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.