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Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. These activites are not approved for AMA PRA Category 1 Credit

Acknowledgment of Commercial Support

This activity is supported by an educational grant from Lilly.

For further information concerning Lilly grant funding, visit www.lillygrantoffice.com.

Community Practice Connections™: Oncology Best Practice™ Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and Gastroesophageal Junction Cancer Treatment PER Pulse™ Recap

PER Pulse Recap

PER Pulse™ Recap


1 of 3
PER Pulse™ Recap

The live continuing medical education activity, Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment, comprised a series of programs in which national gastric cancer experts synthesized data sets on newly available and late-stage investigational strategies for the management of advanced gastric cancers to assist community practitioners in optimizing outcomes for their patients. Two of the renowned faculty members, Manish A. Shah, MD, and Tanios Bekaii-Saab, MD, FACP, were interviewed, and their insights into best practices for the care of patients with gastric or gastroesophageal junction (GEJ) cancers were provided in short video clips. This first of 3 PER Pulse™ Recaps reviews the diagnosis and treatment planning of patients with gastric cancer.

Below are some highlights from the interview with Dr Shah:

  • There are 4 molecular gastric cancer subtypes: Epstein-Barr virus (EBV)-positive tumors, microsatellite instable (MSI) tumors, genomically stable (GS) tumors, and tumors with chromosomal instability (CIN). GS tumors tend to be enriched for diffuse gastric cancers, whereas the CIN and MSI subtypes tend to be intestinal tumors. Even more molecular gastric cancer subtypes are emerging, including the TP53 and epithelial–mesenchymal transition (EMT) subtypes. Dr Shah believes they do have clinical significance, but more research needs to be done to clarify this.
  • HER2 testing of gastric cancers and breast cancers have some distinct differences. For instance, rather than requiring that 10% of cells stain positive for HER2 to consider the tumor HER2-positive, as in breast cancer, only 5 cells per sample are required to be positive in gastric cancer. Also, gastric cancer does not require the luminal surface of the cells to stain for HER2, in contrast to breast cancer, which requires the entire circumference of the cell to express HER2. Therefore, different rules apply to these 2 cancers in order to determine which patients can be treated with trastuzumab.
  • Less than 10 years ago, treatment options were limited for patients with gastric and GEJ cancers and relatively few patients received any second- or third-line therapy. That changed with the approvals of trastuzumab in 2010 and ramucirumab in 2014. However, for HER2-negative disease, the standard first-line therapy remains platinum chemotherapy plus 5-fluorouracil (5-FU). Taxanes are typically reserved for the second-line setting to be used in combination with ramucirumab.
  • The biggest challenge in the community oncology setting is the fact that most oncologists see very few patients with gastric cancer. The goal is for patients to receive standard first-line therapy with a platinum and 5-FU, with the possibility of adding a taxane in certain select circumstances. For HER2-positive disease, trastuzumab should be added to the first-line regimen, but it should not be continued beyond progression.

For additional commentary about this topic and Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment activity, please visit www.gotoper.com.


2 of 3
PER Pulse™ Recap

The live continuing medical education activity, Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment, comprised a series of programs in which national gastric cancer experts synthesized data sets on newly available and late-stage investigational strategies for the management of advanced gastric cancers to assist community practitioners in optimizing outcomes for their patients. Two of the renowned faculty members, Manish A. Shah, MD, and Tanios Bekaii-Saab, MD, FACP, were interviewed, and their insights into best practices for the care of patients with gastric or gastroesophageal junction (GEJ) cancers were provided in short video clips. This second of 3 PER Pulse™ Recaps discusses the second-line management of patients with advanced gastric or GEJ cancer.

Below are some highlights from the interview with Dr Bekaii-Saab:

  • Several clinical factors are important when deciding which patients with gastric or GEJ cancer should receive second-line therapy. Generally, patients with a performance status of 3 or 4, those who progress quickly on first-line therapy (<6 months), and those with more than 2 involved organs are not good candidates for second-line therapy.
  • Several therapies are available for patients with gastric or GEJ cancers in the second line, including the single-agent chemotherapy options of irinotecan, paclitaxel, and docetaxel, and the targeted therapy option of ramucirumab, an angiogenesis inhibitor. However, the preferred second-line option is the combination of ramucirumab plus paclitaxel, which demonstrated a 2.2-month improvement in overall survival compared with paclitaxel alone in the RAINBOW trial.
  • Patients with HER2-positive disease will receive trastuzumab plus doublet chemotherapy in the first line, but Dr Bekaii-Saab advocates against continuing HER2-directed therapy in the second line, saying there is no strong evidence to support it. For patients who received doublet chemotherapy in the first line but who are not eligible to receive ramucirumab in the second line (in combination with paclitaxel), Dr Bekaii-Saab suggests that paclitaxel alone would be his next choice because he believes it is more active and easier to tolerate than the other single-agent chemotherapy options.
  • For patients who received an investigational drug in the second line (in combination with paclitaxel) and who can still tolerate third-line chemotherapy, Dr Bekaii-Saab reports that he would choose single-agent ramucirumab.

For additional commentary about this topic and Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment activity, please visit www.gotoper.com.


3 of 3
PER Pulse™ Recap

The live continuing medical education activity, Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment, comprised a series of programs in which national gastric cancer experts synthesized data sets on newly available and late-stage investigational strategies for the management of advanced gastric cancers to assist community practitioners in optimizing outcomes for their patients. Two of the renowned faculty members, Manish A. Shah, MD, and Tanios Bekaii-Saab, MD, FACP, were interviewed, and their insights into best practices for the care of patients with gastric or gastroesophageal junction (GEJ) cancers were provided in short video clips. This third of 3 PER Pulse™ Recaps describes the promise of investigational agents in the treatment of gastric and GEJ cancers.

Below are some highlights from these interviews:

  • Dr Shah mentioned that some recent late-stage gastric cancer trials have had negative results. For instance, results from 2 large-scale studies examining MET pathway inhibitors were negative. Although this was disappointing, it highlighted the fact that more attention needs to be given to removing some of the heterogeneity from the patient populations and more actively determining who might benefit from investigational targeted therapies.
  • Three ongoing clinical trials are examining investigational first-line regimens in gastric and GEJ cancers. The first phase III trial is studying ramucirumab, which is already approved for the second-line treatment of this disease, in combination with cisplatin and capecitabine. Another ongoing phase III trial is examining andecaliximab (GS-5745), an anti-MMP9 monoclonal antibody, combined with mFOLFOX6. Finally, an anti-claudin 18.2 monoclonal antibody called claudiximab (iMAB362) is being studied in a phase II trial as an addition to combination chemotherapy.
  • Napabucasin (BBI608), an inhibitor of cancer stemness, has been examined in the second-line setting with a taxane in the phase III BRIGHTER trial.

Immune checkpoint inhibitors are showing promise in gastric cancer as well. In a mostly Asian phase Ib trial of pembrolizumab (KEYNOTE-012), promising responses were observed and PD-L1 expression did not appear to predict responses. In the phase III ATTRACTION-2 study of nivolumab in gastric cancer, nivolumab demonstrated an overall survival benefit compared with placebo in the second-line setting. However, that study was conducted primarily in Asian patients, so it remains unknown whether these results will be replicated in Western patients. A phase I/II trial of US patients who received nivolumab ± ipilimumab has shown promising response rates of 14% to 26%. Dr Bekaii-Saab shared that he would look for a clinical trial of an immune checkpoint inhibitor for patients who are eligible for third-line treatment.

For additional commentary about this topic and Oncology Best Practice™: Optimizing Outcomes When Quality Is Being Measured: A Focus on Evidence-Based Care for Gastric and GEJ Cancer Treatment activity, please visit www.gotoper.com.

PER® Practice Pulse
Practice Pattern Questions
How often do you attend society oncology/hematology meetings? (ASCO, ASH, SABCS)
Practice Pattern Questions
What is the most significant barrier to implementing new information in your clinical practice?






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