. 2022 Jan 31;7(1):100362. doi: 10.1016/j.esmoop.2021.100362

Table 3.

Treatment protocols and ESMO CPGs^a for gastric cancer

Kazakh treatment regimens	Expert review
Docetaxel + cisplatin + 5-FU	No clear advantage
Cisplatin + 5-FU	Important option
Epirubicin + cisplatin + 5-FU	Epirubicin probably not needed
Epirubicin + oxaliplatin + 5-FU	Epirubicin probably not needed
Epirubicin/cisplatin/capecitabine	Epirubicin probably not needed
Etoposide + calcium folinate + 5-FU	Not needed
Irinotecan + cisplatin	Second line option
5-FU+ doxorubicin + cisplatin	Not needed
Docetaxel + cisplatin	Not in common use
Trastuzumab + capecitabine + cisplatin	First line option if HER2 overexpressed
5-FU	Single agent has minimal activity
Monotherapy protocols (5-FU, docetaxel)	Second-line therapy

ESMO Clinical Practice Guidelines
First-line treatment 1. Doublet or triplet platinum/fluoropyrimidine combinations are recommended for fit patients with advanced gastric cancer [I, A]. Triplets containing taxanes are also an evidence-based treatment choice for first-line chemotherapy. 2. Patients with inoperable locally advanced and/or metastatic (stage IV) disease should be considered for systemic treatment (chemotherapy), which has shown improved survival and quality of life compared with best supportive care alone [I, A]. However, comorbidities, organ function and PS must always be taken into consideration [II, B]. 3. Capecitabine is associated with improved OS compared with infused 5-FU within doublet and triplet regimens [I, A]. DCF in a 3-weekly regimen was associated with improved OS, but also added significant toxic effects, including increased rates of febrile neutropaenia [I, C]. 4. As an alternative to platinum-based therapy, irinotecan plus leucovorin and infusional 5-FU (FOLFIRI) has been studied in both phase II trials and one phase III randomised trial in the first-line setting and may be considered for selected patients. Elderly patients with gastric cancer 5. Regimens that have been specifically addressed in phase II trials in elderly patients with comparable survival results include capecitabine and oxaliplatin, FOLFOX (leucovorin, 5-FU and oxaliplatin), single-agent capecitabine and S1 (in Asian patients) [III, B]. 6. The FLOT regimen (5-FU, leucovorin, oxaliplatin and docetaxel) is associated with a trend towards improved PFS and increased toxicity [II, B]. Second- andfurther-linetreatment 7. Second-line chemotherapy with a taxane (docetaxel, paclitaxel), or irinotecan, or ramucirumab as a single agent or in combination with paclitaxel is recommended for patients who are of PS 0-1 [I, A]. 8. Similar efficacy has been demonstrated for weekly paclitaxel and irinotecan [I, A]. 9. In patients with disease progression >3 months following first-line chemotherapy, it may be appropriate to consider a re-challenge with the same drug combination [IV, C]. 10. In patients with symptomatic locally advanced or recurrent disease, hypo-fractionated RT is an effective and well-tolerated treatment modality that may palliate bleeding, obstructive symptoms or pain [III, B].

ESMO Clinical Practice Guidelines

First-line treatment

1.
Doublet or triplet platinum/fluoropyrimidine combinations are recommended for fit patients with advanced gastric cancer [I, A]. Triplets containing taxanes are also an evidence-based treatment choice for first-line chemotherapy.
2.
Patients with inoperable locally advanced and/or metastatic (stage IV) disease should be considered for systemic treatment (chemotherapy), which has shown improved survival and quality of life compared with best supportive care alone [I, A]. However, comorbidities, organ function and PS must always be taken into consideration [II, B].
3.
Capecitabine is associated with improved OS compared with infused 5-FU within doublet and triplet regimens [I, A].
DCF in a 3-weekly regimen was associated with improved OS, but also added significant toxic effects, including increased rates of febrile neutropaenia [I, C].
4.
As an alternative to platinum-based therapy, irinotecan plus leucovorin and infusional 5-FU (FOLFIRI) has been studied in both phase II trials and one phase III randomised trial in the first-line setting and may be considered for selected patients.

Elderly patients with gastric cancer

5.
Regimens that have been specifically addressed in phase II trials in elderly patients with comparable survival results include capecitabine and oxaliplatin, FOLFOX (leucovorin, 5-FU and oxaliplatin), single-agent capecitabine and S1 (in Asian patients) [III, B].
6.
The FLOT regimen (5-FU, leucovorin, oxaliplatin and docetaxel) is associated with a trend towards improved PFS and increased toxicity [II, B].

Second- andfurther-linetreatment

7.
Second-line chemotherapy with a taxane (docetaxel, paclitaxel), or irinotecan, or ramucirumab as a single agent or in combination with paclitaxel is recommended for patients who are of PS 0-1 [I, A].
8.
Similar efficacy has been demonstrated for weekly paclitaxel and irinotecan [I, A].
9.
In patients with disease progression >3 months following first-line chemotherapy, it may be appropriate to consider a re-challenge with the same drug combination [IV, C].
10.
In patients with symptomatic locally advanced or recurrent disease, hypo-fractionated RT is an effective and well-tolerated treatment modality that may palliate bleeding, obstructive symptoms or pain [III, B].

5-FU, 5-fluorouracil; CPGs, Clinical Practice Guidelines; DCF, docetaxel, cisplatin, 5-day infusion of 5-FU; HER2, human epidermal growth factor receptor 2; OS, overall survival; PFS, progression-free survival; PS, performance status; RT, radiotherapy; S1, S-1 is a novel oral fluoropyrimidine derivative, widely used for treating gastric, pancreatic, lung, head, neck and breast carcinomas. It is designed to enhance the clinical utility of an oral fluoropyrimidine and is associated with low gastrointestinal toxicity.

Data 2017.