Surgery and chemotherapy are both important treatments for gastric cancer, and doctors will develop individualized treatment plans based on the patient’s different conditions. Therefore, patients may find that some patients have surgery before chemotherapy, while others have chemotherapy before surgery, what is the difference between the two?
Prior to decision making, disease assessment is a priority
For gastric cancer, for which surgery is the primary treatment, staging is critical before deciding whether to operate.
Physicians typically evaluate localized lesions, usually using endoscopic ultrasound, abdominal enhancement CT, and other means. Ultrasound images provide insight into the depth of tumor invasion (T staging), lymph node involvement (N assessment), the presence of peri-organic lesions with metastases (M staging), or the presence of ascites.
Patients also need to undergo comprehensive, detailed whole-body imaging, including CT, magnetic resonance imaging (MRI), emission tomography (ECT) to clarify the presence of metastases in the lungs, liver, brain, bone, and, if necessary, whole-body positron emission computed tomography (PET-CT). The physician may also perform laparoscopic exploration of patients with progressive gastric cancer to determine whether there are abdominal implants as well as small liver metastases, and may perform abdominal lavage fluid cytology along with the laparoscopy.
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What is the role of ultrasound endoscopy in gastric cancer diagnosis and treatment?
Which patients are suitable for surgery first?
For patients whose staging is determined to be early to mid-stage after evaluation, physicians will in most cases treat them surgically first, and most patients can be cured directly with surgery, and some do not even require chemotherapy after surgery.
For patients with locally advanced gastric cancer, if complete resection is predicted and the cancer is at risk for hemorrhage, obstruction, or perforation, physicians will also generally treat the patient surgically first to reduce the tumor load and associated complications. Such patients usually receive chemotherapy after surgery, but there is still some risk of recurrence even with postoperative chemotherapy and other combination therapy.
Physicians sometimes also consider the type of pathology of gastric cancer when making decisions. Some specific types of gastric cancer (for example, hepatocellular adenocarcinoma) do not respond well to chemotherapy, and doctors usually recommend early surgery.
Which patients are suitable for chemotherapy first?
Some patients with locally advanced disease who have not yet developed distant metastases to the liver, lung, bone, and brain may still have the opportunity to have the lesion surgically removed. These patients have tumors that have invaded surrounding areas that are difficult to remove (e.g., the head of the pancreas), invaded the mesenteric root, encircled major large blood vessels, or developed metastases in the para-aortic lymph nodes, which are difficult to operate in these cases, so the surgeon will usually administer chemotherapy first and then operate after the tumor has shrunk and is eligible for surgery. Some physically fit patients with post-operative recurrence or advanced gastric cancer with distant metastases from a single organ (e.g. liver metastases, ovarian metastases) may also be evaluated again for surgical resection after conversion therapy if there is a possibility of complete resection. Patients usually also receive chemoradiotherapy after surgery.
In conclusion, the decision to treat is sometimes more important than the treatment itself. The decision between surgery and chemotherapy should not be generalized, but should be made on a patient-by-patient basis, with each patient receiving a standardized and individualized treatment plan. (Contributed by Xiaoyu Guo, Department of Medical Oncology, The First Affiliated Hospital of China Medical University)