The evolving landscape of treatment for advanced gastric cancer and the role of anti-angiogenic therapy: implications from results of the INTEGRATE study
Gastric cancer (GC) is the fifth most common malignancy worldwide. Nearly 2/3 of all cases are in developing countries in Eastern Europe, South America, and Asia, 42% of all new cases are in China (1). Empiric chemotherapy has been the mainstay of treatment for patients presenting with advanced/metastatic disease, to help reduce symptoms and prolong survival. In the first line setting a fluoropyrimidine backbone is utilized (5-FU, capecitabine, S1), in combination with a platinum agent (cisplatin, oxaliplatin) or a taxane (2). Therapy has evolved in a stepwise fashion, with incremental gains with each additional agent to this backbone, with doublet then triplet chemotherapy leading to improvements in median overall survival (OS), but at the expense of greater toxicity. Randomised controlled trials have further confirmed the benefit of chemotherapy in the second line setting with paclitaxel, docetaxel and irinotecan (3,4). The next key evolution of therapy has been the addition of a biologic agent to chemotherapy and the use anti-angiogenic therapy in refractory disease.