Q&A: Stomach Cancer Therapy Before Surgery

When is the best time for stomach cancer patients to receive chemotherapy and radiation - before or after surgery?

Answering questions on the topic is Linus Ho, M.D., Ph.D., assistant professor in M. D. Anderson's Department of Gastrointestinal Medical Oncology.

What is the standard treatment?

A large intergroup study published a few years ago established that the standard treatment in the United States for stomach cancer is chemotherapy and radiation after surgery.

What treatment does M. D. Anderson recommend?

We think that it is better for patients to undergo chemotherapy and radiation before surgery.

In general, why do you prefer treatment before surgery?

With the standard treatment, chemotherapy and radiation begin six weeks after surgery. That can be very rough on patients. About 20% to 30% of patients don't recover well enough after surgery to complete postoperative treatment.

When patients receive treatment before surgery, they are in better shape and are better able to tolerate the therapy.

Does it help to see the tumor's response to therapy?

Yes. If a tumor continues to grow, we might try a different chemotherapy.

If a patient's tumor cells are resistant to chemotherapy and radiation, and the cancer progresses, those patients probably will not do well after surgery. In some cases, if a tumor spreads to a different organ, we might call off the surgery. We might be saving patients from an operation that would not have benefited them.

What other factors might affect the order of treatment?

Another reason for having treatment before surgery is that the delivery of chemotherapy drugs may be better before the operation. During surgery blood vessels that were connected to the stomach need to be tied off, so theoretically the delivery of drugs may not be as effective after surgery as it would be before when everything is still intact.

Why is treatment needed in addition to surgery?

Surgery is the mainstay of treatment for stomach cancer, but surgery alone just isn't good enough. If a patient has cancer that has spread to the lymph nodes, the cure rate drops to 50% or less, so additional therapy is needed.

What does stomach cancer surgery involve?

During surgery, some or all of the stomach needs to be removed. Several centimeters around the tumor also need to be taken out. Surgeons want clean margins around the tumor to ensure the cancer does not return, and pathologists can tell them when they need to take more.

(After the stomach is removed, surgeons attach the bottom of the esophagus to the intestine. This allows patients to digest food through the small intestine, although they must eat smaller, more frequent meals).

What results do patients have with pre-operative treatment?

Many survivors have done well. I just saw a patient earlier this week with gastric cancer who was treated in 2004, and he's doing well with no evidence of disease.

Are you conducting studies on treatment before surgery?

We are working on our third clinical trial studying treatment before surgery, and it involves using different chemotherapies. Data is still pending on the studies because it takes years of patient follow-up.

In our current trial, we are using the drug oxaliplatin (Eloxatin), which has been approved by the U.S. Food and Drug Administration for colorectal cancer. It is our hope that the addition of oxaliplatin will improve results. The trial is ongoing, and we are enrolling patients.

For more information, please contact the M. D. Anderson Information Line at 1-800-392-1611, option 3.