Gastric cancer

***This page is in the process of being updated. However, since there is significant overlap between regimens for gastric cancer and esophageal cancer, we recommend that you check if there is a suitable reference listed in esophageal cancer for your desired regimen.***

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Perioperative chemotherapy

ECF

Level of Evidence: Phase III

ECF: Epirubicin, Cisplatin, Fluorouracil

Regimen

• Epirubicin (Ellence) 50 mg/m2 IV on day 1
• Cisplatin (Platinol) 60 mg/m2 IV on day 1
• Fluorouracil (5-FU) 200 mg/m2/day IV continuous infusion on days 1-21
• Surgery is performed 3-6 weeks after the completion of cycle 3

21-day cycles x 3 cycles prior to surgery, then 3 cycles to begin 6-12 weeks after surgery

Supportive medications:

• Warfarin (Coumadin) 1 mg PO daily suggested as thrombosis prophylaxis

References

1. Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE, Verma M, Weeden S, Chua YJ, MAGIC Trial Participants. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 Jul 6;355(1):11-20. link to original article contains protocol PubMed

Cisplatin & 5-FU

Level of Evidence: Phase III

Regimen

• Cisplatin (Platinol) 100 mg/m2 IV as a 1 hour infusion on day 28
• Fluorouracil (5-FU) 800 mg/m2/day IV continuous infusion on days 1-5

28-day cycles x 2-3 cycles prior to surgery, then 3-4 cycles after surgery, for a total of 6 cycles

References

1. Ychou M, Boige V, Pignon JP, Conroy T, Bouché O, Lebreton G, Ducourtieux M, Bedenne L, Fabre JM, Saint-Aubert B, Genève J, Lasser P, Rougier P. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol. 2011 May 1;29(13):1715-21. link to original article contains protocol PubMed

Adjuvant chemotherapy

Fluorouracil (5-FU) & Folinic acid (Leucovorin)

Regimen

Cycles 1, 3, 4:

• Fluorouracil (5-FU) 425 mg/m2 IV bolus on days 1-5
• Folinic acid (Leucovorin) 20 mg/m2 IV bolus on days 1-5

28-day cycles x 3 total cycles, interrupted by cycle 2 as described below

Cycle 2:

• Fluorouracil (5-FU) 400mg/m2 IV bolus on days 1-4 and the last 3 days of radiation therapy
• Folinic acid (Leucovorin) 20 mg/m2 IV bolus on days 1-4 and the last 3 days of radiation therapy
• Concurrent radiation therapy starting cycle 2 day 1 with 180 cGy, 5 days per week; 25 fractions given over 5 weeks for a total of 4500 cGy

35-day cycle x 1 cycle, to be followed by cycle 3 as described above

References

1. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, Haller DG, Ajani JA, Gunderson LL, Jessup JM, Martenson JA. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001 Sep 6;345(10):725-30. link to original article contains protocol PubMed

Adjuvant chemoradiotherapy

5-FU & RT

Regimen, Macdonald et al. 2001

Level of Evidence: Phase III

Chemotherapy & concurrent radiation therapy

• Fluorouracil (5-FU) 425 mg/m2/day IV continuous infusion, days 1-5 of cycle 1
• Fluorouracil (5-FU) 400 mg/m2/day IV continuous infusion, days 1-4 and final 3 days of radiotherapy
• Folinic acid (Leucovorin) 20 mg/m2/day IV, days 1-5 of cycle 1
• Folinic acid (Leucovorin) 20 mg/m2/day IV, days 1-4 and final 3 days of radiotherapy
• Concurrent radiation therapy, 4500 cGy of radiation at 180 cGy per day, 5 days per week for 5 weeks, delivered in 25 fractions to the tumor bed, regional nodes, and 2 cm beyond the proximal and distal margins of resection.

28-day cycles; starting 20 to 40 days after surgery

Consolidation chemotherapy

• Fluorouracil (5-FU) 425 mg/m2/day IV continuous infusion, days 1-5
• Folinic acid (Leucovorin) 20 mg/m2/day IV days 1-5

28-day cycles, for a total of 2 cycles, to be commenced 1 month after completion of radiotherapy

References

1. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, Haller DG, Ajani JA, Gunderson LL, Jessup JM, Martenson JA. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001 Sep 6;345(10):725-30. link to original article contains verified protocol PubMed

Chemotherapy for metastatic or locally advanced disease (non-radiation/surgery candidate)

CX, XP - Cisplatin & Capecitabine

CX: Cisplatin, Xeloda
XP: Xeloda, Platinol

Regimen, Kang et al. 2009 & Lordick et al. 2013 (EXPAND)

• Cisplatin (Platinol) 80 mg/m2 IV over 2 hours once on day 1
• Capecitabine (Xeloda) 1000 mg/m2 PO BID on days 1 to 14
  • Lordick et al. 2013 gave Capecitabine (Xeloda) 1000 mg/m2 PO BID from the evening of day 1 to the morning of day 15 (28 doses per cycle)

21-day cycles, given until progression of disease or unacceptable toxicity

Supportive medications per Kang et al. 2009:

• "Hyperhydration" for cisplatin

References

1. Kang YK, Kang WK, Shin DB, Chen J, Xiong J, Wang J, Lichinitser M, Guan Z, Khasanov R, Zheng L, Philco-Salas M, Suarez T, Santamaria J, Forster G, McCloud PI. Capecitabine/cisplatin versus 5-fluorouracil/cisplatin as first-line therapy in patients with advanced gastric cancer: a randomised phase III noninferiority trial. Ann Oncol. 2009 Apr;20(4):666-73. Epub 2009 Jan 19. link to original article contains verified protocol PubMed
2. Lordick F, Kang YK, Chung HC, Salman P, Oh SC, Bodoky G, Kurteva G, Volovat C, Moiseyenko VM, Gorbunova V, Park JO, Sawaki A, Celik I, Götte H, Melezínková H, Moehler M; Arbeitsgemeinschaft Internistische Onkologie (AIO) and EXPAND Investigators. Capecitabine and cisplatin with or without cetuximab for patients with previously untreated advanced gastric cancer (EXPAND): a randomised, open-label phase 3 trial. Lancet Oncol. 2013 May;14(6):490-9. doi: 10.1016/S1470-2045(13)70102-5. Epub 2013 Apr 15. link to original article contains verified protocol PubMed