STAGE 4 STOMACH CANCER: NOT A DEATH SENTENCE BUT AN OPPORTUNITY

In 2025, there will be 30,300 new cases of gastric (stomach) cancer and 10,780 deaths associated with this diagnosis. At the same time there will be 22,070 new esophageal cancers with 16,250 deaths. Clearly, upper gastrointestinal cancer, despite some advances, remains a lethal disease.

I was reminded of this as I reviewed a PET/CT from 11/13/25 that confirmed a 3-year complete remission for a 57-year-old woman with Stage 4 stomach cancer who I treated 3 years earlier using our EVA/PCD laboratory analysis to select drug therapy. Laparoscopic tissue analysis guided us to the treatment she needed and now almost 3 years to the day, she is alive and free of disease.

Despite the uniform use of FLOT (Fluorouracil (5FU), Leucovorin, Oxaliplatin, and Docetaxel) or FOLFOX (folinic acid (leucovorin), fluorouracil (5-FU), and oxaliplatin) at the time, the most active combination for this woman proved to be FOLFOXIRI (FOLFOX with irinotecan). Following FOLFOXIRI combined an immune therapy she achieved a complete remission followed by gastrectomy (partial or total removal of the stomach) with no evidence of residual disease. Here 3 years later I was very gratified to read the PET/CT report.

This suggested several cases we had managed.

One is a 48-year-old Vietnamese gentleman who presented in February 2014 with active gastrointestinal bleeding from a gastroesophageal adenocarcinoma. Laparoscopic staging established extensive intra-abdominal disease.

Tissue submitted to our laboratory revealed superior activity for 5FU plus platinum and paclitaxel consistent with the closely related FLOT regimen. But this was fully 2 years before German investigators published the FLOT study (Salah-Eddin Al-Baltran, Lancet 2016).

After only 2 drug therapy cycles, there was complete resolution of disease shown by his PET/CT scan. After 2 additional cycles, surgical resection revealed no evidence of residual disease. He is alive, well and free of disease now 11 years later.

More recently a 77-year-old man presented with gastrointestinal bleeding and anemia. He underwent laparoscopic staging however biopsy samples were insufficient for us to conduct our EVA/PCD analysis, and we were forced to use the standard FOLFOX plus nivolumab that achieved minimal response.

A gastrectomy in April of 2024 revealed gross residual disease. A portion of the stomach was submitted for EVA/PCD identified activity for the taxanes drug class. With post op Taxol-based treatment, he achieved PET/CT-complete remission that continues at 2 years.

Each of these patients presented with what is considered “incurable” disease. However, each of them proved potentially curable IF they received the right therapy.

More importantly none of them received the same treatment.

The problem with protocol therapies like FLOT plus Durvalumab, is that they only provide marginal improvements.

In the Matterhorn study (Janigian , NEJM 2025) the 2-year survival was improved from 70.4% to 75.7% while only 19.2% of patients achieved complete remission. Yet without complete remission, patients with residual disease will virtually all relapse and die of their disease. Are we accepting an 80% failure rate as the new standard of care?

The take home message: stomach cancer is not incurable. Indeed, it may be eminently curable with the right treatment.

It is time to stop giving patients the protocol that we doctors prefer and start giving them the protocol that works.

One of these patients needed FOLFOXIRI but would likely have been given FOLFOX or FLOT. The second received a taxane-based combination 2 years before it was being used, while the third patient required “salvage therapy” selected based on his surgical biopsy to achieve remission despite initial failure of “standard” care.

As seen from our 48-year-old patient, now 11 years since diagnosis, the right treatment for stomach (gastric) and gastroesophageal cancer can be curative.

The question: What treatment should you receive?

The answer: The one that is right for you.