title: Neoadjuvant or adjuvant therapy for resectable gastric cancer: a systematic review and practice guideline for North America.
abstract: BACKGROUND
  Gastric cancer is a global health problem accounting for 10% of all new cancer cases and 12% of all cancer deaths worldwide. Many clinical trials and meta-analyses have explored the value of neoadjuvant or adjuvant chemotherapy and radiation therapy in gastric cancer; however, these studies have produced conflicting results. The purpose of this guidance document was to determine whether patients with resectable gastric cancer should receive neoadjuvant or adjuvant therapy in addition to surgery. Outcomes of interest were overall survival, disease-free survival, and adverse events.
  
  
  METHODS
  A systematic review was undertaken to inform recommendations regarding neoadjuvant and adjuvant therapy in resectable gastric cancer in Ontario, Canada. MEDLINE and EMBASE databases, as well as American Society of Clinical Oncology (ASCO) annual meeting proceedings and American Society for Therapeutic Radiology and Oncology (ASTRO) proceedings were systematically searched from 2002 to 2010. Oral fluoropyrimidine trials were excluded owing to the unavailability of these agents in North America.
  
  
  RESULTS
  Overall, 22 randomized controlled trials (RCTs), 13 meta-analyses, and two secondary analyses were included. The systematic review informed the development of a clinical practice guideline with the following recommendations. Postoperative 5-fluorouracil-based chemoradiotherapy based on the Macdonald approach or perioperative ECF (epirubicin, cisplatin, fluorouracil) chemotherapy based on the Cunningham/MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) approach are both acceptable standards of care in North America. Choice of treatment should be made on a case-by-case basis. Adjuvant chemotherapy is a reasonable option for those patients for whom the Macdonald and MAGIC protocols are contraindicated. All patients with resectable gastric cancer should undergo a pretreatment multidisciplinary assessment to determine the best plan of care.
  
  
  CONCLUSIONS
  Overall survival in patients with resectable gastric cancer is significantly improved with the use of either postoperative chemoradiation (Macdonald approach) or perioperative ECF (MAGIC protocol).
authors.affiliation: Grand River Regional Cancer Centre, 835 King Street West, P O Box 9056, Kitchener, ON, N2G 1G3, Canada. gregory.knight@grhosp.on.ca
authors.forename: Greg
authors.initials: G
authors.lastname: Knight
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.forename: Roxanne
authors.initials: R
authors.lastname: Cosby
authors.forename: Natalie
authors.initials: N
authors.lastname: Coburn
authors.forename: Youssef
authors.initials: Y
authors.lastname: Youssef
authors.forename: Richard
authors.initials: R
authors.lastname: Malthaner
authors.forename: Rebecca K S
authors.initials: RK
authors.lastname: Wong
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use; D002170:Canada; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods*; D017024:Chemotherapy, Adjuvant / Q000379:methods; D018572:Disease-Free Survival; D006801:Humans; D020360:Neoadjuvant Therapy / Q000009:adverse effects / Q000379:methods*; D017410:Practice Guidelines as Topic; D013274:Stomach Neoplasms / Q000473:pathology / Q000628:therapy*; D015996:Survival Rate; D014481:United States