***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: The following treatments show promise but are as yet to be established as st and ard . They should be prospect ively evaluated in appropriate clinical research setting s. Patient consent for investigational treatments should be sought and the rationale behind them given ( Refer to the Sect . 6 ‘ ‘ Commentary on investigational treatments ’ ’ for details ) . The following constitute investigational treatments : – Endoscopic submucosal dissection under exp and ed criteria – Laparoscopic gastrectomy – Local tumor resection – Neoadjuvant chemotherapy – Adjuvant chemotherapy using agents other than S-1 – Neoadjuvant chemoradiotherapy – Adjuvant chemoradiotherapy – Debulking surgery BACKGROUND D2 gastrectomy is recommended in US and European guidelines , and is preferred in east Asia , for patients with resectable gastric cancer .  Adjuvant chemotherapy improves patient outcomes after surgery , but the benefits after a D2 resection have not been extensively investigated in large-scale trials . We investigated the effect on disease-free survival of adjuvant chemotherapy with capecitabine plus oxaliplatin after D2 gastrectomy compared with D2 gastrectomy only in patients with stage II-IIIB gastric cancer . METHODS The capecitabine and oxaliplatin adjuvant study in stomach cancer ( CLASSIC ) study was an open-label , parallel-group , phase 3 , r and omised controlled trial undertaken in 37 centres in South Korea , China , and Taiwan . Patients with stage II-IIIB gastric cancer who had had curative D2 gastrectomy were r and omly assigned to receive adjuvant chemotherapy of eight 3-week cycles of oral capecitabine ( 1000 mg/m(2 ) twice daily on days 1 to 14 of each cycle ) plus intravenous oxaliplatin ( 130 mg/m(2 ) on day 1 of each cycle ) for 6 months or surgery only . Block r and omisation was done by a central interactive computerised system , stratified by country and disease stage . Patients , and investigators giving interventions , assessing outcomes , and analysing data were not masked . The primary endpoint was 3 year disease-free survival , analysed by intention to treat . This study reports a prespecified interim efficacy analysis , after which the trial was stopped after a recommendation by the data monitoring committee . The trial is registered at Clinical Trials.gov ( NCT00411229 ) . FINDINGS 1035 patients were r and omised ( 520 to receive chemotherapy and surgery , 515 surgery only ) . Median follow-up was 34·2 months ( 25·4 - 41·7 ) in the chemotherapy and surgery group and 34·3 months ( 25·6 - 41·9 ) in the surgery only group . 3 year disease-free survival was 74 % ( 95 % CI 69 - 79 ) in the chemotherapy and surgery group and 59 % ( 53 - 64 ) in the surgery only group ( hazard ratio 0·56 , 95 % CI 0·44 - 0·72 ; p<0·0001 ) . Grade 3 or 4 adverse events were reported in 279 of 496 patients ( 56 % ) in the chemotherapy and surgery group and in 30 of 478 patients ( 6 % ) in the surgery only group . The most common adverse events in the intervention group were nausea ( n=326 ) , neutropenia ( n=300 ) , and decreased appetite ( n=294 ) . INTERPRETATION Adjuvant capecitabine plus oxaliplatin treatment after curative D2 gastrectomy should be considered as a treatment option for patients with operable gastric cancer . FUNDING F Hoffmann-La Roche and Sanofi-Aventis Background Endoscopic resection has been limited to intestinal-type gastric cancer ( cT1a ) with a low risk of lymph node metastasis ( T1a ≤2 cm , without ulcers ) . This single-arm confirmatory trial evaluated the efficacy and safety of endoscopic submucosal dissection ( ESD ) for > 2 cm ulcer-negative and ≤3 cm ulcer-positive intestinal-type gastric cancer ( cT1a ) . Methods The eligibility criteria included endoscopically diagnosed cT1a , a single primary intestinal-type gastric adenocarcinoma , an ulcer-negative lesion of any size or a ≤3 cm ulcer-positive lesion , cN0M0 , and no prior treatment . If ESD result ed in noncurative resection , surgical resection was added . The primary endpoint was the 5-year overall survival ( OS ) ( planned sample size was 470 , with a one-sided alpha level of 2.5 % ) . The threshold 5-year OS was 86.1 % . Results We enrolled 470 early gastric cancer patients [ median tumor size , 25 ( 5–130 ) mm ] from 29 institutions between June 2007 and October 2010 . These patients had 152 ulcer-negative lesions ( > 2 and ≤3 cm ) , 111 ulcer-negative lesions ( > 3 cm ) , and 207 ulcer-positive lesions ( ≤3 cm ) .  The success rate for en block resection was 99.1 % ( 466/470 ) . Additional gastrectomy was conducted in 131 patients ( 28 % ) who did not fulfill the curative resection criteria . The 5-year OS of all patients was 97.0 % ( 95 % confidence interval , 95.0–98.2 % ) , which was higher than the threshold 5-year OS ( 86.1 % ) . The 317 patients who satisfied the curative resection criteria had no recurrence . There were no ESD-related grade 4 adverse events . Conclusion ESD for early gastric cancers that met the exp and ed criteria for intestinal-type gastric cancer ( cT1a ) was acceptable and should be the st and ard treatment instead of gastrectomy PURPOSE Surgical resection of gastric cancer has produced suboptimal survival despite multiple r and omized trials that used postoperative chemotherapy or more aggressive surgical procedures . We performed a r and omized phase III trial of postoperative radiochemotherapy in those at moderate risk of locoregional failure ( LRF ) following surgery . We originally reported results with 4-year median follow-up . This up date , with a more than 10-year median follow-up , presents data on failure patterns and second malignancies and explores selected subset analyses . PATIENTS AND METHODS In all , 559 patients with primaries ≥ T3 and /or node-positive gastric cancer were r and omly assigned to observation versus radiochemotherapy after R0 resection . Fluorouracil and leucovorin were administered before , during , and after radiotherapy . Radiotherapy was given to all LRF sites to a dose of 45 Gy . RESULTS Overall survival ( OS ) and relapse-free survival ( RFS ) data demonstrate continued strong benefit from postoperative radiochemotherapy . The hazard ratio ( HR ) for OS is 1.32 ( 95 % CI , 1.10 to 1.60 ; P = .0046 ) . The HR for RFS is 1.51 ( 95 % CI , 1.25 to 1.83 ; P < .001 ) . Adjuvant radiochemotherapy produced substantial reduction in both overall relapse and locoregional relapse . Second malignancies were observed in 21 patients with radiotherapy versus eight with observation ( P = .21 ) . Subset analyses show robust treatment benefit in most subsets , with the exception of patients with diffuse histology who exhibited minimal nonsignificant treatment effect . CONCLUSION Intergroup 0116 ( INT-0116 ) demonstrates strong persistent benefit from adjuvant radiochemotherapy . Toxicities , including second malignancies , appear acceptable , given the magnitude of RFS and OS improvement . LRF reduction may account for the majority of overall relapse reduction . Adjuvant radiochemotherapy remains a rational st and ard therapy for curatively resected gastric cancer with primaries T3 or greater and /or positive nodes BACKGROUND The quality of life ( QOL ) of patients who survive early gastric cancer ( EGC ) is an area of increasing interest . OBJECTIVE To compare the QOL and degree of worry of cancer recurrence in EGC patients who underwent endoscopic submucosal dissection ( ESD ) or surgery .  DESIGN Cross-sectional study . SETTING S A tertiary referral center . PATIENTS A total of 565 patients with EGC who received ESD or surgery .  INTERVENTION Question naires . MAIN OUTCOME MEASUREMENTS QOL was evaluated using the Short-form Health Survey and the European Organization for Research and Treatment of Cancer QOL question naires ( QLQ-C30 and EORTC-QLQ-STO22 ) . Mood disorders and the worry of cancer recurrence were estimated using the Hospital Anxiety and Depression Scale ( HADS ) and Worry of Cancer Scale , respectively . RESULTS Question naires were completed by 55.7 % of the ESD ( 137/246 ) and 58.9 % of the surgery ( 188/319 ) patients . The surgery group had more QOL-related symptomatic and functional problems , including fatigue ( P=.044 ) , nausea/vomiting ( P=.032 ) , appetite loss ( P=.023 ) , diarrhea ( P<.001 ) , pain ( P=.013 ) , reflux symptoms ( P=.005 ) , eating restrictions ( P<.001 ) , anxiety ( P=.015 ) , taste impairment ( P=.011 ) , and poor body image ( P<.001 ) . The ESD group had significantly higher worry of cancer recurrence scores after adjusting for covariates , especially when visiting their physicians . The HADS results did not differ between the groups . LIMITATIONS Cross-sectional design . CONCLUSIONS Endoscopic treatment for EGC provides a better QOL , but stomach preservation might provoke cancer recurrence worries . Endoscopists should address this issue for relieving a patient 's concern of cancer recurrence during follow-up period after ESD . ( CLINICAL TRIAL REGISTRATION NUMBER WHO ICTRP KCT0000791 . ) BACKGROUND AND AIMS Although endoscopic submucosal dissection ( ESD ) for exp and ed-indication lesions of differentiated-type early gastric cancer ( EGC ) has been widely accepted , no prospect i ve r and omized study has been conducted on this subject . This study aim ed to evaluate the long-term outcomes of ESD and surgery for exp and ed-indication lesions of differentiated-type EGC . METHODS Between 1997 and 2012 , 1500 consecutive patients with EGC were treated in Osaka City University Hospital . Using propensity score matching and inverse probability of treatment weighting ( IPTW ) , we retrospectively evaluated the long-term outcomes , risk factors for mortality , and adverse events for patients with exp and ed-indication lesions of differentiated-type EGC who underwent ESD or surgical treatments .  RESULTS A total of 308 patients with exp and ed-indication lesions of differentiated-type EGC confirmed by pathologic examination after ESD or surgery met the eligibility criteria . After matching , the 5-year overall survival rate was higher in the ESD group than in the surgery group ( 97.1 % vs 85.8 % ; P = .01 ) . We also found that surgery was significantly associated with mortality using both the IPTW method ( hazard ratio [ HR ] , 10.89 ; 95 % confidence interval [ CI ] , 1.37 - 86.6 ; P < .01 ) , and Cox analysis ( HR , 8.60 ; 95 % CI , 1.11 - 66.52 ; P = .04 ) after matching . Significantly fewer adverse events were associated with ESD than with surgery ( 6.8 % vs 28.4 % ; P < .01 ) . No cause-specific mortality was observed in either group . CONCLUSIONS Our results indicate that ESD might be an alternative treatment modality for exp and ed-indication lesions of differentiated-type EGC Background A multicentre r and omized study of surgical treatment of gastric cancer has shown increased mortality and morbidity rates in patients having D2 resection . The aim of this report is to analyse risk factors in these patients BACKGROUND & AIMS It is difficult to accurately diagnose patients with depressed gastric mucosal cancer based on conventional white-light imaging ( C-WLI ) endoscopy . We compared the real-time diagnostic yield of C-WLI for small , depressed gastric mucosal cancers with that of magnifying narrow-b and imaging ( M-NBI ) . METHODS We performed a multicenter , prospect i ve , r and omized , controlled trial of patients with undiagnosed depressed lesions ≤10 mm in diameter identified by esophagogastroduodenoscopy .  Patients were r and omly assigned to groups that were analyzed by C-WLI ( n = 176 ) or M-NBI ( n = 177 ) immediately after detection ; the C-WLI group received M-NBI after C-WLI . We compared the diagnostic accuracy , sensitivity , and specificity between C-WLI and M-NBI and assessed the diagnostic yield of M-NBI conducted in conjunction with C-WLI . RESULTS Overall , 40 gastric cancers (  
    Output:
    
Overall , exp and ing the indication for endoscopic resection to include mucosal nonulcerated differentiated lesions irrespective of size and differentiated mucosal ulcerated lesions <3 cm is justified with minimal increased risk in comparison to the absolute criteria .