Surgical resection remains the key component in the current treatment of gastric carcinoma; however, it is clear that improved outcome for patients even with apparently localized disease will depend not on more radical surgical extirpation (46,47) but on a coordinated, multidisciplinary effort engaging clinicians in surgical, medical, and radiation oncology, basic scientists, and medical statisticians.

At the present time, patients referred to the University of Southern California's Kenneth Norris Jr. Comprehensive Cancer Center with localized, resectable gastric cancer referred prior to surgical resection are offered the adjuvant chemoradiation program of postoperative 5-FU, leucovorin, and radiation that was shown effective in the United States Intergroup Trial (43,44) or the combined preoperative and postoperative regimen of epirubicin, cisplatin, and infusional 5-FU described in the British MAGIC trial (62). Patients referred after curative surgical resection are offered the postoperative chemoradiation regimen.

Further improvements in outcome await the results of various clinical trials now underway to test the safety and potential antitumor efficacy of new agents or, more likely, new combinations of agents and modalities in the optimal temporal relationship to the core surgical operation. Customizing chemotherapy based on the analysis of intratumoral molecular markers that correlate with drug efficacy needs to be pursued not only to identify the most appropriate therapy but also to avoid the toxicity of agents destined to be ineffective.

The new concept of targeted therapy, such as inhibition of tumor angiogenesis, is exciting based both on ...