GASTROINTESTINAL CANCER PART-7
Welcome to the seventh part of educational series on GastroIntestinal Cancers. In last part, we discussed the staging of a newly diagnosed stomach cancer.
Question: Dr. Chiragbhai, how do you take care of patients with gastric cancer?
Ans: Most important first step is to have a multidisciplinary evaluation. Please note that it is a MUST in most western institutes. This type of evaluation, done with a team work, provides best chance to the patient for survival, and quality of life (according to his/her definition). In our setting also, it can be done in most cases, and in our experience, it has shown the same benefits as in west.
Since advances are rapidly occurring in every field of medicine, it is important for all specialists to work together in this deadly disease to provide best results to an individual patient. Also since frequently patients do not fall into the category of guidelines or published studies, collective experience and expertise are required to decide plan.
Que: What are the treatment options?
Ans: Surgery is the mainstay of treatment. There is enough published evidence to recommend that specific training in dealing with such cancers is extremely important. Otherwise we will never see results quoted in western literature. A surgeon who deals with cancers regularly, preferably focused in GI cancers should be the one operating. Almost all developed countries have regional surgery experts for any cancer surgery i.e. people specializing in surgery of one area e.g. GI, head and neck, breast, thoracic… More awareness of this concept will certainly lead to improved results in our country.
There are some controversies with regard to type of surgery i.e. extent of dissection D1 vs D2 vs extended D2; also about total vs subtotal gastrectomy. In short, a good margin i.e. about 4-5 cm, and minimum 15 lymph nodes removed are the least expected.
Que: How do you incorporate other modalities in treatment?
Ans: There are many emerging approaches. However, based on good data and guidelines, following are most widely accepted:
- Perioperative chemotherapy i.e. before and after surgery, is preferred for most patients (based on MAGIC trial results) – standard of care in most of Europe, and many US institutes. Improves survival/cure rate by a large extent, improves complete resection rate by downsizing tumor.
- Postoperative chemoradiation (in most stages) – if patient is referred after surgery. However, this treatment is difficult to tolerate for most patients, and only the most medically fit patients are able to complete course.
- Locally advanced – chemoradiation – if medically fit
- Metastatic – chemotherapy or supportive care alone
There are many important points to follow in planning of radiotherapy and chemotherapy. Many chemotherapy drugs and regimens are acceptable, most active and studied are ECF, DCF, and now capecitabine or oxaliplatin based.
In short, early diagnosis, complete staging, multidisciplinary evaluation, pre and post operative chemotherapy in operable patients, trained surgeon in high volume center, use of standard regimens is what can provide best possible results in stomach cancer.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496
Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Nehrunagar Circle, Ahmedabad.