Evaluating Total Neoadjuvant Approaches: Balancing Treatment Intensity, Surgical Timing, and Patient Selection

In this segment, the panel examines the concept of total or extended neoadjuvant therapy for resectable gastric and gastroesophageal junction cancers. A community oncology perspective describes institutional experience giving most or all planned chemotherapy before surgery, often with structured prehabilitation and interim imaging after several cycles to confirm disease control and fitness for resection. The panel notes that patients can frequently tolerate six or more preoperative cycles without substantial delay to surgery, and that symptom improvement during treatment may support nutritional and functional recovery. A surgical perspective stresses that, although extended neoadjuvant approaches are increasingly used in selected patients who may struggle with postoperative therapy, the original perioperative FLOT data were generated with four preoperative and four postoperative cycles. The panel underscores that dedicated trials comparing total neoadjuvant therapy with traditional perioperative sequencing are lacking. Another surgical viewpoint highlights the need for individualized planning, careful restaging, and close collaboration to balance treatment intensity with operative risk and long term outcomes.