What future approaches will be used in attempting to improve the survival of patients with stomach cancer? The results of SWOG 9008/INT-0116 demonstrate that for the population of gastric cancer patients undergoing gastrectomy in the United States, postoperative chemoradi-ation improves survival and future results in clinical trials, and to be considered successful, it must have outcomes equal or superior to the treatment arm of SWOG 9008/INT-0116. The current National Intergroup Adjuvant Therapy Study (Fig. 2) for postgastrectomy cases tests ECF chemotherapy before and after chemoradiation compared to a standard arm, which is essentially the same as the treatment arm of SWOG 9008/INT-0116. Another strategy of interest resulting from the recent evidence of benefit from neoadjuvant chemotherapy would be to combine neoadjuvant chemotherapy with postoperative chemoradiation. To fully understand
the potential for combined modality approaches to gastric cancer management, clinical trials need to be mounted to critically evaluate adjuvant and neoadjuvant therapy strategies in appropriate groups of patients. For example, patients identified preoperatively should be candidates for phase III trials testing neoadjuvant therapy followed by surgery versus surgery alone. These preoperative cases also would be candidates for explanatory phase II trials testing the tolerability and efficacy of combined pre- and postoperative modality therapy programs. Patients identified postgastric resection, may be enrolled on the current U.S. Intergroup Study, which evaluates an improved chemoradiation regimen. The specific neoadjuvant and treatment programs of the future may use chemotherapy or chemotherapy plus radiation, as well as newer targeted therapies such as epidermal growth factor receptor (EGFR) (34) and/or vascular endothelial growth factor (VEGF) (35) inhibition.
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