In advanced gastroesophageal cancer, a common clinical practice for patients achieving a complete response on immunotherapy is to stop treatment after two years. For those with residual disease confirmed by biopsy, clinicians advocate for extending therapy beyond this point, contingent on payer approval.
Experts indicate that Tumor Mutational Burden (TMB) is losing relevance for guiding immunotherapy in GI cancers. The TMB cutoff of 10 is not considered reliable across tumor types, and clinicians still prefer combination chemo-immunotherapy even in TMB-high patients, unless MMR deficiency is also present.
Experts favor a Nivolumab plus Ipilimumab (NIVO+EP) combination for newly diagnosed, MSI-high, stage IV gastroesophageal cancer patients who can tolerate it. This approach avoids chemotherapy and yields high, sustained response rates, including potential for complete pathologic responses in metastatic settings.
As patients with metastatic gastroesophageal cancer live longer, managing long-term toxicity like neuropathy is crucial. Experts recommend stopping oxaliplatin after just 6-8 cycles. By month six, if disease is controlled, some even stop 5-FU, continuing only with the biologic agent to improve quality of life.