Cunningham D et al. (2006) Perioperative chemotherapy versus surgery alone for resectable esophageal cancer. N Engl J Med 355: 11–20

It has long been known that chemotherapy prolongs survival of patients with inoperable gastric cancer. A new, multinational study has now shown that perioperative chemotherapy can prolong survival of patients with surgically resected gastric cancer, compared with patients treated with surgery alone. Benefits of perioperative chemotherapy might, however, depend on the regime chosen.

Cunningham et al. randomly allocated patients diagnosed with resectable gastric, gastroesophageal junction, or lower-esophageal adenocarcinoma to undergo either surgery alone (n = 253), or surgery plus three preoperative and three postoperative cycles of chemotherapy (n = 250). Chemotherapy cycles comprised 50 mg/m2 epirubicin and 60 mg/m2 cisplatin on day 1, with continuous infusion of fluorouracil 200 mg/m2 daily for 21 days. Dose modification was permitted in response to treatment-related toxicity. Median follow up was 47–49 months.

Compared with patients who underwent surgery alone, patients who received perioperative chemotherapy had markedly improved progression-free survival (difference between groups, P <0.001) and overall survival (5-year survival rates of 36% versus 23%). As expected, they also had reduced tumor size and stage at surgery. Only 104 of 250 patients assigned to perioperative chemotherapy completed all six cycles; reasons for not completing chemotherapy varied, but patient choice was an important factor. The authors note that acceptability of this chemotherapy regime is impaired by the need for lengthy intravenous infusions, and suggest that substitution of newer agents such as capecitabine and oxaliplatin might improve patient compliance.