Approach to Unresectable Stage 4 Gastric Adenocarcinoma - Episode 1
Daniel Catenacci, MD:My initial impression of this case is that it is a typical presentation for gastric cancer, presenting with vague symptoms: fatigue, anorexia, some weight loss, and mild abdominal pain. Eventually the patient gets worked up to have an upper endoscopy and is found to have a mass in the distal stomach; confirmed to be a stomach cancer. Ultimately with staging of CT scans and other blood tests, it’s determined that it’s metastatic stage 4 to the liver.
After typical staging and discussing the prognosis with the patient, that it’s an incurable cancer in the stage 4 setting, the patient received standard first-line chemotherapy. There are a number of different chemotherapy regimens available, all with phase III data to support their use; various 2-drug and 3-drug regimens. Though recently, FOLFOX chemotherapy has emerged as a preferred standard therapy, which is what this patient received. Also, what we would expect, most patients derive some clinical benefit and palliation from this chemotherapy, with a response rate of approximately 40%, and another 40% of patients having at least disease control.
This patient, at the first imaging time point at 3 months, demonstrated that there was a response on imaging and was doing well with therapy. Unfortunately, and also as expected, by 7 months into treatment, the patient demonstrated progression, and that is a typical median progression-free survival on most studies.
At that time point, the patient was assessed and had a preserved performance status, and so she appropriately was offered second-line therapy. Typically, there is, again, a number of options for chemotherapy in the second-line settingirinotecan-based, taxane-based. Most recently, there was a large phase III study, called the RAINBOW study, which was assessing paclitaxel with ramucirumab, compared to the control of paclitaxel alone; this demonstrated an improved overall survival, as well as a response rate. So, this patient received paclitaxel with ramucirumab; that’s where the patient was in terms of when we left off with their case.
Transcript edited for clarity.
A 61-Year-Old Woman With Stage 4 Gastric Cancer