Practical Perspectives on Treatment of Advanced Gastric/GEJ Cancers - Episode 20

Improving the Management of Advanced Gastric/GEJ Cancer


Manish Shah, MD: Supportive care is a key aspect of managing anybody with gastric and GE junction cancer. Patients commonly have dysphagia, weight loss, and nutritional issues. Peritoneal disease can affect nutrition as well. Neuropathy can play a role and the psychosocial factors as well. I found that the better we are at supportive care, the better we are at delivering chemotherapy, and the better it’s tolerated. Ultimately, outcomes are better. I’m fortunate to practice in an area where we have access to lots of help with social workers, dietitians, gastroenterologists, and surgeons. I think we need to take advantage of that support to provide ancillary support to our patients.

There can be challenges for multidisciplinary involvement. I think one obvious challenge is that people are busy: the physicians, surgeons, medical oncologists, and radiation oncologists. I think I’m fortunate I practice in an area where we feel that we gain a lot in terms of learning from each other and offering our patients better care with a multidisciplinary approach. But if someone is unable to come, I’m sure to e-mail or text them or follow up to see if they had any questions about any cases, to get their input, and to remind them that their input matters. That’s one challenge.

I think another challenge is that in many areas, unfortunately, it’s not convenient to do multidisciplinary care. People are coming from a distance. They don’t all practice in the same area, so coordinating that time is a challenge. I’m hopeful that with our new technology, we can do more virtual multidisciplinary meetings. We’re doing that more and more through my involvement in ASCO and other things like that. But I think it may be of some benefit because physicians can participate in a multidisciplinary program at their office, so they can still participate with their guidance and learn from others.

The TAGS study was a phase III study in the third-line setting. It was a study of TAS-102 versus placebo or best supportive care. It’s actually surprising that we can do a best-supportive-care phase III study in the third-line setting, but it was done. In fact, it was positive. Over 500 patients were randomized. It was a 2:1 randomization. The median survival with TAS-102 was about 5 months versus 3 months with the placebo. These data were just reported at the World GI Cancer meeting in Barcelona, and it’s fantastic because it will likely add another drug to our armamentarium for treating gastric cancer.

There have been many, many studies performed in gastric cancer in terms of phase III registrational trials. Recently, there were several that were negative, but there are several that are ongoing. We’re awaiting the results of the phase III first-line study of FOLFOX, plus or minus the MMP-9 inhibitor, andecaliximab. The phase II study that supported the phase III study just was published in Clinical Cancer Research, and the data were compelling. The median survivals were well over a year. So that may change the landscape. The use of pembrolizumab or nivolumab in the first-line setting may change the landscape as well. I think drug development is quite active. There was a novel ADC, antibody drug conjugate, that was recently published on in Lancet Oncology that targeted HER2. There are studies ongoing examining that in the advanced-line setting as well.

Transcript Edited for Clarity