A new era in management of gastrointestinal cancers
A new era in management of? gastrointestinal cancers
New and emerging treatment regimens for gastrointestinal (GI) cancers were presented at the Seventh Annual Oncology Congress, held in San Francisco, California, October 13-15, 2011. Researchers presented studies on the efficacy of preoperative and postoperative chemotherapy with surgical resection for gastric cancer, combination radiotherapy-chemotherapy for locally advanced pancreatic cancer, the effects of genetics on treatment response, the association between Helicobacter pylori infection and gastric cancer, and a new approach to early diagnosis of GI cancers. This article reviews the study results presented at the 2011 Oncology Congress.
PREOPERATIVE/ POSTOPERATIVE CHEMOTHERAPY AND RESECTION
Management of gastrointestinal tract cancer is much different today than it was just a few years ago. Studies are demonstrating that adjuvant and neoadjuvant therapies are increasingly effective for gastric cancer, gastroesophageal junction tumors, and esophageal cancer, according to David Ilson, MD, PhD, of the Memorial Sloan-Kettering Cancer Center in New York, New York.
Ilson, who presented Prevention, Screening, and Management: New Frontiers in Managing Gastric Cancer at the 2011 Oncology Congress, said preoperative regimens of carboplatin, paclitaxel (Abraxane, generics), and radiotherapy are becoming the new standard of care. "For esophageal and gastroesophageal (GE) junction cancers, the addition of chemotherapy to radiation therapy seems to offer survival and local control benefits," Ilson said. Many new agents for treating this disease are in clinical trials, including phase III evaluation of adding cetuximab and bevacizumab to preoperative and postoperative therapy. Positron emission tomography (PET) is being used to direct therapy in esophageal and gastroesophageal junction cancers in the preoperative setting.
Studies suggest survival rates are poor (20%-30%) for patients with locally invasive gastric cancer when treated with surgery alone. However, preoperative chemotherapy and chemotherapy plus radiation may improve overall survival rates. In addition, the latest data suggest that chemotherapy plus radiation may have advantages over chemotherapy alone.
"Nurses will need to understand management of patients with preoperative chemotherapy and chemotherapy/radiation, in particular chemotherapy/radiation because it is more toxic. Attention to treatment of toxicities including esophagitis from radiation therapy, nutritional needs, and assessment preoperatively are key nursing issues," Ilson said.
A large, phase III trial, by the US GI Intergroup Study led by the Southwest Oncology Group (INT 0116), previously demonstrated improved survival when treatment consisted of a combination of postoperative radiation therapy and chemotherapy with fluorouracil and leucovorin.1 The Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial also demonstrated that perioperative chemotherapy can provide a significant survival benefit.2 This trial showed a significant downstaging or downsizing of tumors.
The MAGIC trial included patients with adenocarcinoma of the stomach, the lower third of the esophagus, and the esophagogastric junction.2 All the subjects were recruited through medical centers in Europe, South America, Asia, and New Zealand. The patients were randomly assigned to receive surgery alone (250 patients) or surgery and perioperative chemotherapy (250 patients) with epirubicin (Ellence, generics), cisplatin, and infused 5-fluorouracil (ECF). Perioperative chemotherapy in this trial consisted of three preoperative cycles and three postoperative cycles. Patients were given epirubicin and cisplatin intravenously on the first day of each cycle, and fluorouracil was given daily for 21 days as a continuous IV infusion.2
The researchers found significantly smaller tumors in the chemotherapy group.2 In addition, patients receiving perioperative chemotherapy had a significantly higher likelihood of both progression-free and overall survival. The 5-year survival rate was higher in the chemotherapy group compared with the surgery-only group (36.3% versus 23.0%, respectively). Postoperative complication rates were similar in both groups (46% in the chemotherapy group versus 45% in the surgery-only group). The MAGIC trial researchers concluded that administering chemotherapy before and after surgery resulted in improved survival. "But we don't know if that is better than chemotherapy and radiation," said Andrew Ko, MD, an associate professor in the division of Hematology/Oncology at the University of California, San Francisco.