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X) Strategies to Improve Outcome for Gastric Cancer in Taiwan
Symposium (X)
STRATEGIES TO IMPROVE OUTCOME FOR GASTRIC CANCER IN TAIWAN
DIFFERENCES IN THE SURVIVAL OF GASTRIC CANCER PATIENTS BETWEEN TAIWAN AND OTHER COUNTRIES
Yan-Shen Shan College of Medicine, National Cheng Kung University, Tainan, Taiwan Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
After eradication of HP in Taiwan, the incidence of gastric cancer reached a lower plateau. The new diagnosed gastric cancer patients are around 3800people/ year since 2008. The crude incidence rate is 12.18/105 in male and 6.76/105 in female. Though different discipline expert treated patients carefully, the 5-year survival of gastric cancer patients is still lower than eastern Asian countries about 10%.
The reasons contribute to the modest survival of Taiwan gastric cancer patients should be explored honestly. After investigated the causes, there are three reasons should be discussed deeply: 1. No screening project in Taiwan, which caused 60% Taiwan gastric cancer patients was diagnosed at stage III/IV. 2. Too many hospitals jointed the cancer patient program rapidly, increased from 50 hospitals to 92 hospitals in 5 years. Insufficient experience in diagnosis and surgical resection will increase morbidity and mortality during treatment. 3. Health insurance payment of DOH for advanced stage gastric cancer patients is not enough, only first line drugs and one second line drug. It will reduce the chance of patients to receive salvage chemotherapy.
Symposium (X)
STRATEGIES TO IMPROVE OUTCOME FOR GASTRIC CANCER IN TAIWAN
Jaw-Yuan Wang Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Multimodal treatment strategies – perioperative chemotherapy and radical surgery – are currently accepted as treatment standard for locally advanced gastric cancer (GC). Complete surgical resection remains the only chance for a cure, and multimodality treatment approaches are implemented to improve survival chances. Thus, dismal outcomes in patients with locally advanced GC (LAGC) highlight the need for effective systemic neoadjuvant treatment to improve clinical results. Recently, several clinical trials have shown that neoadjuvant chemoradiotherapy (CCRT) can benefit patient survival after surgery for GC. Moreover, neoadjuvant CCRT has more theoretical benefits than neoadjuvant chemotherapy in patients with LAGC, including more favorable progression-free survival and overall survivalwithout a significant toxicity increase in patients. These strategies improve disease-related outcomes more than surgery alone but are associated with higher rates of treatmentrelated morbidity. Illustrating this fact, only 64% of patients in the Intergroup-0116 trial and 42% in the Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial could complete their prescribed treatment courses. Platinum-based oxaliplatin regimens are active and well-tolerated in patients with advanced or metastatic gastric cancer. However, the prognosis remains largely unknown, and a biological parameter that can be used to evaluate whether a neoadjuvant chemotherapy should be administered in patients susceptible to the response is not available. Therefore, genetic biomarkers that can predict the response in patients with locally advanced or metastatic GC, who would greatly benefit from neoadjuvant chemotherapy, should be identified. Based on prospective randomized data, perioperative chemotherapy is the preferred treatment strategy for patients with surgically resectable GC in the United States and other Western countries. The strength of this ‘‘sandwich’’ approach is the assurance that patients receive at least some systemic therapy. However, many patients fail to receive the intended postoperative chemotherapy, calling into question its importance in the overall management of GC.
Symposium (X)
STRATEGIES TO IMPROVE OUTCOME FOR GASTRIC CANCER IN TAIWAN
PROPHYLATIC HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY FOR THE PATIENTS WITH ADVANCED GASTRIC CANCER
Ting-Ying Lee Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Patients with clinical T4 gastric cancers with high recurrent rate and lower 5-year overall survival even underwent radical gastrectomy (D2 lymphadenectomy) and adjuvant chemotherapy. The invisible peritoneal metastasis may result in local recurrence due to tumor invaded serosa and nearby organ. We evaluated the prophylactic HIPEC post gastrectomy for the clinical T4 gastric cancer patients. Here we retrospect 132 patients with clinical T4 gastric cancer underwent gastrectomy + D2 lymphadenectomy from 2014 to 2020. There were 35 patients also underwent prophylactic HIPEC peri-operatively. We used propensity score matching (PSM) in order to reduce the selection bias. We evaluated the risk factors for the recurrence and compared the overall survival (OS) and disease-free survival (DFS) between gastrectomy group and prophylactic HIPEC group. Among 132 eligible patients were included in the study. 70 preoperative patients’ characteristics were homogeneous post PSM. The prophylactic HIPEC seems to reduce the risk of postoperative peritoneal recurrence but not influence the risk of distal metastasis. The risk factors for recurrence included advanced N stage, ascites, and lymphovascular invasion. The OS (p=0.035) and DFS (p=0.017) were also better in prophylactic HIPEC group. Prophylactic HIPEC plus radical gastrectomy can reduce the postoperative peritoneal recurrence and improve the OS and DFS for clinical T4 gastric cancer patient.
Symposium (X)
STRATEGIES TO IMPROVE OUTCOME FOR GASTRIC CANCER IN TAIWAN
CRS WITH HIPEC FOR ADVANCED GASTRIC CANCER WITH PM
Mao-Chih Hsieh Department of Surgery, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced to treat gastric cancer (GC) patients with peritoneal metastasis (PM). With curative intent, it developed early since 1981. However, complex surgical procedures and high surgical complication rates restricted this treatment to be widely accepted. At least 100 cases experience was considered to lower surgical complication rates.
Repeated intraperitoneal chemotherapy or pressured intraperitoneal aerosol chemotherapy (PIPAC) without hyperthermia also improved patient survival. Both are considered as alternative methods to treat these patients without an extensive surgery. Neoadjuvant intraperitoneal chemotherapy (NIPS) followed by CRS/HIPEC developed in recent years. This made some cases with severe peritoneal disseminated became suitable for “conversion surgery.” After surgery, early postoperative intraperitoneal chemotherapy (EPIC) or regular systemic chemotherapy is also considered important.
Patient selection is another issue in applying CRS/HIPEC for GC patients with PM. How to select patients to get the maximal benefits from CRS/HIPEC is depending on the purpose of therapy. In recent years, more and more surgeons started to apply CRS/HIPEC to treat GC patients with PC. It is important to setup a consensus of standard protocols.
