center in Tampa, Florida, tells SurvivorNet
What is Neoadjuvant Chemotherapy?
Read MoreWhy is Neoadjuvant Chemotherapy Used?
Gastric cancer often presents at an advanced stage, and combining chemotherapy with surgery has shown better survival rates compared to surgery alone. The key reasons doctors may recommend neoadjuvant chemotherapy include:- Downstaging the Tumor: This means reducing the size or extent of the tumor, making it easier to remove surgically.
- Targeting Microscopic Cancer Cells: Chemotherapy can help eliminate cancer cells that may have already started to spread but are too small to detect on imaging tests.
- Improving Surgical Outcomes: Research has shown that patients who receive neoadjuvant chemotherapy are more likely to have a complete tumor resection (R0 resection), meaning no visible cancer remains after surgery.
Evidence Supporting Neoadjuvant Chemotherapy
Clinical trials have shown significant benefits for patients receiving chemotherapy before surgery for gastric cancer.
The MAGIC trial
The MAGIC trial was a large study that looked at how chemotherapy before and after surgery (called perioperative chemotherapy) affects patients with gastric cancer. The goal of the study was to see if adding chemotherapy could help people live longer compared to having surgery alone.
The study randomly assigned patients with resectable gastric cancer (meaning cancer that can be removed by surgery) into two groups:
- Surgery Alone: One group of patients only had surgery to remove the cancer
- Surgery + Chemotherapy: The other group received chemotherapy both before and after surgery
The chemotherapy used in the study was a combination of three drugs: epirubicin, cisplatin, and fluorouracil (ECF). This was given in three cycles before surgery and three cycles after surgery.
The study found that patients who had chemotherapy before and after surgery did better than those who had surgery alone. The study showed:
- Longer survival: Patients who received chemotherapy had a better chance of living longer. After five years, 36% of these patients were still alive, compared to 23% of those who had only surgery.
- Smaller tumors before surgery: The chemotherapy helped shrink the tumors before surgery, making it easier for doctors to remove them completely.
- More successful surgeries: Patients who had chemotherapy were more likely to have their cancer completely removed (this is called an R0 resection, meaning no visible cancer was left after surgery).
The FLOT trial
Another significant study in this area is the FLOT trial, which has led to better treatment approaches for stomach and gastroesophageal junction cancers.
The FLOT trial was a large clinical study that compared two different chemotherapy treatments given before and after surgery for stomach cancer:
- FLOT Regimen: This treatment uses a combination of four chemotherapy drugs—fluorouracil (5-FU), leucovorin, oxaliplatin, and docetaxel. Patients received four cycles before surgery and four cycles after surgery, with each cycle lasting two weeks.
- Standard Epirubicin-Based Therapy: This was the previous standard treatment, involving three cycles before surgery and three cycles after surgery. It included epirubicin, cisplatin, and either fluorouracil (ECF) or capecitabine (ECX), with each cycle lasting three weeks.
The FLOT trial included over 700 patients with operable stomach or gastroesophageal junction cancer. The main goal was to see which treatment helped patients live longer.
- Improved Survival: Patients who received the FLOT regimen lived longer on average. After about three and a half years, the median survival was 50 months for the FLOT group compared to 35 months for those on the standard treatment.
- Higher Survival Rates: Three years after treatment, 57% of patients in the FLOT group were alive compared to 48% in the standard treatment group.
- Better Cancer Response: More patients in the FLOT group had a complete response, meaning no cancer cells were found in the tissue removed during surgery.
- Increased Rates of Certain Side Effects: Patients experienced higher rates of certain side effects like low white blood cell counts, which can increase infection risk. Note that t here are treatments that can help attenuate the drop of the white blood cells.
What to Expect During Treatment
“The chemotherapy regimen of FLOT, given that it’s a combination of multiple drugs, does have considerable side effects, but they tend to be very well-tolerated as long as we’re working in conjunction as a patient and a provider,” Dr. Nicholas Hornstein, a medical oncologist at Northwell Cancer Institute in Manhattan, tells SurvivorNet.
Receiving chemotherapy before surgery is an important step in your treatment plan, but it’s natural to have concerns about what to expect. Chemotherapy can cause side effects, including fatigue, nausea, and hair loss. However, your care team will be there every step of the way, working to manage these side effects and keep you as comfortable as possible.
The side effects experienced from these two chemo approaches varied slightly:
- FLOT Regimen: Patients experienced higher rates of certain side effects like low white blood cell counts (which can increase infection risk), diarrhea, infections, and numbness or tingling in hands and feet.
- Standard Therapy (epirubicin, cisplatin, and fluorouracil – ECF): Patients had higher rates of nausea, vomiting, and blood clots.
It’s also important to keep in mind that while chemotherapy can be challenging, it is a powerful tool in your fight against cancer. Many patients tolerate treatment well and are able to continue with their normal activities, albeit with some adjustments.
Surgery After Neoadjuvant Chemotherapy
After completing chemotherapy, your doctor will evaluate the response to treatment. This usually involves imaging studies to assess whether the tumor has shrunk and if there are any signs of cancer spread. If the tumor has responded well, you will undergo surgery to remove the remaining cancer. The ultimate goal is to remove all visible cancer, and in many cases, chemotherapy helps make this possible.
Coping with a gastric cancer diagnosis is never easy, but neoadjuvant chemotherapy offers hope. This approach allows for a more targeted attack on the cancer before surgery, and studies show that it can significantly improve survival rates. While the road ahead may be difficult, it’s important to remember that you are not alone. Your medical team is dedicated to guiding you through every step, from chemotherapy to surgery and beyond.
Questions to Ask Your Doctor
- What stage is my gastric cancer?
- Should I receive chemotherapy before surgery? Why?
- What are the potential side effects of chemotherapy?
- How can I manage the side effects?
- What are the risks and benefits of combining chemotherapy with surgery vs. surgery alone?
- How long will my treatment last?
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