Therapeutic targets
- Cure or improvement of prognosis
- If necessary, also improvement of symptoms, reduction of tumor mass, palliative (palliative treatment).
Therapy recommendations
- The most important therapeutic procedure is surgery with the aim of complete tumor removal.
- Chemotherapy [S3 guideline]
- Perioperative chemotherapy may be given for localized adenocarcinoma of the stomach or esophagogastric (esophagus-gastric) junction with category cT2.
- For nonremote metastatic adenocarcinoma of the esophagogastric junction with categories cT3 and resectable cT4 tumors, neoadjuvant radiochemotherapy (combined radio (radiation) and chemotherapy to reduce tumor mass before a planned surgical procedure) or perioperative (“timed around surgery”) chemotherapy should be performed.
- Perioperative therapy with the combination SOX of S1 (tegafur/gimeracil/osteracil) plus oxaliplatin was superior to adjuvant treatment and was similarly effective to the perioperative oxaliplatin/capecitabine combination (XELOX).
- After preoperative (“before surgery”) chemotherapy and subsequent surgery, postoperative (“after surgery”) chemotherapy should be decided on a multidisciplinary basis.
- If after surgery, with complete removal of the tumor, a recurrence occurs: adjuvant therapy (chemotherapy and radiotherapy).
- Adjuvant chemotherapy in patients with advanced tumors (survival benefit approximately 4-6%)In patients from Western countries with advanced gastric cancer, first-line therapy with a triple-drug combination-especially when based on fluoropyrimidines or platinum-resulted in better overall survival compared with a dual-drug combination. Note: Review HER2 expression status of primary tumor and/or metastases before selecting first-line therapy.
- Tumor-directed palliative therapy for advanced metastatic gastric cancer [S3 guideline]:
- Patients in good general health (ECOG o-1) should be offered systemic chemotherapy.
- In the palliative setting, platinum/fluoropyrimidine-containing combination therapy should be given in the first-line setting.
- If a taxane-based triple combination is planned, a modified DCF regimen (e.g., FLOT) should be performed.
- For HER2-overexpressing tumors, first-line cisplatin/fluoropyrimidine-based chemotherapy should be supplemented with trastuzumab.
- Patients in good general condition should be offered second-line chemotherapy. The treatment regimen to be chosen should be based on the respective prior therapy.
- Second-line therapy should include irinotecan* , docetaxel* , paclitaxel* , ramucirumab, or paclitaxel with ramucirumab, taking into account the approval status. * = Off-label use (prescription of a finished drug product outside of use approved by drug regulatory authorities).
- Monoclonal antibodies
- Trastuzumab (monoclonal antibody that binds to the epidermal growth factor receptor HER2/neu on the cell surface of tumor cells): about 20% of all gastric carcinomas have Her2 receptors (= Her2-positive gastric carcinoma) In HER2-positive tumors, a combination of the HER2/neu antibody trastuzumab and 5-FU/folinic acid or cisplatin can also be used.Red-hand letter: Herceptin (trastuzumab), 03/23/2017: monitor cardiac function before, during, and after treatment with trastuzumab to reduce the incidence and severity of left ventricular dysfunction and congestive heart failure (CHI).
- For HER2-positive tumors, a combination of the HER2/neu antibody trastuzumab and 5-FU/folinic acid or cisplatin may also be used.
- Red Hand Letter: Herceptin (trastuzumab), 03/23/2017: cardiac function monitoring before, during, and after trastuzumab treatment to reduce the incidence and severity of left ventricular dysfunction and congestive heart failure (CHI).
- Ramucirumab (monoclonal antibody that binds to the cell surface angiogenesis-inducing VEGF receptor-2 and interrupts the subsequent signaling cascade to the nucleus; thus, angiogenesis (formation of new blood vessels) is prevented): In patients with advanced or metastatic adenocarcinoma of the stomach or gastroesophageal junction who have experienced disease progression during or after treatment with fluoropyrimidine- or platinum-containing chemotherapy; combination with paclitaxel is mandatory unless the patient cannot receive praclitaxel for a specific reason.
- In inoperable gastric cancer, the addition of the antibody cetuximab to chemotherapy has not improved progression-free survival.
- Patients in good general health (ECOG o-1) should be offered systemic chemotherapy.
- In advanced stages, palliative therapy (palliative treatment) is given:
- Enteral nutrition (artificial feeding and intake of food through the gastrointestinal tract).
- Infusion therapy via a port catheter (port; permanent access to venous or arterial blood circulation)
- Supplementation (“complementary therapy”) of micronutrients.
- Pain therapy (according to WHO stage scheme; see below “Chronic pain“).
- See also under “Radiotherapy” and “Other therapy”.
No detailed information on agents and dosages is provided here, as therapy regimens are constantly being modified.