Therapeutic Approach for Stage 4 Gastric Cancer - Episode 3
Manish A. Shah, MD:The care of cancer patients has evolved tremendously in the past 2 or 3 decades. I think that for most solid tumors, including gastric and GE junction cancer, we really do benefit from the multidisciplinary setting. So, at our institution, all patients are in fact presented in a multidisciplinary fashion. That includes the surgeonsthoracic and the general or gastric surgeons—pathology, radiology, and other medical oncologists, Fellows, and Residents. So, it’s a big group of people, and it’s educational, but it also helps uniform our care. The care coordination is complex, even for patients with metastatic disease. One issue in this case, for example, is he had 12 lbs of weight loss and dysphasia. The question that could come up is, how do we manage that if he doesn’t respond initially to chemotherapy? Should we play the stent? Should we do palliative radiation to the mass and the GE junction? These questions really can be addressed in a multidisciplinary fashion and, I think, for the benefit of patients. So, I think it’s actually really challenging if you’re practicing in an area where you don’t have access to multidisciplinary care. It’s tough for patients as well because they often have seen multiple physicians at the same time to get the same level of coordination.
There are many factors that play a role in deciding what treatment is appropriate. Obviously, there are tumor-related factors, such as the extent of the disease and the molecular profile. So, this patient had a locally advanced tumor with metastatic disease to the liver, and his molecular profile was negative forHER2, mismatch repair, and PD-L1.
There are patient-specific factors as well. So, if they have comorbid illnesses like cardiac disease or obesity, or peripheral neuropathy from diabetes, that may affect how we initially treat patients. Most patients really will receive a platinum and 5-FU in the first-line setting. However, if they have significant peripheral neuropathy at the beginning, it may be appropriate to start with FOLFIRI, for example.
Patients who have significant cardiac disease or a stroke may not be a big candidate for ramucirumab in the second-line setting. If they have a reduced ejection fraction, they may not be a good candidate for trastuzumab even if they’reHER2-positive. So, there are patient-specific factors, as well as tissue- or cancer-specific factors, that we address when we’re deciding on our treatment options.
Transcript edited for clarity.
A 54-Year-Old Man With Stage IV Gastroesophageal Junction Cancer