The American Society for Radiation Oncology (ASTRO) recently released a set of recommendations in its 2025 clinical practice guideline, Radiation Therapy for Gastric Cancer. To facilitate the creation of the guideline, ASTRO assembled a multidisciplinary task force of medical, surgical, and radiation oncologists, a radiation oncology resident, a medical physicist, and a patient representative. The American Society of Clinical Oncology, the European Society for Radiotherapy and Oncology, and the Society of Surgical Oncology provided peer reviewers and representatives to collaborate with ASTRO on the development of this guideline.
Today, we spotlight the key recommendations made in the 2025 ASTRO guideline, Radiation Therapy for Gastric Cancer. The following are recommendations that ASTRO marked as the strongest recommendations in the guideline. View the full-text version to view the complete guideline, along with the additional conditional recommendations.
Key Recommendations:
Perioperative Chemotherapy:
- For patients with cT2-4 and/or N+ resectable gastric cancer, perioperative chemotherapy is recommended.
- For patients with cT2-4 and/or N+ resectable gastric cancer receiving perioperative chemotherapy, FLOT (5-FU, leucovorin, oxaliplatin and docetaxel) is recommended over ECF or ECX (epirubicin, cisplatin and 5-FU or capecitabine).
Preoperative Chemoradiation:
- For patients with cT2-4 and/or N+ resectable gastric cancer who are not candidates for perioperative chemotherapy with FLOT, ECF, or ECX, preoperative chemoradiation with concurrent 5-FU or capecitabine is recommended.
Postoperative Chemotherapy:
- For patients with pT1N2-3, pT2N+, and/or pT3-4 any N stage disease following R0 resection and D2 lymphadenectomy, postoperative chemotherapy alone is recommended.
- Implementation remark: Preferred regimens include fluoropyrimidine-based therapies (eg, 5-FU, capecitabine, or S1) with a platinum agent (eg, oxaliplatin).
Nonmetastatic, Initial Diagnosis, Curative Intent:
- For patients with nonmetastatic gastric cancer who are not candidates for surgery or decline surgery, chemoradiation with or without induction and/or consolidation systemic therapy, is recommended.
Symptomatic, Noncurative Intent:
- For patients with gastric cancer-associated bleeding and/or pain from the primary tumor, palliative RT is recommended.
Nonmetastatic, Resectable/Resected, Initial Diagnosis, Curative Intent:
- For patients with nonmetastatic gastric cancer receiving preoperative or postoperative chemoradiation (with concurrent 5-FU or capecitabine), 4500 cGy in 25 fractions is recommended.
- For patients with nonmetastatic gastric cancer receiving preoperative chemoradiation, coverage of the entire stomach and perigastric extension and regional lymph nodes is recommended.
- For patients with nonmetastatic gastric cancer receiving postoperative chemoradiation, inclusion of the tumor bed, anastomoses, and regional nodes is recommended.
- For patients with nonmetastatic gastric cancer receiving preoperative or postoperative chemoradiation, IMRT (including VMAT) or 3-D CRT is recommended.
Symptomatic, Palliative Intent:
- For patients with gastric cancer receiving palliative RT for symptoms related to the primary tumor, regimens of 1-10 fractions with a BED range of 1440-3900 cGy10 (eg, 800 cGy in 1 fraction, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions) are recommended.
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