The first 60 days: PD-L1-high gastric cancer
PD-L1-high gastric cancer expresses the immune checkpoint protein PD-L1 on tumour and immune cells, and this is the group in which nivolumab or pembrolizumab added to chemotherapy clearly extends life. The benefit shrinks as the score falls, so regulators now restrict the antibodies to tumours with at least some PD-L1 expression. Below, week by week, is what OnCo's record of PD-L1-high gastric cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Advanced, first line, CPS 1 to 4.
- Medical oncologistNamed in the standard of care for: Advanced, first line, CPS 5 or above, Advanced, first line, CPS 1 to 4, Resectable stage II to III, Second line.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Perioperative FLOT with durvalumab (MATTERHORN), given irrespective of PD-L1 score.
Nivolumab with FOLFOX or CAPOX (CheckMate 649) or pembrolizumab with platinum-fluoropyrimidine chemotherapy (KEYNOTE-859).
PD-1 antibody with chemotherapy is permitted in the United States and offered with a smaller expected gain; chemotherapy alone or zolbetuximab where claudin 18.2 is positive.
Ramucirumab with paclitaxel (RAINBOW); no established role for continued PD-1 blockade.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example PD-L1 combined positive score, Epstein-Barr virus in situ hybridisation, Microsatellite instability and mismatch repair, HER2, Claudin 18.2), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include PD-L1 CPS 10 or above, PD-L1 CPS 5 or above, PD-L1 CPS 1 to 4.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Advanced, first line, CPS 5 or above
- For my situation (advanced, first line, cps 5 or above), which of the standard options do you recommend and why?Guideline options include: Nivolumab with FOLFOX or CAPOX (CheckMate 649) or pembrolizumab with platinum-fluoropyrimidine chemotherapy (KEYNOTE-859).
- Am I a candidate for Nivolumab, Pembrolizumab, FOLFOX (5-FU, leucovorin, oxaliplatin) or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CheckMate 649 and KEYNOTE-859 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Advanced, first line, CPS 1 to 4
- For my situation (advanced, first line, cps 1 to 4), which of the standard options do you recommend and why?Guideline options include: PD-1 antibody with chemotherapy is permitted in the United States and offered with a smaller expected gain; chemotherapy alone or zolbetuximab where claudin 18.2 is positive.
- Am I a candidate for Nivolumab, Pembrolizumab, Zolbetuximab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Resectable stage II to III
- For my situation (resectable stage ii to iii), which of the standard options do you recommend and why?Guideline options include: Perioperative FLOT with durvalumab (MATTERHORN), given irrespective of PD-L1 score.
- Am I a candidate for Durvalumab, FLOT (5-FU, leucovorin, oxaliplatin, docetaxel), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of MATTERHORN apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Second line
- For my situation (second line), which of the standard options do you recommend and why?Guideline options include: Ramucirumab with paclitaxel (RAINBOW); no established role for continued PD-1 blockade.
- Am I a candidate for Ramucirumab, Paclitaxel / nab-paclitaxel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of RAINBOW apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Any stage
- Are there clinical trials I could join, for example of MATTERHORN, Tislelizumab, Biomarker-directed first-line quadruplets in gastric cancer, Gotistobart?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Two assays with different thresholds leave patients near the cut-off in an uncertain position”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Most patients still progress within a year on chemo-immunotherapy”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- PD-L1-high gastric cancer: the full pagePD-L1-high gastric cancer expresses the immune checkpoint protein PD-L1 on tumour and immune cells, and this is the group in which nivolumab or pembrolizumab added to chemotherapy clearly extends life. The benefit shrinks as the score falls, so regulators now restrict the antibodies to tumours with at least some PD-L1 expression.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Combined positive score (CPS): A PD-L1 score that counts stained tumour cells and immune cells together.
Every term links to the glossary.