Combination Chemotherapy With or Without Bevacizumab in Treating Patients With Previously Untreated Stomach Cancer, Gastroesophageal Junction Cancer or Lower Oesophageal Cancer That Can Be Removed by Surgery (ST03)

• Safety [ Time Frame: at the end of phase II and phase III ] [ Designated as safety issue: Yes ]
• Efficacy [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Overall survival [ Time Frame: end of trial ] [ Designated as safety issue: No ]

• Safety
• Efficacy
• Overall survival

• Feasibility [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Treatment-related morbidity [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Response rates to pre-operative treatment [ Time Frame: at phase II review and at end of trial ] [ Designated as safety issue: No ]
• Surgical resection rates [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Disease-free survival [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Quality of life [ Time Frame: end of trial ] [ Designated as safety issue: No ]
• Cost-effectiveness [ Time Frame: end of trial ] [ Designated as safety issue: No ]

• Feasibility
• Treatment-related morbidity
• Response rates to pre-operative treatment
• Surgical resection rates
• Disease-free survival
• Quality of life
• Cost-effectiveness

RATIONALE: Drugs used in chemotherapy, such as epirubicin, cisplatin, and capecitabine, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as bevacizumab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. Bevacizumab may also stop the growth of tumor cells by blocking blood flow to the tumor. Giving combination chemotherapy together with bevacizumab may kill more tumor cells.

PURPOSE: This randomized phase II/III trial is studying the side effects and how well giving combination chemotherapy together with bevacizumab works compared with combination chemotherapy alone in treating patients with previously untreated stomach cancer, gastroesophageal junction cancer or lower oesophageal cancer that can be removed by surgery.

OBJECTIVES:

Primary

• Assess the safety and efficacy of neoadjuvant and adjuvant chemotherapy comprising epirubicin hydrochloride, cisplatin, and capecitabine with or without bevacizumab in patients with previously untreated, resectable gastric, gastroesophageal junction or lower oesophageal cancer.

OUTLINE: This is a multicenter, randomized, open-label, controlled study. Patients are randomized to 1 of 2 treatment arms.

• Arm I: Patients receive epirubicin hydrochloride IV and cisplatin IV over 4 hours on day 1 and capecitabine orally twice daily on days 1-21. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity.

Patients undergo surgery 5-6 weeks after completion of chemotherapy. Patients then receive 3 additional courses of chemotherapy beginning 6-10 weeks after surgery.

• Arm II: Patients receive bevacizumab IV over 30-90 minutes, epirubicin hydrochloride IV, and cisplatin IV over 4 hours on day 1 and capecitabine orally twice daily on days 1-21. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity.

Patients undergo surgery 5-8 weeks after completion of chemotherapy. Patients then receive 3 additional courses of chemotherapy and bevacizumab beginning 6-10 weeks after surgery. Patients then receive maintenance therapy comprising bevacizumab IV over 30-90 minutes on day 1. Maintenance therapy repeats every 21 days for up to 6 courses in the absence of disease progression or unacceptable toxicity.

Quality of life is assessed at baseline, during treatment, and during the follow-up period.

After completion of study treatment, patients are followed at 9, 18, and 27 weeks after the start of course 4, 1 year post surgery, every 6 months for 2 years, and then annually thereafter.

PROJECTED ACCRUAL: A total of 1,100 patients will be accrued for this study.

• Biological: bevacizumab
  7.5mg/kg IV Day 1 of each 21 cycle of chemotherapy (6 cycles) plus day 1 of each maintenance dose every 21 days for 6 doses.
• Drug: capecitabine
  dose banded as based on patient BSA. Oral dose given twice a day during each 21 day cycle of chemotherapy (6 cycles in total)
• Drug: cisplatin
  60mg/m2 IV day one of each 21 day cycle of chemotherapy (6 cycles in total)
• Drug: epirubicin hydrochloride
  50mg/m2 IV day one of each 21 day cycle of chemotherapy (6 cycles in total)
• Procedure: adjuvant therapy
  3 cycles of ECX chemotherapy post operatively
• Procedure: conventional surgery
  Surgery undertaken after 3 cycles of pre-operative chemotherapy. Followed by 3 cycles of chemotherapy.
• Procedure: neoadjuvant therapy
  3 cycles of pre-operative ECX chemotherapy.

• Experimental: ECX + Bevacizumab
  ECX + Bevacizumab
  Interventions:

  • Biological: bevacizumab
  • Drug: capecitabine
  • Drug: cisplatin
  • Drug: epirubicin hydrochloride
  • Procedure: adjuvant therapy
  • Procedure: conventional surgery
  • Procedure: neoadjuvant therapy
• Active Comparator: ECX
  ECX chemotherapy
  Interventions:

  • Drug: capecitabine
  • Drug: cisplatin
  • Drug: epirubicin hydrochloride
  • Procedure: adjuvant therapy
  • Procedure: conventional surgery
  • Procedure: neoadjuvant therapy

DISEASE CHARACTERISTICS:

• Histologically confirmed gastric or type I, II or III gastroesophageal junction adenocarcinoma or lower oesophageal

Gastric and Type III junctional tumours should be Stage Ib (T1 N1, T2a/b N0), II, III or stage IV (T4 N1 or N2) with no evidence of distant metastases (M0)

Lower oesophageal and Type I and II junctional tumours should be Stage II to Stage IVa (T1 N1, T2 N1, T3 N0-1, but not T2N0). T4 (N0 or N1) tumours are also eligible providing that they involve only the crura OR invade only the mediastinal pleura. Patients with nodal disease affecting the origin of the left gastric and splenic artery or coeliac axis (staged as M1a) are also eligible.

• Resectable disease
• Previously untreated disease

PATIENT CHARACTERISTICS:

• WHO performance status 0 or 1
• Absolute neutrophil count ≥ 1,500/mm^3
• Platelet count ≥ 100,000/mm^3
• Hemoglobin ≥ 9 g/dL (can be post transfusion)
• WBC ≥ 3,000/mm^3
• Glomerular filtration rate ≥ 60 mL/min
• Proteinuria ≤ 1 g by 24-hour urine collection
• Bilirubin ≤ 1.5 times upper limit of normal (ULN)
• ALT and AST ≤ 2.5 times ULN
• Alkaline phosphatase ≤ 3 times ULN (in the absence of liver metastases)
• INR ≤ 1.5
• PTT ≤ 1.5 times ULN
• FEV_1 ≥ 1.5 L
• Cardiac ejection fraction ≥ 50% by MUGA scan or echocardiogram
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective contraception
• Must be fit enough to receive protocol treatment
• No other malignancies within the past 5 years except for curatively treated basal cell carcinoma of the skin and/or in situ carcinoma of the cervix

• No prior or concurrent significant medical conditions, including any of the following:

  • Cerebrovascular disease (including transient ischemic attack and stroke) within the past year

  • Cardiovascular disease, including the following:

    • Myocardial infarction within the past year
    • Uncontrolled hypertension while receiving chronic medication
    • Unstable angina
    • New York Heart Association class II-IV congestive heart failure
    • Serious cardiac arrhythmia requiring medication
  • Major trauma within the past 28 days
  • Serious nonhealing wound, ulcer, or bone fracture
  • Evidence of bleeding diathesis or coagulopathy

  • Recent history of any active gastrointestinal inflammatory condition (e.g., peptic ulcer disease, diverticulitis, or inflammatory bowel disease)

    • If patients have a known diagnosis of any of the above, evidence of disease control is required by negative endoscopy within the past 28 days
• No severe tinnitus
• No lack of physical integrity of the upper gastrointestinal tract, malabsorption syndrome, or inability to take oral medication
• No known peripheral neuropathy ≥ 1 (absence of deep tendon reflexes as the sole neurological abnormality does not render the patient ineligible)
• No known dihydropyrimidine dehydrogenase deficiency

• No known allergy to any of the following:

  • Chinese hamster ovary cell proteins
  • Other recombinant human or humanized antibodies
  • Any excipients of bevacizumab formulation or platinum compounds
  • Any other components of the study drugs

Due to an increase in perforations associated with self-expandable metal stents in patients with colorectal cancer receiving bevacizumab, patients with an oesophageal or gastric stent (metal or biodegradable) in situ are ineligible for the study.

PRIOR CONCURRENT THERAPY:

• No prior anthracycline
• More than 28 days since prior major surgery or open biopsy
• More than 10 days since prior thrombolytic therapy
• No concurrent thrombolytic therapy
• No concurrent dipyridamole or allopurinol
• No concurrent capecitabine or sorivudine (or sorivudine analogues [e.g., brivudine])
• No chronic, daily high-dose acetylsalicylic acid (> 325 mg/day) or nonsteroidal anti-inflammatory drugs

• No chronic corticosteroids (≥ 10 mg/day methylprednisolone equivalent)

  • Inhaled steroids allowed
• No other concurrent cytotoxic agents
• No other concurrent investigational drugs
• No concurrent radiotherapy
• Low molecular weight heparin allowed