Chemotherapy of disseminated gastric cancer. A joint effort of the Northern California oncology group and the Japanese gastric cancer chemotherapy group Gastrectomy plus chemotherapy versus chemotherapy alone for advanced gastric cancer with a single non-curable factor (REGATTA): a phase 3, randomised controlled trial. A comparison of combination chemotherapy and combined modality therapy for locally advanced gastric carcinoma The second British Stomach Cancer Group trial of adjuvant radiotherapy or chemotherapy in resectable gastric cancer: five-year follow-up Second-line chemotherapy for patients with advanced gastric cancer: who may benefit? Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine. Randomized controlled trial comparing gastrectomy plus chemotherapy with chemotherapy alone in advanced gastric cancer with a single non-curable factor: Japan Clinical Oncology Group Study JCOG 0705 and Korea Gastric Cancer Association Study KGCA01. [Surgical treatment for advanced gastric cancer]. Controlled trial of adjuvant chemotherapy following curative resection for gastric cancer ADJUVANT CHEMOTHERAPY IN OPERABLE GASTRIC CANCER: 5 Year Follow-up of First British Stomach Cancer Group Trial A controlled, prospective, randomised trial of adjuvant chemotherapy or radiotherapy in resectable gastric cancer: interim report. British Stomach Cancer Group. Five-year outcomes of a randomized phase III trial comparing adjuvant chemotherapy with S-1 versus surgery alone in stage II or III gastric cancer. A phase II study of radical surgery followed by postoperative chemotherapy with S-1 for gastric carcinoma with free cancer cells in the peritoneal cavity (CCOG0301 study). Combined intensive chemotherapy and radical surgery for incurable gastric cancer Neoadjuvant chemotherapy versus surgery alone for locally advanced gastric cancer: a retrospective comparative study. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer.
A consortium of Northern California and Japanese investigators studied 142 patients with advanced gastric adenocarcinoma . Patients were r and omized to one of two combination chemotherapy programs in each nation ( one common therapy shared and one therapy  unique to each nation ) . Median duration of survial ranged between 5 and 45 weeks , depending on performance status , extent of disease , and chemotherapy program . More importantly , there was considerable comparability with respect to toxicity and outcome between patients in the US and Japan .  Overall median survival was 26 weeks for Japanese and 27 weeks for US patients . This study helps provide the basis for future comparative multinational trials BACKGROUND Chemotherapy is the st and ard of care for incurable advanced gastric cancer . Whether the addition of gastrectomy to chemotherapy improves survival for patients with advanced gastric cancer with a single non-curable factor remains controversial . We aim ed to investigate the superiority of gastrectomy followed by chemotherapy versus chemotherapy alone with respect to overall survival in these patients . METHODS We did an open-label , r and omised , phase 3 trial at 44 centres or hospitals in Japan , South Korea , and Singapore . Patients aged 20 - 75 years with advanced gastric cancer with a single non-curable factor confined to either the liver ( H1 ) , peritoneum ( P1 ) , or para-aortic lymph nodes ( 16a1/b2 ) were r and omly assigned ( 1:1 ) in each country to chemotherapy alone or gastrectomy followed by chemotherapy by a minimisation method with biased-coin assignment to balance the groups according to institution , clinical nodal status , and non-curable factor . Patients , treating physicians , and individuals who assessed outcomes and analysed data were not masked to treatment assignment . Chemotherapy consisted of oral S-1 80 mg/m(2 ) per day on days 1 - 21 and cisplatin 60 mg/m(2 ) on day 8 of every 5-week cycle . Gastrectomy was restricted to D1 lymphadenectomy without any resection of metastatic lesions . The primary endpoint was overall survival , analysed by intention to treat . This study is registered with UMIN-CTR , number UMIN000001012 . FINDINGS Between Feb 4 , 2008 , and Sept 17 , 2013 , 175 patients were r and omly assigned to chemotherapy alone ( 86 patients ) or gastrectomy followed by chemotherapy ( 89 patients ) . After the first interim analysis on Sept 14 , 2013 , the predictive probability of overall survival being significantly higher in the gastrectomy plus chemotherapy group than in the chemotherapy alone group at the final analysis was only 13·2 % , so the study was closed on the basis of futility . Overall survival at 2 years for all r and omly assigned patients was 31·7 % ( 95 % CI 21·7 - 42·2 ) for patients assigned to chemotherapy alone compared with 25·1 % ( 16·2 - 34·9 ) for those assigned to gastrectomy plus  chemotherapy . Median overall survival was 16·6 months ( 95 % CI 13·7 - 19·8 ) for patients assigned to chemotherapy alone and 14·3 months ( 11·8 - 16·3 ) for those assigned to gastrectomy plus chemotherapy ( hazard ratio 1·09 , 95 % CI 0·78 - 1·52 ; one-sided p=0·70 ) . The incidence of the following grade 3 or 4 chemotherapy-associated adverse events was higher in patients assigned to gastrectomy plus chemotherapy than in those assigned to chemotherapy alone  : leucopenia ( 14 patients [ 18 % ] vs two [ 3 % ] ) , anorexia ( 22 [ 29 % ] vs nine [ 12 % ] ) , nausea ( 11 [ 15 % ] vs four [ 5 % ] ) , and hyponatraemia ( seven [ 9 % ] vs four [ 5 % ] ) . One treatment-related death occurred in a patient assigned to chemotherapy alone  ( sudden cardiopulmonary arrest of unknown cause during the second cycle of chemotherapy ) and one occurred in a patient assigned to chemotherapy plus gastrectomy  ( rapid growth of peritoneal metastasis after discharge 12 days after surgery ) . INTERPRETATION Since gastrectomy followed by chemotherapy did not show any survival benefit compared with chemotherapy alone in advanced gastric cancer with a single non-curable factor , gastrectomy can not be justified for treatment of patients with these tumours . FUNDING The Ministry of Health , Labour and Welfare of Japan and the Korean Gastric Cancer Association This controlled trial compared the survival of 90 patients with locally advanced gastric carcinoma treated with either chemotherapy alone ( 5‐FU and methyl‐CCNU ) or external radiotherapy of 5000 rad combined with the same chemotherapy .  The minimum period of followup is 4 years . During the initial 12 months , combined modality therapy was associated with an increased number of early deaths attributable to progression of tumor within the radiation field , or nutritional and hematologic complications . During the second to fourth years of followup , patients treated with combined radiation therapy have shown a significantly lower death rate compared to those treated with chemotherapy alone , with eight of 45 patients alive and disease‐free . Patients who received only chemotherapy , in contrast , have demonstrated a continued probability for tumor relapse and death , with three of 45 patients alive at 4 years . Palliative resection of the primary tumor was associated with an improved survival , independent of the form of postoperative therapy employed . It is possible that the superior late survival achieved with combined modality therapy in this program can be further improved with measures to decrease the toxicity of upper abdominal irradiation , and with the use of more effective forms of chemotherapy The overall survival in patients with gastric cancer is low , even among those undergoing resection . It has been hoped that the development of adjuvant therapy might improve survival in patients following surgery when tumour burden was minimal and both chemotherapy and radiotherapy have been proposed as suitable for use in gastric cancer . Their value has been evaluated by the British Stomach Cancer Group Second adjuvant therapy trial . 436 patients entered a prospect i ve , r and omised , controlled trial of adjuvant radiotherapy or cytotoxic chemotherapy with mitomycin , doxorubicin , and fluorouracil  after gastrectomy for adenocarcinoma . After at least 5 years , there have been 372 deaths of which 7 were due to surgical complications and 327 from recurrent cancer . Following stratified r and omisation , 145 patients were allocated to  surgery alone  , 153 to receive adjuvant radiotherapy , and 138 to adjuvant combination chemotherapy . The overall 2-year and 5-year survival were 33 % ( 95 % confidence interval 31 - 35 % ) and 17 % ( 13 - 21 % ) . No survival advantage has been shown for those patients receiving either adjuvant therapy compared to those undergoing surgery alone . The 5-year survival for surgery alone was 20 % , for surgery plus radiotherapy 12 % , and for surgery plus chemotherapy 19 % . Surgery , therefore , remains the st and ard treatment for this condition and the use of adjuvant treatments should be restricted to controlled trials No established second-line chemotherapy is available for patients with advanced gastric cancer failing to respond or progressing to first-line chemotherapy . However , 20–40 % of these patients commonly receive second-line chemotherapy . We evaluated the influence of clinico-pathologic factors on the survival of 175 advanced gastric cancer patients , who received second-line chemotherapy at three oncology departments . Univariate and multivariate analyses found five factors which were independently associated with poor overall survival : performance status 2 ( hazard ratio ( HR ) , 1.79 ; 95 % CI , 1.16–2.77 ; P=0.008 ) , haemoglobin ⩽11.5 g l−1 ( HR , 1.48 ; 95 % CI , 1.06–2.05 ; P=0.019 ) , CEA level > 50 ng ml−1 ( HR , 1.86 ; 95 % CI , 1.21–2.88 ; P=0.004 ) , the presence of greater than or equal to three metastatic sites of disease ( HR , 1.72 ; 95 % CI , 1.16–2.53 ; P=0.006 ) , and time-to-progression under first-line chemotherapy ⩽6 months ( HR , 1.97 ; 95 % CI , 1.39–2.80 ; P<0.0001 ) . A prognostic index was constructed dividing patients into low- ( no risk factor ) , intermediate- ( one to two risk factors ) , or high- ( three to five risk factors ) risk groups , and median survival times for each group were 12.7 months , 7.1 months , and 3.3 months , respectively ( P<0.001 ) . In the absence of data deriving from r and omised trials , this analysis suggests that some easily available clinical factors may help to select patients with advanced gastric cancer who could derive more benefit from second-line chemotherapy BACKGROUND Advanced gastric cancer can respond to S-1 , an oral fluoropyrimidine . We tested S-1 as adjuvant chemotherapy in patients with curatively resected gastric cancer . METHODS Patients in Japan with stage II or III gastric cancer who underwent gastrectomy with extended ( D2 ) lymph-node dissection were r and omly assigned to undergo surgery followed by adjuvant therapy with S-1 or to undergo surgery only . In the S-1 group , administration of S-1 was started within 6 weeks after surgery and continued for 1 year . The treatment regimen consisted of 6-week cycles in which , in principle , 80 mg of oral S-1 per square meter of body-surface area per day was given for 4 weeks and no chemotherapy was given for the following 2 weeks . The primary end point was overall survival . RESULTS We r and omly assigned 529 patients to the S-1 group and 530 patients to the surgery-only group between October 2001 and December 2004 . The trial was stopped on the recommendation of the independent data and safety monitoring committee , because the first interim analysis , performed 1 year after enrollment was completed , showed that the S-1 group had a higher rate of overall survival than the surgery-only group ( P=0.002 ) . Analysis of follow-up data showed that the 3-year overall survival rate was 80.1 % in the S-1 group and 70.1 % in the surgery-only group . The hazard ratio for death in the S-1 group , as compared with the surgery-only group , was 0.68 ( 95 % confidence interval , 0.52 to 0.87 ; P=0.003 ) . Adverse events of grade 3 or grade 4 ( defined according to the Common Toxicity Criteria of the National Cancer Institute ) that were relatively common in the S-1 group were anorexia ( 6.0 % ) , nausea ( 3.7 % ) , and diarrhea ( 3.1 % ) . CONCLUSIONS S-1 is an effective adjuvant treatment for East Asian patients who have undergone a D2 dissection for locally advanced gastric cancer . ( Clinical Trials.gov number , NCT00152217 [ Clinical Trials.gov ] . ) A r and omized controlled trial has started in both Japan and Korea to evaluate the role of gastrectomy in the management of incurable advanced gastric cancer ( AGC ) . Patients with AGC diagnosed as having a single non-curable factor are r and omized to gastrectomy plus chemotherapy or chemotherapy alone . Surgeons at 33 specialized centers in Japan and at 15 high-volume hospitals in Korea will recruit 330 patients . Primary end-point is overall survival , and secondary end-points are progression-free survival and adverse events associated with either gastrectomy or chemotherapy Despite the incidence of gastric cancer is decreasing , it remains the fourth most common malignancy and the second leading cause of cancer-related death around the world . The prognosis of gastric cancer is still poor and surgery is the mainstay treatment . Lymph node dissection plays an important role in the surgery of gastric cancer due to the high incidence of lymph node metastasis and recurrence . There has been a consensus between the West and the East that D2 lymph node dissection is the st and ard dissection for advanced gastric cancer . Some clinical trials have showed good results of  neoadjuvant chemotherapy  in advanced gastric cancer . Large sample r and omized controlled studies are needed to confirm the value of neoadjuvant chemotherapy Following curative resection for gastric adenocarcinoma , 142 patients were r and omized to receive adjuvant chemotherapy of methyl‐CCNU and 5‐FU or to be  closely followed without chemotherapy . The median patient has been followed for four years . At the present time , there have been 38 recurrences and 40 deaths among the 71 patients in the control arm and 28 recurrences with 29 deaths in the group of patients r and omized to chemotherapy .  Median survival for control patients is 33 months whereas it is estimated to be in excess of four years for the adjuvant therapy group . A survival advantage appears to be associated with adjuvant treatment , a test for treatment difference being significant ( P < 0.03 ) after adjustment for important covariates . Survival and disease‐free intervals are longer in the chemotherapy arm for patients in all prospect i ve stratification subgroups ( proximal and total vs distal subtotal gastrectomy , presence or absence of lymph node metastases , invasion of adjacent organs vs confined to stomach wall and location of tumor within the stomach ) . A final assessment of this surgical adjuvant approach must await complete results of this trial , as well as of others currently in progress evaluating this same concept 411 patients were entered into a prospect i ve , r and omised controlled trial of adjuvant chemotherapy after gastrectomy for adenocarcinoma . After a follow-up of at least 5 1/2 years there has been no survival advantage for those receiving adjuvant 5-fluorouracil and mitomycin C with or without an induction course of 5-fluorouracil , vincristine , cyclophosphamide , and methotrexate compared with those undergoing surgery only . There have been 366  deaths , including 22 from treatment-related conditions . A multivariate analysis of prognostic factors demonstrated that stage of disease , nodal and resection margin involvement , and the presence of residual disease are significant determinants of survival . Weight loss before surgery had a significant independent influence on survival . The combination of preoperative symptoms and intraoperative findings may be used to select patients for radical or palliative procedures A prospect i ve , r and omised controlled trial of surgery , surgery with adjuvant radiotherapy and surgery with adjuvant chemotherapy ( 5-fluorouracil , adriamycin and mitomycin C ) in operable gastric cancer is described . Four hundred and thirty-six patients were r and omly allocated to one of three treatment groups . With 12 months ' minimum follow-up , 334 patients have died , 292 from recurrent cancer . The median survival for all patients was 15 months . Neither form of adjuvant therapy provides any survival advantage . Surgery remains the principal treatment for operable gastric cancer . Care should be taken to st and ardise surgical treatment and any adjuvant treatments must be compared within the confines of controlled , r and omised trials PURPOSE The first planned interim analysis ( median follow-up , 3 years ) of the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer confirmed that the oral fluoropyrimidine derivative S-1 significantly improved overall survival , the primary end point . The results were therefore opened at the recommendation of an independent data and safety monitoring committee . We report 5-year follow-up data on patients enrolled onto the ACTS-GC study . PATIENTS AND METHODS Patients with histologically confirmed stage II or III gastric cancer who underwent gastrectomy with D2 lymphadenectomy were r and omly assigned to receive S-1 after surgery or surgery only . S-1 ( 80 to 120 mg per day ) was given for 4 weeks , followed by 2 weeks of rest . This 6-week cycle was repeated for 1 year . The primary end point was overall survival , and the secondary end points were relapse-free survival and safety . RESULTS The overall survival rate at 5 years was 71.7 % in the S-1 group and 61.1 % in the surgery-only group ( hazard ratio [ HR ] , 0.669 ; 95 % CI , 0.540 to 0.828 ) . The relapse-free survival rate at 5 years was 65.4 % in the S-1 group and 53.1 % in the surgery-only group ( HR , 0.653 ; 95 % CI , 0.537 to 0.793 ) . Subgroup analyses according to principal demographic factors such as sex , age , disease stage , and histologic type showed no interaction between treatment and any characteristic . CONCLUSION On the basis of 5-year follow-up data , postoperative adjuvant therapy with S-1 was confirmed to improve overall survival and relapse-free survival in patients with stage II or III gastric cancer who had undergone D2 gastrectomy BACKGROUND Patients with gastric cancer who have positive cytologic results for cancer cells in peritoneal washings ( CY1 ) have poor outcomes , even in the absence of other distant metastases . A st and ard treatment for such patients remains to be established . METHODS We conducted a phase II trial with the 2-year survival rate as the primary endpoint . Patients who had gastric cancer with CY1 status but no other residual disease received postoperative chemotherapy with S-1 ( 1 M tegafur-0.4 M gimestat-1 M otastat potassium ) at a daily dose of 80mg/m(2 ) for 4 weeks , followed by 2 weeks of rest . This cycle was continued until disease progression or intolerable adverse events . D2 dissection was the recommended surgical procedure ; splenectomy could be omitted at the discretion of the surgeon . Accrual of 50 patients was planned , and a 2-year survival rate of more than 36 % was needed to exceed the historical control . RESULTS Forty-eight patients were enrolled , among whom 47 were assessable for survival and 46 for  adverse reactions  . Median overall survival was 705 days , and progression-free survival was 376 days . The 2-year survival rate was 47 % . Median time to treatment failure was 288 days . Neutropenia was the commonest > or = grade 3 toxicity ( 6 patients ) , and anorexia was the most frequent > or = grade 2 non-hematologic toxicity ( 10 patients ) . CONCLUSIONS Gastrectomy followed by S-1 monotherapy result ed in survival that surpassed historical data and can serve as an active control treatment for future trials in patients who have gastric cancer with CY1 status in the Far East Abstract Background : To improve the poor prognosis of patients with advanced incurable gastric cancer , intensive chemotherapy combined with radical surgery was used . Patients and Methods : Thirty patients with incurable gastric cancer were treated with a combination of 5-fluorouracil ( 370 mg/m2 ) and leucovorin ( 30 mg/person ) , given intravenously for five consecutive days , followed by cisplatinum ( 70 mg/m2 ) and etoposide ( 70 mg/m2 ) on days 6 and 20 , delivered through a catheter placed either in the aorta with its tip at the level of the ninth thoracic vertebra or in the celiac artery . This treatment ( FLEP therapy ) was repeated twice every 5 weeks . Radical or palliative surgery followed chemotherapy . Results : The overall response rate to the chemotherapy was 50.0 % ( 15 of 30 patients , 95 % confidence limit 0.305–0.671 ) . Nineteen patients ( 15 with a partial response , three showing no change , and one with progressive disease ) underwent surgery . Of these , nine underwent curative surgery and 10 palliative surgery .  The median survival time was 6.5 months overall , 12.7 months for responders , and 4.7 months for nonresponders . Long-term survivors were exclusively found among patients with distant lymph node metastasis treated by curative surgery ( 55.6 % at 5 years ) . Conclusions : Favorable results of this small phase II study justify a phase III trial BACKGROUND / AIMS Preoperative chemotherapy is considered an effective treatment option for patients with gastric cancer . We retrospectively evaluated neoadjuvant chemotherapy with oxaliplatin , leucovorin and 5-flurouracil ( OLF ) in patients with locally advanced gastric cancer to determine its feasibility , as well as impact on the curative resection rate and patients ' survival . METHODOLOGY A total of 87 patients with locally advanced gastric cancer that underwent preoperative chemotherapy combined with surgery or surgery alone were r and omly matched according to the clinical TNM stage . The clinical responses to chemotherapy were assessed . The curative rate , postoperative complications and patients ' survival between both groups were compared . RESULTS The two groups were well matched . Complete or partial response was observed in 51.7 % ( 15/29 ) of patients in the OLF group , and three ( 10.3 % ) of them had complete pathologic response . The curative resection rates were 89.7 % in the OLF group and 77.6 % in the surgery alone group . The postoperative complications were equal for both groups . The mean survival is 20.6 months in the OLF group vs. 19.9 months in the surgery alone group ( p=0.02 ) . CONCLUSIONS Neoadjuvant chemotherapy using OLF combination is active in gastric cancer and the toxicity level is acceptable . This treatment improves the curative resection rate and patients ' survival in locally advanced gastric cancer OBJECTIVE In 1986 a prospect i ve multicenter observation trial in patients with resected gastric cancer was initiated in Germany . An analysis of prognostic factors based on the 10-year survival data is now presented . PATIENTS AND METHODS A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included . The resected specimen were evaluated histopathologically according to a st and ardized protocol . The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment ( 25 or fewer removed nodes , D1 or st and ard lymphadenectomy ; > 25 removed nodes , D2 or extended lymphadenectomy ) . Endpoint of the study was death . Follow-up is complete for 97 % of the included patients ( median follow-up of the surviving patients is 8.4 years ) . Prognostic factors were assessed by multivariate analysis . RESULTS A complete macroscopic and microscopic tumor resection ( R0 resection according to the UICC 1997 ) could be achieved in 1182 of the 1654 patients ( 71.5 % ) . The calculated 10-year survival rate in the entire patient population was 26.3 % + /- 4.7 % ; it was 36.1 % + /- 1.6 % after an R0 resection . In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes , the residual tumor ( R ) category , the pT category , the presence of postsurgical complications , and the presence of distant metastases . Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status , the pT category , and the presence of postsurgical complications as the major independent prognostic factors . The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors . This effect was present in the subgroups with ( pT2N1 ) and without ( pT3N0 ) lymph node metastases on st and ard histopathologic assessment . The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection ( < 15 nodes ) were excluded from the analysis . There was no difference in the postsurgical morbidity and mortality rates between patients with st and ard and extended lymph node dissection . CONCLUSIONS Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer . In experienced centers , extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II  tumors .  This effect appears to be independent of the phenomenon of stage migration BACKGROUND The extent to which chemotherapy may relieve tumour-related symptoms , improve quality of life and prolong survival in patients with gastric cancer is not known in spite of the extensive use of this treatment modality . The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in these patients . PATIENTS AND METHODS Between January 1991 and February 1995 , 61 patients with gastric cancer were r and omized to either chemotherapy in addition to best supportive care or to best supportive care . Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation . Chemotherapy was the ELF-regimen consisting of 5-fluorouracil , leucovorin and etoposide , or , in elderly patients with poor performance , a 5-fluorouracil/leucovorin regimen ( FLv ) .  Quality of life was evaluated with the EORTC-QLQ-C30 instrument . RESULTS More patients in the chemotherapy group ( 45 % , 14/31 ) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group ( 20 % , 6/30 , P < 0.05 ) . A similar difference was seen in the treating physician 's evaluation of whether the patient was subjectively improved or continued to do well for at least 4 months ( 17/31 , 55 % versus 6/30 , 20 % , P < 0.01 ) . Overall survival was longer in the chemotherapy group ( median 8 vs. 5 months ) although the difference was not statistically significant ( P = 0.12 ) . After corrections for imbalances in pretreatment characteristics , chemotherapy treatment was , however , associated with a survival benefit ( P = 0.003 ) . Also , the quality -adjusted survival time and time to disease progression were longer for patients r and omized to chemotherapy ( median 5 vs. 2 months , P = 0.03 ) . CONCLUSIONS The results show that chemotherapy can add to both quantity and quality of life in advanced gastric cancer . The number of patients who benefit from treatment is , however , still rather limited
Within a combination chemotherapy regimen , oral capecitabine is preferred over intravenous 5-fluorouracil (5fu)-that is , epirubicin-cisplatin-capecitabine is preferred over the prior st and ard regimen , epirubicin-cisplatin-5fu (ecf).Epirubicin-oxaliplatin-capecitabine ( eox ) is a reasonable alternative to ecf .
QUESTION What is the optimal chemotherapy regimen in advanced gastric cancer ?
PERSPECTIVES Gastric cancer is the second leading cause of cancer mortality worldwide .
Despite low incidence rates for gastric cancer in Ontario , the overall prognosis is bleak , with 5-year survival rates of approximately 23 % in Canada .
Even with the considerable body of research available on chemotherapy for advanced gastric cancer , uncertainty remains .
There is no recognized st and ard treatment , and there appears to be geographic variation in practice .