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

Figure 2 Proposed roadmap for future research on precision timing in gastric cancer. This schematic outlines the key steps and priorities required to transition from feasibility studies to clinical implementation. The roadmap is divided into three phases: (1) Discovery & validation: Focuses on mechanistic studies to define the optimal biological window, identification and validation of robust biomarkers [e.g., circulating tumor DNA (ctDNA) and immune profiles], and the establishment of standardized Enhanced Recovery After Surgery protocols; (2) Clinical development: Encompasses prospective, biomarker-enriched randomized controlled trials with adaptive designs to evaluate the efficacy of ctDNA-guided timing, alongside dose optimization studies to maintain relative dose intensity; and (3) Implementation & standardization: Involves the development of clinical guidelines, incorporation of patient-reported outcomes and cost-effectiveness analyses, and the establishment of standardized, blinded endpoints for trials. ERAS: Enhanced Recovery After Surgery; ctDNA: Circulating tumor DNA; RCT: Randomized controlled trial; RDI: Relative dose intensity.