Approach to Unresectable Stage 4 Gastric Adenocarcinoma - Episode 3

Frontline Approach in Gastric Cancer: Double vs Triplet

Daniel Catenacci, MD:Typically, at our center, despite having multiple regimens to choose from for first-line palliative therapy, we tend to use 2-drug regimen FOLFOX (oxaliplatin, 5-FU, folinic acid). This is an emerging preference across centers. Despite having many regimens that have similar outcomes, we prefer FOLFOX chemotherapy because it’s better tolerated with fewer side effects.

Three-drug regimens, typically we use very sparingly to palliate symptoms in a potentially very young patient with a very good performance status. But ultimately, the goal is to treat patients with our treatments in tandem. So, 2-drug treatments in tandem, rather than lumping everything up front and having a higher toxicity profile without much difference in overall survival.

This patient in this case had a response at the first assessment after 3 months of therapy. The response rate with FOLFOX chemotherapy is approximately 40%, so that’s not that surprising. Patients often have disease control but improved symptoms, whether it’s from dysphasia, if the primary tumor is located in the distal esophagus or GE junction, or like, in this patient, having mild abdominal pain, fatigue, etc. Many of these things get better with treatment and patients could still have stable disease on scans. Very few patients will progress after the first image after first-line therapy. Only about 5% to 10% of patients will have inherent resistance to first-line chemotherapy.

Transcript edited for clarity.

A 61-Year-Old Woman With Stage 4 Gastric Cancer

November 2017

  • A 61-year-old Hispanic woman presents to her PCP complaining of unexplained weight loss (15 lbs over 6 months), intermittent abdominal pain, fatigue, and recent onset of vomiting
  • BMI: 23
  • PE: negative for ascites
  • Notable laboratory findings:
    • HB: 11.2 g/dL
    • LFT: WNL
    • GFR: 100
    • CEA, 18.4 ng/mL
    • AFP, CA 19-9, and CA 125: WNL
  • Upper gastric endoscopy: suspicious 7.2-cm ulcerative lesion involving the pyloric region
  • Endoscopic ultrasound: suspicious lymph node
  • Biopsy: confirmed poorly differentiated, gastric adenocarcinoma, diffuse histologic subtype; positive lymph node
  • Molecular testing: HER2(-), MSI-stable, PD-L1 expression 0%
  • CT of chest, abdomen, and pelvis: showed diffuse invasion of the gastric wall and visceral peritoneum, lymph node involvement, 1 hepatic lesion
  • Staging: stage IV gastric adenocarcinoma, unresectable
  • ECOG PS 0

January 2018

  • The patient was started on fluorouracil and oxaliplatin (FOLFOX)
  • Follow up CT at 3 months showed a response to systemic therapy

July 2018

  • Patient reports increasing nausea, fatigue, and shortness of breath
  • CT imaging at 7 months shows metastatic spread to multiple suprapyloric nodes and a new liver lesion
  • LFT: mildly elevated; GFR: WNL; HB: 10.8 g/dL
  • ECOG PS 1
  • Patient is motivated to try another systemic therapy
  • Treatment with paclitaxel/ramucirumab is planned