Ep. 3: Balancing Therapy Intensity and Patient Tolerability in Gastric and GEJ Cancer
Key Points
-
Circulating tumor DNA (ctDNA) testing may identify high-risk patients but does not yet reliably guide perioperative therapy decisions.
-
Multidisciplinary tumor board review ensures optimal surgical planning and therapy sequencing.
-
Dose adjustments and patient-centered decisions are critical in balancing efficacy, toxicity, and patient goals.
Circulating Tumor DNA and Risk Stratification in Perioperative Therapy
Rahul Gosain, MD, MBA, of Wilmot Cancer Institute, and Rohit Gosain, MD, of Roswell Park Comprehensive Cancer Center, hosted a Clinical Insights session coinciding with the 2026 American Society of Clinical Oncology Gastrointestinal Cancers Symposium (ASCO GI 2026) to discuss ctDNA’s emerging role in perioperative gastric and gastroesophageal junction (GEJ) cancer management. Panelists included Angela Alistar, MD, of Atlantic Health; Steven Maron, MD, MSc, of Memorial Sloan Kettering Cancer Center; Reetu Mukherji, MD, of MedStar Health; and Raji Shameem, MD, of Orlando Health.
Despite growing interest, ctDNA provides clinical insight rather than directly guiding perioperative therapy. Patients with high-risk features or positive ctDNA may be prioritized for clinical trials, while standard perioperative chemotherapy and immunotherapy remain the backbone of treatment. Panelists emphasized the importance of balancing the intensity of adjuvant therapy with patient recovery and tolerability, particularly when considering under- versus overtreatment.
Multidisciplinary Planning and Personalized Therapy
A multidisciplinary tumor board is central to planning therapy, sequencing, and surgery for locally advanced disease. Imaging, diagnostic laparoscopy, and biomarker testing are reviewed in detail to assess resectability and guide perioperative decisions.
Therapy intensity is tailored to the patient’s functional status and goals. Full fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) dosing with durvalumab is preferred when tolerated, while dose reductions or omission of select chemotherapy agents may be considered for patients who are frail or have significant comorbidities. In certain cases, immunotherapy alone may be continued postoperatively if patients cannot tolerate full chemotherapy. Early recognition and management of adverse effects, including nausea, diarrhea, and immunotherapy-related organ inflammation, are crucial to maintain therapy and prevent complications.