Neoadjuvant Chemotherapy versus Neoadjuvant Chemoradiotherapy for Locally Advanced Gastric Cancer

Abstract

Introduction: Perioperative chemotherapy is a standard for locally advanced gastric cancer. The addition of radiotherapy remains controversial. This review compares neoadjuvant chemotherapy alone versus neoadjuvant chemoradiotherapy followed by surgery.

Methods: A literature review identified randomized controlled trials and large cohort studies comparing the two strategies. Outcomes included pathologic complete response rate, R0 resection, overall survival, and postoperative complications.

Results: Six trials and ten cohorts were included. Chemoradiotherapy significantly increased pathologic complete response rates (fifteen to twenty percent versus five to ten percent) and improved local control. However, overall survival benefit was inconsistent, with no significant difference in most studies. R0 resection rates were similar or slightly higher with chemoradiotherapy. Postoperative complications and mortality did not differ significantly.

Discussion: The improved local control with radiotherapy may be more relevant for tumors with a high risk of local recurrence, such as diffuse histology or positive circumferential margin. However, most survival failures in gastric cancer are distant, so systemic therapy remains critical. The addition of radiotherapy may be delayed or omitted in many protocols without compromising survival. Patient selection based on response to initial chemotherapy is a promising strategy.

Conclusions: Neoadjuvant chemoradiotherapy improves pathologic response but not overall survival compared to chemotherapy alone in unselected gastric cancer. It may benefit patients with high local recurrence risk.