Post-op pile-on.

Recently reported outcomes with peri-operative FLOT chemotherapy for esophagogastric junction (EGJ) and gastric adenocarcinomas, while promising, highlighted the truly systemic nature of the beast. Now an NCDB analysis out yesterday reports on >10K similar patients receiving pre-operative chemoradiation with or without additional post-operative chemo. With the caveats of a non-randomized non-prospective cohort, analysis with propensity score-matching showed an overall survival advantage with post-op chemotherapy of 34 -> 40 months. We know, we know...another huge NCDB analysis destined to find a difference somewhere. But, interestingly, the two cohorts differed drastically in pathologic (post-neoadjuvant therapy) burden of disease with a ypN+ rate of 72% among the post-op chemo group versus only 39% among those who were observed. At the least, this is something to think about if referred a ypN+ patient treated à la Stahl (you remember, the trial that was dismayingly underpowered and drastically undervalued). At the most, this calls for a systematic re-evaluation via prospective clinical trial of a whole new treatment algorithm. And, while we're at it, this time let’s accrue.