Great Debate: Should Surgery Be Omitted in the Management of Gastroesophageal Junction Cancers?

BACKGROUND

Perioperative therapies for gastric and gastroesophageal junction (GEJ) adenocarcinoma have improved significantly in recent years, especially for mismatch-repair deficient (dMMR/MSI-H) tumors. Pathologic complete response (pCR) rates are now established which has raised the question as to whether surgery can be omitted.

METHODS

This article summarizes the debate between two gastric cancer experts supporting each side of the argument on the possibility of omitting surgery.

RESULTS

Total, proximal, and esophagogastrectomy remain highly morbid procedures that still carry significant risk of mortality, particularly in older patients and at low-volume centers. Patients with dMMR/MSI-H gastric and GEJ adenocarcinoma have a pCR rate to neoadjuvant immunotherapy of 60% and those with mismatch repair intact (MMR-intact) tumors experience pCR to neoadjuvant chemo-immunotherapy with a rate of approximately 20%. The ability to assess for clinical complete response in gastric and GEJ adenocarcinoma has limitations, however, and there is a lack of long-term data to support omission of surgery.

CONCLUSION

pCR rates are established and durable in gastric and GEJ adenocarcinoma. Omission of surgery is a consideration in patients with dMMR/MSI-H tumors with cCR to immunotherapy. Surgery remains the standard-of-care for patients with MMR-intact tumors but patients should be counseled about the possibility of pCR in shared decision making.