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SHOULD PERIOPERATIVE CHEMOTHERAPY BE THE STANDARD OF CARE FOR RESECTABLE GASTRIC CANCER?
Brooke Vuong*1, Ahmed Dehal1, Amanda Graff-Baker1, Trevan Fischer1, Shrawan G. Gaitonde1, Stacey Stern1, Shu-Ching Chang2, melanie Goldfarb1, Anton J. Bilchik1
1Surgical Oncology, John Wayne Cancer Institute, Santa Monica, CA; 2Providence Health and Services, Portland, OR

Background: Many consider perioperative chemotherapy (PC) to be the standard of care in patients with resectable gastric cancer (GC), based on the randomized MAGIC trial that compared surgery alone (SA) versus surgery plus PC. However, this trial did not include a separate treatment arm for adjuvant chemotherapy (AC).
Objective: To determine the optimal treatment algorithm for locoregional GC.
Methods: The National Cancer Data Base was queried from 2004-2013 to identify patients with locoregional GC, defined as stage IB to IIIC. Treatment was categorized as SA, PC, or AC. Univariate and multivariable analyses compared risk-adjusted overall survival by treatment category and clinical stage.
Results: Of 5203 patients who met inclusion criteria, 1271 (24.4%) underwent SA, 2525 (48.5%) received PC, and 1407 (27.0%) received AC. The 3-year overall survival (OS) for patients with clinical stages IB to IIIC was 43.3% for SA, 50.7% for PC, and 51.6% for AC (p<.0001). The median OS was 27.2, 36.4, and 38.5 months, respectively. Compared with PC, SA had increased relative risk of death for patients with all stages of disease [Hazard Ratios (HRs) 1.55-2.30, p<.0001] except stage IB [HR 1.06, 95% confidence interval (CI) 0.82-1.37, p=0.674]. Survival after AC was equivalent to or better than survival with PC across all stages (Table).
Conclusions: AC demonstrated either equivalent or superior survival advantage over PC for locoregional GC. AC may avoid overtreatment and should be considered as a treatment option for locoregional disease. Randomized trials of multimodal therapy for resectable GC should include AC in their design.

Risk Adjusted Hazard Ratio for Overall Survival: Adjuvant Chemotherapy versus Perioperative Chemotherapy
Clinical StageHR95% CIp-value
IB0.670.50-0.880.005
IIA1.020.83-1.250.865
IIB0.780.63-0.960.019
IIIA0.930.68-1.270.655
IIIB1.050.76-1.460.762


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