Adjuvant chemoradiotherapy vs chemotherapy after R0 D2 gastrectomy for gastric cancer: Meta-analysis of randomized trials

Table 1 Characteristics of included randomized trials

Ref.	Direct N	Population	CRT arm	CT arm	Main randomized evidence
Kwon et al[15] (2010)	61	R0/D2; stage IIIA-IV (M0)	FP → 45 Gy/capecitabine → FP	6 FP cycles	5-year DFS 76.7% vs 59.1%; reconstructed DFS HR = 0.57 (0.23-1.41)
Kim et al[16] (2012)	90	R0/D2; stage III-IV (M0)	FL → 45 Gy/FL → FL	5 FL cycles	Overall DFS/OS estimates were imprecise; locoregional recurrence-free survival favored CRT in the report
Zhu et al[17] (2012)	404 randomized; 351 analyzed	D2; stage IB-IV (M0)	FL → 45 Gy IMRT/FL → FL	Matched FL	RFS HR = 0.74 (0.56-0.97); OS HR = 0.81 (0.61-1.06), standardized to CRT vs CT
Lee et al[18]/Park et al[19] (ARTIST)	458	Completely resected; D2	2 XP → 45 Gy/capecitabine→ 2 XP	6 XP cycles	Final DFS HR = 0.74 (0.52-1.05); OS HR = 1.13 (0.78-1.65)
Xie et al[20] (2018)	144 report-eligible	T3-4/N1-3 after D2	2 XELOX → 45 Gy/capecitabine→ 4 XELOX	6 XELOX cycles	3-year DFS 72.8% vs 76.3%; no HR/CI; qualitative only
Park et al[21] (ARTIST 2)	364 direct contrast	Stage II-III, node-positive; D2	SOX + 45 Gy	SOX for 6 months	DFS HR = 0.971; published 95%CI: 0.663-1.421; P = 0.879. Prior P-based approximation retained only for sensitivity audit
Qiao et al[22] (2025)	312	High-risk after D2	4-6 SOX → 45 Gy/S-1; total 6 SOX	8 SOX cycles	3-year DFS HR = 0.82 (0.54-1.25); grade 3/4 acute events 18.5% vs 26.1%
Wang et al[23] (2026)	620	R0/D2; T4 or node-positive; M0	1 SOX → 50.4 Gy/S-1 → 3 SOX	6 SOX cycles	DFS HR = 0.98 (0.73-1.33); OS HR = 0.86 (0.60-1.23)

CI: Confidence interval; CT: Chemotherapy; CRT: Chemoradiotherapy; DFS: Disease-free survival; FL: Fluorouracil plus leucovorin; FP: Fluorouracil plus cisplatin; HR: Hazard ratio; IMRT: Intensity-modulated radiotherapy; OS: Overall survival; RFS: Recurrence-free survival; SOX: S-1 plus oxaliplatin; XP: Capecitabine plus cisplatin; XELOX: Capecitabine plus oxaliplatin.

Table 2 Summary of quantitative syntheses

Analysis	k /n	Effect	Modified KH 95%CI	I²	GRADE	Interpretation
DFS/RFS, all eras	7/2256	HR = 0.82	0.69-0.98	0%	Low	Point estimate favors CRT; indirect legacy evidence
DFS/RFS, oral fluoropyrimidine–platinum doublets	4/1754	HR = 0.88	0.66-1.18	0%	Moderate	Imprecise; benefit and harm remain possible
DFS/RFS, excluding Kwon et al[15] and Kim et al[16] reconstructions	5/2105	HR = 0.84	0.68-1.03	0%	Low	Conservative CI crosses no effect
Overall survival	5/1580	HR = 0.89	0.69-1.15	0%	Low	Imprecise; no equivalence inference
Locoregional recurrence, legacy	4/960	OR = 0.50	0.26-0.94	0%	Low	Improved local control; uncertain current relevance
Distant recurrence, legacy	4/960	OR = 0.81	0.50-1.29	0%	Low	Uncertain effect

n is the sum of participants represented by the selected outcome comparisons rather than a uniform randomized denominator. Grading of Recommendations Assessment, Development and Evaluation categories are the final author-reviewed certainty ratings for the evidence bodies shown in Table 2; detailed downgrade reasons and sensitivity-analysis membership are supplied in the audit workbook. CI: Confidence interval; CRT: Chemoradiotherapy; GRADE: Grading of Recommendations Assessment, Development and Evaluation; HR: Hazard ratio; OR: Odds ratio; DFS: Disease-free survival; RFS: Recurrence-free survival.