Chemoradiotherapy after Surgery Compared with Surgery Alone for Adenocarcinoma of the Stomach or Gastroesophageal Junction
John S. Macdonald, M.D., Stephen R. Smalley, M.D., Jacqueline Benedetti, Ph.D., Scott A. Hundahl, M.D., Norman C. Estes, M.D., Grant N. Stemmermann, M.D., Daniel G. Haller, M.D., Jaffer A. Ajani, M.D., Leonard L. Gunderson, M.D., J. Milburn Jessup, M.D., and James A. Martenson, M.D.
Background Surgical resection of adenocarcinoma of the stomachis curative in less than 40 percent of cases. We investigatedthe effect of surgery plus postoperative (adjuvant) chemoradiotherapyon the survival of patients with resectable adenocarcinoma ofthe stomach or gastroesophageal junction.
Methods A total of 556 patients with resected adenocarcinomaof the stomach or gastroesophageal junction were randomly assignedto surgery plus postoperative chemoradiotherapy or surgery alone.The adjuvant treatment consisted of 425 mg of fluorouracil persquare meter of body-surface area per day, plus 20 mg of leucovorinper square meter per day, for five days, followed by 4500 cGyof radiation at 180 cGy per day, given five days per week forfive weeks, with modified doses of fluorouracil and leucovorinon the first four and the last three days of radiotherapy. Onemonth after the completion of radiotherapy, two five-day cyclesof fluorouracil (425 mg per square meter per day) plus leucovorin(20 mg per square meter per day) were given one month apart.
Results The median overall survival in the surgery-only groupwas 27 months, as compared with 36 months in the chemoradiotherapygroup; the hazard ratio for death was 1.35 (95 percent confidenceinterval, 1.09 to 1.66; P=0.005). The hazard ratio for relapsewas 1.52 (95 percent confidence interval, 1.23 to 1.86; P<0.001).Three patients (1 percent) died from toxic effects of the chemoradiotherapy;grade 3 toxic effects occurred in 41 percent of the patientsin the chemoradiotherapy group, and grade 4 toxic effects occurredin 32 percent.
Conclusions Postoperative chemoradiotherapy should be consideredfor all patients at high risk for recurrence of adenocarcinomaof the stomach or gastroesophageal junction who have undergonecurative resection.
Source Information
From the St. Vincent's Comprehensive Cancer Center, New York (J.S.M.); the Kansas City Community Clinical Oncology Program, Kansas City, Mo. (S.R.S.); the Southwest Oncology Group Statistical Center, Seattle (J.B.); the University of Hawaii, Honolulu (S.A.H.); the University of Illinois College of Medicine, Peoria (N.C.E.); the University of Cincinnati Medical Center, Cincinnati (G.N.S.); the University of Pennsylvania Cancer Center, Philadelphia (D.G.H.); the M.D. Anderson Cancer Center, Houston (J.A.A.); the Mayo Clinic, Rochester, Minn. (L.L.G., J.A.M.); and the University of Texas at San Antonio, San Antonio (J.M.J.).
Address reprint requests to the Publications Office, Southwest Oncology Group (SWOG-9008), Operations Office, 14980 Omicron Dr., San Antonio, TX 78245-3217.
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