Palliative chemotherapy is a treatment to control cancer progression, improve quality of life, and prolong life as long as possible to maintain long-term “human-tumor coexistence” for patients with extensive metastases that are not completely resectable.
Why palliative chemotherapy?
Why palliative chemotherapy?
The goal of palliative chemotherapy is to control further tumor growth, invasion, and metastasis through chemotherapy, shrink the tumor, and control the symptoms associated with the tumor in order to maximize life and quality of life. For example, for gastric cancer patients with extensive peritoneal metastasis, palliative chemotherapy can reduce or even disappear a large amount of ascites while shrinking the primary lesion. For patients with extensive liver metastases, palliative chemotherapy can bring the liver metastases under control or even reduce and disappear, which can relieve liver insufficiency, ascites and even liver failure caused by secondary liver metastases.
Under what circumstances should palliative chemotherapy be given for gastric cancer?
Palliative chemotherapy is mainly indicated for patients who have extensive metastases that cannot be completely removed, or for patients whose tumors have invaded or adhered to vital tissues and organs and cannot be operated on. The National Comprehensive Cancer Network (NCCN) guidelines state that unresectable gastric cancer includes primarily gastric cancer with peritoneal metastases (including positive cytology of peritoneal fluid), distant metastases, or locally advanced (highly suspicious on imaging or pathologically confirmed N3 or N4; invading or encapsulating large vascular structures other than splenic vessels). However, in recent years, with newer treatments (e.g., radiofrequency ablation) and treatment concepts (combined organ resection), some distant metastatic gastric cancers have become resectable.
For example, when gastric cancer has extensive liver metastases or peritoneal metastases, surgery cannot completely remove the cancer, and aggressive surgery does not benefit the patient but increases trauma; when gastric cancer infiltrates important structures such as the abdominal aorta, forced surgical debridement is bound to cause acute hemorrhage or even death, and palliative chemotherapy is needed to control the local tumor.
When and for how long should palliative chemotherapy be done?
Physicians assess when to start palliative chemotherapy based primarily on the patient’s condition and physical status. If medical conditions allow, palliative chemotherapy is usually started when the tumor is found to be unresectable or when there is recurrence or metastasis. During the chemotherapy period, the doctor will usually evaluate the efficacy of chemotherapy every 2 cycles or 2-3 months, and based on the results, the doctor will decide the next treatment plan. If a serious adverse reaction occurs during chemotherapy, the doctor will consider changing the drug or stopping it.
There is no definite end date for when palliative chemotherapy should be used, but it is not meant to be used all the time. For example, when a patient with end-stage cancer has deteriorated and is no longer benefiting from chemotherapy, doctors may consider stopping chemotherapy and switching to supportive care. Doctors may also try “stop-and-go” or “beat therapy” chemotherapy modalities, taking into account the patient’s tolerance. With the gradual adoption of targeted therapies and immunotherapy in gastric cancer, patients with advanced gastric cancer may have more options beyond palliative chemotherapy.
In conclusion, it is certain that palliative chemotherapy has a crucial role in improving the quality and prolonging the survival of patients with advanced gastric cancer. Patients who are evaluated for palliative chemotherapy will be started by their physicians as early as possible and will be evaluated regularly during chemotherapy to determine the next step. (Contributed by Xin Wang, Department of Gastrointestinal Oncology, The First Hospital of China Medical University)