Optimizing Therapies in the Perioperative Management of Gastric Cancer.

OPINION STATEMENT: Gastric cancer is a major health burden worldwide. Only about one-third of all the gastric cancer patients survive beyond 5-years. Management of this deadly disease has evolved over the last few decades due to the incorporation of better staging techniques, surgical approach, effective systemic treatment, and sequencing of different therapeutic modalities. There are some global differences in how local-regional gastric cancer is managed and treated. In the USA and some parts of Europe, perioperative chemotherapy is a preferred management approach. Adjuvant chemoradiation is considered if the surgical resection is performed upfront. However, in Asia, postoperative chemotherapy alone after D2 surgical resection is considered standard of care treatment. Based on recent evidence, perioperative treatment with triplet chemotherapy regimen FLOT (5FU, leucovorin, oxaliplatin, docetaxel) is the preferred regimen. However, doublet fluoropyrimidine/platinum combination is a reasonable alternative if triplet regimen cannot be given. At present, there are no approved targeted or immunotherapy agents in perioperative setting; however, there are a number of ongoing trials designed to examine the efficacy of targeted therapy and checkpoint inhibitors in various combinations with systemic therapy in perioperative setting.