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Immunotherapy has reshaped the treatment pattern of advanced gastric cancer and provided new ideas
for the perioperative treatment of early and middle gastric cancer.
In order to further promote the development of gastric cancer diagnosis and treatment, Yimaitong specially invited Professor Liang Han of Tianjin Medical University Cancer Hospital as an expert host, and joined hands with Professor Zhu Zhenggang of Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine and Professor Deng Ting of Tianjin Medical University Cancer Hospital to form an expert group to participate in the "Reach the World, Enjoy the Stomach" - Gastric Cancer Expert Roundtable Dialogue to discuss the hot topics
of gastric cancer immunotherapy.
In the era of immunization 1.
0, multidisciplinary experts joined hands with Professor Liang Han
The emergence of immunotherapy has broken the "ceiling" of chemotherapy efficacy of advanced gastric cancer and injected new vitality
into the treatment of early and intermediate gastric cancer.
Can you ask experts to talk about how the emergence of immunotherapy has changed clinical practice? Can you share some of your thoughts?
A number of clinical studies at home and abroad have confirmed the status and efficacy of immunotherapy in the comprehensive treatment of gastric cancer, which can bring significant survival benefits to patients, especially patients with clear targets, such as those with
high combined positive score (CPS).
From the surgeon's point of view, the combination of immunotherapy-based programs allows some patients who cannot be operated or cannot be radically resected to regain the opportunity of radical surgery, significantly improving the treatment efficacy
.
Personally, I believe that gastric cancer has entered the era of immunotherapy, and how to strengthen the cooperation between surgeons and physicians in internal medicine and other departments will be an important topic
for the development of comprehensive treatment of gastric cancer in the future.
The emergence of immunotherapy has broken the situation that only HER2 is used as a stratified index for gastric cancer, and provides CPS as a stratified index
for first-line treatment of advanced gastric cancer.
The treatment of gastric cancer is still in the era of immunity 1.
0, and more immune combination regimens, immunotherapy window forward, and perioperative immunotherapy strategies can be further explored in the future
.
"
Under the condition of ensuring radical cure, it is of great significance
to preserve the anatomical structure and physiological function of part of the stomach to improve the quality of life of gastric cancer patients after surgery.
With the development of drugs, can multidisciplinary cooperation achieve "both fish and bear's paw" and achieve the "win-win goal" of radical cure and functional preservation?
Striving to achieve radical tumor treatment and protection, and maintain the quality of life of patients is the main purpose of
surgery.
For patients with locally advanced or advanced gastric cancer, clinicians should focus on the above principles when formulating surgical treatment plans after neoadjuvant therapy or conversion therapy, and preserve the patient's stomach or other tissues and organs under the premise of ensuring radical tumor treatment to maintain the quality of life of
patients after surgery.
For the question of the scope of surgical resection after preoperative treatment, whether according to the scope of resection of lesions before treatment or according to the range of lesions after treatment, there is no unified conclusion in clinical practice, and more clinical studies are needed to further clarify
.
According to personal experience, in the absence of sufficient evidence-based medical evidence, if the main purpose is to radically cure the tumor, surgical resection
is still required in the original area of the lesion.
For some patients who require total gastrectomy due to a wide range of lesions, the quality of life and nutritional status
of patients can be improved to a certain extent by means of digestive tract reconstruction and postoperative nutritional support.
The immunotherapy window continues to move forward, providing more treatment options
for early-stage and advanced patients.
Can you please talk about the unsolved problems of perioperative immunotherapy for gastric cancer?
There are two clinical views
on whether patients who achieve complete clinical remission (cCR) with preoperative treatment receive surgery.
Since there is no guarantee that the tumor will not recur or progress after reaching cCR, some surgeons advocate surgical treatment
.
At the same time, overseas scholars have recently put forward another point of view - if the patient achieves cCR after preoperative treatment, a follow-up observation strategy
can be adopted.
Once the tumor has regrown, clinicians may use the original drug to control the tumor, and if the drug cannot control the tumor, surgery may be considered
.
In addition, the jury is still out on whether adjuvant chemotherapy is still
required for patients who have achieved complete pathologic remission (pCR) with surgery.
Since gastric cancer is a highly heterogeneous tumor, more thorough and individualized treatment measures should be adopted in clinical practice
.
Therefore, the above issues still require clinical studies to provide more adequate clinical evidence to advance clinical practice
.
In the perioperative stage of gastric cancer, the problem of population selection for immunotherapy needs to be solved
urgently.
In clinical practice, HER2 positivity, PD-L1 CPS≥5 or dMMR are biomarkers of gastric cancer immunotherapy, and whether immunotherapy can be used in conventional people without the above characteristics remains to be explored
.
In addition, the best combination of immunization schemes, combination methods, treatment cycles and other aspects also need to be further explored
by researchers.
Comprehensive treatment is the "basic principle" of gastric cancer diagnosis and treatment, what are the differences in the goals and strategies of comprehensive treatment for patients with different disease stages? How to rationally use a variety of treatment methods to "maximize" the benefits of patients?
Professor Deng TingIf the hospital has sufficient capacity, it should adopt a multidisciplinary collaboration model (MDT), and based on the patient's imaging and pathological data, medical and surgical physicians should jointly formulate a comprehensive and holistic treatment plan
for patients with gastric cancer who are newly treated.
However, due to the large patient base of gastric cancer in China, and most of the patients are in the advanced stage at the time of initial diagnosis, clinicians may select patients with more complex conditions for MDT
.
In the process of MDT, not only the collaboration of physicians and surgeons, but also nutritionists and psychologists is required to provide multi-faceted support
to patients.
MDT treatment for gastric cancer can be divided into three levels, namely early, locally advanced and advanced gastric cancer
.
The treatment of early gastric cancer is still mainly surgery, and for some patients, it can be appropriately combined with adjuvant therapy to enable patients to achieve long-term survival
.
For locally advanced gastric cancer, more and more studies have proved that preoperative neoadjuvant therapy can reduce the recurrence rate of patients after surgery, increase the rate of radical surgical resection, and further improve the survival of
patients.
Clinicians should develop an individualized perioperative treatment plan
based on the patient's condition.
Patients with advanced gastric cancer have more complicated conditions (such as peritoneal metastasis) and lack effective treatment
.
For patients with locally distant metastases or oligometastases, clinicians still expect to create opportunities for surgical radical treatment through conversion therapy or perioperative therapy to further improve prognosis
.
Therefore, in clinical practice, patients who may achieve radical resection through conversion therapy should be selected according to the scope and degree of metastasis of the lesion, and given active treatment, while those with extensive metastasis and inoperable radical treatment can adopt comprehensive treatment strategies
.
The efficacy evaluation system is an important part of tumor treatment, in addition to judging the treatment effect to make decisions about subsequent treatment, it also plays an important role
in early detection of disease progression to adjust treatment plan.
What are the limitations of the current evaluation system for the efficacy of perioperative treatment of gastric cancer? Where can we go in the future?
In terms of imaging, the first problem is that there is an inconsistency
of about 40% between the preoperative imaging stage and the postoperative pathological stage.
In the RESOLVE study, the proportion of T4 and N+ patients included in the CapOx or SOX postoperative adjuvant therapy group was as high as 97%, but only 57% and 51% of patients had T4 in postoperative pathological staging, and N0 1 in 16% and 19% of patients
.
The RESOLVE study suggests that there is a problem
of over-staging in the current pre-academic staging of images.
Whether the accuracy can be improved by radiomics and other methods will need to be further considered
by researchers and clinicians in the future.
Second, the addition of immunotherapy also poses challenges
to imaging evaluation.
In practice, clinicians sometimes encounter imaging findings suggesting tumor cells remain despite immunotherapy, but surgical pathology suggests lymphocyte infiltration
.
How to distinguish between real tumor progression and retraction has become another puzzle
in the era of immunotherapy.
How to accurately judge the efficacy of advanced or advanced gastric cancer treatment, personal experience is based on four aspects: imaging, tumor serum markers, pathology and laparoscopic exploration
.
Among them, laparoscopic exploration is especially important
for patients with advanced or late stage gastric cancer.
If the patient requires preoperative neoadjuvant or conversion therapy, the surgeons at Ruijin Hospital will give the patient laparoscopic exploration to determine the peritoneal metastasis and then formulate a treatment plan
.
Multi-dimensional examination helps clinicians to collect and understand the patient's tumor extent, biological characteristics and disease severity as much as possible, so as to lay a good foundation
for judging the efficacy of treatment.
In recent years, there have been many successes in the field of gastric cancer treatment, immunotherapy has broken the inherent treatment model, and targeted therapy has also made breakthroughs
.
Could you please talk about the changes and development of the "general environment" of gastric cancer treatment in recent years based on your experience of participating in the CGCC conference?
The treatment of gastric cancer is constantly developing in the direction of precision and individualization, and markers such as HER2, CPS and dMMR have emerged one after another, providing a basis
for precise stratification of patients.
As a clinician, I hope to reduce the incidence of gastric cancer by establishing a good lifestyle, and with the help of the model of "early screening and early diagnosis", reduce the proportion of patients with advanced gastric cancer in China, achieve early radical treatment of gastric cancer, and help China's goal of "Healthy China 2030
".
The diagnosis and treatment level of major research or clinical centers of gastric cancer in China has become closer and closer to the international advanced level, but the diagnosis and treatment concepts and programs of gastric cancer in some grassroots hospitals still need to be improved and perfected
.
It is hoped that through the National Gastric Cancer Conference (CGCC) and other means, advanced treatment concepts and treatment plans with high-level evidence-based medical evidence will be promoted to grassroots hospitals, and the overall
level of gastric cancer diagnosis and treatment in China will be gradually improved.
The goal of stomach cancer in Healthy China 2030 is to increase the current 5-year survival rate by 15%.
Although this task is arduous, the "joining" of immunotherapy and the publication and tour of the Chinese Anti-Cancer Association (CACA) gastric cancer diagnosis and treatment guidelines have injected a "shot in the arm" to achieve the grand goal of "Healthy China 2030"
.
Expert profiles
Professor Liang Han
Director of Gastric Cancer Center, Cancer Hospital of Tianjin Medical University
Director of the Chinese Anti-Cancer Association
Chairman of the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association
Chairman-elect of the Cancer Surgery Professional Committee of the Chinese Medical Doctor Association
Vice Chairman of the Gastric Cancer Expert Committee of the Chinese Society of Clinical Oncology
Vice Chairman of the Gastrointestinal Stromal Tumor Professional Committee of the Chinese Anti-Cancer Association
Deputy leader of the Gastroenterology Group of the Accelerated Rehabilitation Surgery Committee of the Chinese Research Hospital Association
Deputy leader of the Gastroenterology Group of the Oncology Society of the Chinese Medical Association
Member of the Standing Committee of the Digestive Tract Oncology Committee of the Chinese Association of Research Hospitals
Member of the Standing Committee of the Robotics and Laparoscopic Surgery Committee of the Chinese Research Hospital Association
Member of the Standing Committee of the Integrative Medicine Professional Committee of the Chinese Anti-Cancer Association
Member of the Standing Committee of the Digestive Oncology Professional Committee of the Chinese Research Hospital Association
Member of the Standing Committee of the Executive Committee of the Tumor Driver Gene Analysis Alliance of the Chinese Society of Clinical Oncology
Member of the Standing Committee of the Health Science Popularization Branch of the China Association for the Promotion of International Exchanges in Healthcare
Member of the National Expert Committee for Standardized Diagnosis and Treatment of Tumors of the Ministry of Health
Member of the Executive Committee of the National Gastric Cancer Quality Control Expert Committee
Chairman of the Gastric Cancer Professional Committee of Tianjin Anti-Cancer Association
Executive Deputy Editor of Chinese Journal of Clinical Oncology
He has presided over more than 10 national, provincial and ministerial projects, and has won the second prize of National Science and Technology Progress Award; First Prize of Science and Technology Progress Award of Chinese Medical Association and Ministry of Education; The first prize of Hubei Province Science and Technology Progress Award, the third prize of Tianjin Science and Technology Progress Award; The third prize of the Chinese Anti-Cancer Association
published 8 monographs and more than 350 papers, including more than 100 SCI papers
Professor Zhu Zhenggang
Ph.
D.
, doctoral supervisor, discipline leader of gastric cancer professional group of Ruijin HospitalDean of Shanghai Jiao Tong University School of Medicine
President of Ruijin Hospital
Director of Surgery, Ruijin Hospital
Director of Shanghai Institute of Digestive Surgery
Member of the American College of Surgeons
Director of the International Society for the Study of Gastric Cancer
Director of Shanghai Key Laboratory of Gastric Tumors
Shanghai medical cross-century academic leader
Shanghai medical leading talent
Chairman of the National Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association
Member of the Gastroenterology Group of the Surgical Branch of the Chinese Medical Association
Vice President of Shanghai Medical Association and Chairman of the Surgical Society
Vice President of Shanghai Anti-Cancer Association and Chairman of Gastrointestinal Oncology Professional Committee
Chairman of the Gastric Cancer Professional Committee of Shanghai Center for Disease Control
Editor-in-chief, associate editor, executive editor, editorial board member and editorial board member of the following magazines:
"Chinese Journal of Practical Surgery", "Chinese Journal of Gastrointestinal Surgery", "Chinese Journal of General Surgery", "Surgical Theory and Practice", "Chinese Journal of Experimental Diagnostics", "World Journal of Infectious Diseases", "Foreign Medical Gastroenterology Disease Volume", etc
Professor Deng Ting
Cancer Hospital of Tianjin Medical University
Director of the Department of Gastroenterology and Deputy Chief Physician
Vice Chairman of the Youth Committee of the Clinical Research Committee of Oncology Drugs of the Chinese Anti-Cancer Association
Member of the Cancer Support Treatment Committee of the Chinese Anti-Cancer Association
Member of the Chemotherapy Professional Committee of the Chinese Anti-Cancer Association
Member of the CSCO Young Experts Committee
Member of the Youth Committee of the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association
Member of the Professional Committee of Colorectal Cancer Liver Metastasis of the Chinese Medical Doctor Association
Edit: Fish balls
Typesetting: Xiaoyuan
Execution: Koen
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