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"How Should We Treat Gastric Cancer?"

Natalie Coburn
Natalie Coburn

Surgical oncologist Natalie Coburn from the Division of General Surgery and Sunnybrook Health Sciences Centre hosted an expert panel on Processes of Care of Gastric Cancer on Oct. 21-23rd at the Four Seasons Hotel in Toronto. Sixteen experts from six countries specializing in Medical, Radiation and Surgical Oncology, Minimal Access and General Surgery, and Gastroenterology participated. A Rand UCLA appropriateness method was used to organize the meeting. The panelists had scored 2000 scenarios and formulated optimal management strategies for the surgical treatment of gastric cancer.

As background, Natalie first completed a literature review on the outcome of treatment of gastric cancer. The results of surgery are highly variable, and remarkably better in the Eastern hemisphere than in the West. Asian surgeons tend to overwhelmingly favour D2 resections, illustrated in a nearby figure, whereas Western surgeons, influenced by the high mortality reported in earlier randomized trials, tend to treat the disease less radically. The evidence base for more limited surgery comes from earlier randomized trials in which the postoperative mortality was 10% or more for D2 resections. Proponents of the D2 operation point out that the randomized trials included low volume surgeons with a higher than average mortality.

In the convened expert panel discussion, Dr. Sung Hoon Hoh, a senior surgeon from South Korea, stated that he personally performs 500 gastric cancer resections per year, approximately the same number that are performed annually in all of Ontario. The panel agreed that technically challenging minimally invasive resections should not be endorsed unless performed by surgeons with advanced laparoscopic skills and extensive experience in the treatment of gastric cancer. The panel did not endorse resection of the stomach in the presence of metastatic disease unless necessary for palliative reasons.

Gastroenterologist Norman Marcon from St. Michael's Hospital discussed mucosal resections for the earliest lesions, and this was endorsed by the panel. In general, treatment of other gastric cancers by surgery alone was judged to be insufficient. Perioperative chemotherapy or postoperative chemo-radiation treatment were endorsed for all gastric cancers more extensive than T1 N0 lesions. The application of known effective adjuvant treatment is very much dependent on choices made by the various treatment teams. The addition of perioperative chemotherapy raises the five-year survival from 23% to 36%, and adjuvant chemoradiation increased median survival from 27 to 36 months.

D1 resection
D1 LN dissection: right cardial, left cardial, along lesser curvature, along greater curvature, along gastroepiploics, suprapyloric, infrapyloric; all nodes within 3 cm of primary tumour

D2 resection
D2 LN dissection: left gastric artery, common hepatic artery, celiac axis, splenic hilum, splenic artery; all nodes more than 3 cm away from primary as well as along the common hepatic, splenic and L gastric artery

The next step in this important translational research is development of an education program based on outcomes, followed by a study of the program's impact on patients treated for gastric cancer in Ontario. This is the next iteration of the outstanding translational research and education program championed by the Sunnybrook group for treatment of colon cancer patients.

Natalie took her surgical training at Brown University, completed a fellowship in Surgical Oncology at the University of Toronto, and has joined Andy Smith and his colleagues at SHSC and the Odette Cancer Centre, where she specializes in hepatobiliary and upper GI cancer. She conducted her studies under a grant from the Canadian Cancer Society Research Institute and a Ministry of Health Career Scientist Award.


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