Postoperative chemoradiotherapy after curative gastrectomy for cancer

F. Bozzetti*

Istituto Nazionale Tumori, Milan, Italy

*E-mail: dottfb@tin.it

I read with interest the paper by Park et al. on postoperative chemoradiotherapy for gastric cancer, published in a recent issue of Annals of Oncology [1] and I fully agree with the conclusions they report in the Discussion.

In particular, I share the perplexity of the authors in extrapolating the benefit of chemoradiotherapy achieved in the patients undergoing a limited lymphadenectomy in the Intergroup trial INT-0116 [2] also to those undergoing D2 lymph node dissection. In fact, patients in the American trial would be considered undertreated according to the surgical standard of many centers in Europe and Japan and this could account for the success of the subsequent chemoradiotherapy.

In support to this thesis, it is interesting to note that the 5-year survival of the 290 patients in the Korean study [1] who received adjuvant chemoradiotherapy is quite comparable, stage by stage, to that of 618 patients enrolled in an Italian randomised study comparing subtotal versus total gastrectomy alone, both the procedures being associated with D2 lymph node dissection [3]. Namely, the 5-year survival for stages IB, II, III and IV were 93%, 75%, 53% and 13% in the Korean study versus 86%, 75%, 61% and 13% in the Italian study, respectively.

Although such comparisons should always be viewed with caution, I am asking whether it is ethically correct to compare, in a randomized fashion, a D2 gastrectomy with a D2 gastrectomy plus adjuvant chemotherapy if the expected clinical benefit is so limited and this adjuvant treatment appears to be a demanding procedure and is sometimes toxic for the patient. Moreover, I wonder how big the sample size should be if the difference to be detected between the two groups is very small!

I acknowledge that randomized clinical trials are the best way to proceed on the road of evidence-based medicine; nevertheless, surgeons and medical oncologists should realistically consider that the extent of lymphadenectomy makes some difference to the outcome of patients who undergo surgical treatment for cancer of the stomach [4].

REFERENCES

1. Park SH, Kim DY, Heo JS et al. Postoperative chemoradiotherapy for gastric cancer. Ann Oncol 2003; 14: 1373–1377.[Abstract/Free Full Text]

2. MacDonald JS, Smalley SR, Benedetti J et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001; 345: 725–730.[Abstract/Free Full Text]

3. Bozzetti F, Marubini E, Bonfanti G et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg 1999; 230: 170–178.[CrossRef][ISI][Medline]

4. Marubini E, Bozzetti F, Miceli R et al. Lymphadenectomy in gastric cancer: prognostic role and therapeutic implications. Eur J Surg Oncol 2002; 28: 406–412.[CrossRef][ISI][Medline]





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