Rethinking the timing of adjuvant chemotherapy in advanced gastric cancer: From feasibility to precision sequencing

Figure 1 The precision timing framework for adjuvant chemotherapy in gastric cancer. This conceptual framework integrates three core pillars to guide individualized timing of adjuvant chemotherapy: (1) Tumor biology: Molecular subtyping (e.g., microsatellite instability, Epstein-Barr virus, and chromosomal instability) and detection of postoperative circulating tumor DNA (ctDNA) define the risk of recurrence and potential therapeutic sensitivity; (2) Patient recovery: Objective metrics from Enhanced Recovery After Surgery protocols, including functional recovery (QoR-15) and nutritional status, determine patient readiness for early chemotherapy; and (3) Dynamic monitoring: Real-time assessment of ctDNA clearance and immune status allows for adaptive treatment decisions, including dose adjustment or treatment de-escalation. The intersection of these pillars enables a shift from a fixed-timing paradigm to a biologically informed, personalized treatment sequence. MSI: Microsatellite instability; EBV: Epstein-Barr virus; CIN: Chromosomal instability; ctDNA: Circulating tumor DNA; ERAS: Enhanced Recovery After Surgery; AC: Adjuvant chemotherapy.