Neoadjuvant chemotherapy for gastric adenocarcinoma in Japan.

Surgery had been and remains a mainstay in the treatment of gastric cancer. The Japanese surgical oncologists employed surgery-first approach to treat gastric cancer because of the widespread use of D2 lymph node dissection and the high incidence of oncologically resectable cancer, and early attempts at the multimodality treatment strategy featured surgery followed by postoperative chemotherapy. Although evidence to treat Stage II/III gastric cancer with this strategy is now abundant in the Far East, poor compliance of the post-gastrectomy patients to intense combination chemotherapies has been a limitation associated with this strategy. Evidence in support of neoadjuvant chemotherapy in the West and in various other types of cancer prompted the Japan Clinical Oncology Group (JCOG) researchers to explore this strategy, primarily for a selected population of locally advanced cancer that could either be unresectable by the surgery-first approach or is known to suffer from a poor prognosis; cancers with bulky lymph node metastases or those with a scirrhous phenotype. Encouraged by some promising results from these neoadjuvant trials and taking into account the aforementioned limitations associated with postoperative chemotherapy, the JCOG researchers decided to embark on a phase III trial to explore neoadjuvant chemotherapy among patients with clinically Stage III cancer. This review describes the development of the neoadjuvant strategy for gastric cancer in Japan, mainly by going through a series of clinical trials conducted by the JCOG.