Triplet vs doublet adjuvant chemotherapy for gastric cancer: A systematic review and meta-analysis

Figure 1  PRISMA flow diagram illustrating the study selection process for inclusion in the meta-analysis.

Figure 2 Forest plot of objective response rate, disease control rate, overall survival, progression-free survival and grade 3-4 adverse events comparing triplet vs doublet neoadjuvant chemotherapy. A: Objective response rate (ORR). The pooled analysis demonstrated significantly higher ORR with triplet regimens [risk ratio (RR) = 1.73, 95% confidence interval (95%CI): 1.64-1.82, P < 0.0001]. Substantial heterogeneity was present (I² = 84%). Each square represents the point estimate for individual studies, with horizontal lines indicating 95%CIs. The diamond represents the pooled effect estimate; B: Disease control rate (DCR). Triplet regimens achieved significantly superior DCR (RR = 1.22, 95%CI: 1.15-1.28, P < 0.0001) with moderate heterogeneity (I² = 61%). The forest plot displays individual study estimates and the pooled random-effects estimate; C: Overall survival (OS). Despite improved response rates, no significant OS difference was observed [hazard ratio (HR) = 1.24, 95%CI: 0.90-1.72, P = 0.19] with considerable heterogeneity (I² = 96%). HRs less than 1 favor the experimental (triplet) arm; D: Progression-free survival (PFS). No significant PFS benefit was demonstrated for triplet regimens (HR = 1.52, 95%CI: 0.93-2.50, P = 0.09) with substantial heterogeneity (I² = 94%). The wide confidence interval precludes definitive conclusions; E: Grade 3-4 adverse events (AEs). Comprehensive safety analysis demonstrated no significant differences in toxicity profiles between regimens across multiple AEs. The comparable safety suggests good tolerability of triplet therapy with modern supportive care. 95%CI: 95% confidence interval.

Figure 3 Funnel plot for objective response rate. Visual asymmetry suggests potential publication bias, with fewer small studies showing null or negative results in the lower portion of the plot. However, the presence of large high-quality trials supports the validity of pooled estimates despite detected bias. OR: Odds ratio.