Perioperative treatment of gastric cancer: FLOT or not

Introduction: Gastric cancer is one of the most common cases among oncological diseases especially in developing countries of Asia. The same picture nowadays can be observed in Uzbekistan. Despite of breakthrough developments in chemotherapy, gastric cancer is still one of the most leading causes of cancer deaths. Up to day accepted standard of perioperative treatment of patients with operable gastric cancer includes ECF, however survival is still very poor. The aim of this study was to compare docetaxel based triplet FLOT with anthracycline based triplet ECF. Methods: The study enrolled 294 patients with gastric cancer treated in department of Oncology of Tashkent Medical Academy between 2011-2013yy. Eligibility criteria consisted of : stage ≥cT2 and/or cN+ M0, no distant metastatic lesion, absence of severe comorbidities (renal failure, liver failure etc.), no previous chemotherapy. Patients were randomized into 2 arms: 1st arm - 197 patients who received 3 cycles of preoperative and 3 cycles of ECF after radical gastrectomy D2 (cycles repeated every 3 weeks). 2nd arm - 97 patients received 4 preoperative cycles and after surgery 4 postoperative cycles of FLOT regimen (cycle every 2 weeks). Baseline characteristics across 2 arms were similar with respect to age – median age constituted 61; cT3/T4 - 86%, cN+ 83%, disease stage and histological type of cancer. Results: Planned pre- and postoperative cycles in 1st group of ECF were completed in 85,7% and 30,9% correspondingly. However the same indexes in 2nd arm constituted: preoperative 4 cycles were completed in 88,6% and postoperative in 46,3% of cases. Median follow up was 44 months.156 patients died, of them 113 (57,3%) patients form ECF arm, and 43 (44,3%) from FLOT arm. FLOT also improved OS rate 32 months with ECF and 48 months with FLOT (HR 0,72 [CI 0,57-0,89]; p=0.010). 3 year overall survival rate was 43% with ECF and 56% with FLOT. In addition to that FLOT also improved PFS: median PFS made up with ECF 16 months versus 28 months with FLOT, HR 0.72 [0.59 - 0.88]; p = 0.004). However complications rate was slightly higher in group of patients who received FLOT especially diarrhea 2-3 grade, nevertheless these complications were did not impact on the course of chemotherapy and were immediately eliminated. Conclusion: Nevertheless of breakthroughs in targeted and immune therapy, the issue of preoperative and postoperative chemotherapy of gastric cancer is still very important in developing countries, as the choices of immune therapy are very limited due to high financial toxicity in these states. FLOT showed improved outcomes in patients with resectable tumors of stomach in comparison with ECF. The promising results of FLOT let us step forward in fighting gastric cancer.

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