Peter C Enzinger, MD
	Assistant Professor of Medicine Harvard Medical School Clinical Director, Gastrointestinal Cancer Center Dana-Farber Cancer Institute Boston, Massachusetts

I hope that bevacizumab or some newer-generation anti-angiogenic agents end up playing a significant role in the treatment of metastatic gastric cancer.

My perception of the AVAGAST data was that a benefit was apparent for American and European patients. I would be interested in seeing a study that focused on those patients.

	Richard M Goldberg, MD
	Visiting Professor of Medicine Physician-in-Chief, The James Cancer Hospital and Solove Research Institute Associate Director of Outreach Comprehensive Cancer Center The Ohio State University Medical Center Columbus, Ohio

I’m skeptical about bevacizumab having a role, but I’m certainly open to studies that have evaluated other agents that target VEGF. I don’t yet have an opinion about ramucirumab, but I’m hopeful.

	Axel Grothey, MD
	Professor of Oncology Department of Medical Oncology Mayo Clinic Rochester, Minnesota

It very well could be. Ramucirumab is being evaluated right now as second-line therapy in a Phase III trial. A debate is also ongoing about whether or not to redo an AVAGAST-like trial. Progression-free survival was positive in that trial if you eliminate the Asian patient population.

But they are running out of time if ramucirumab is being moved forward. So do I believe there is an opening for anti-VEGF inhibitors? Yes, I do believe there is an opening.

	Howard S Hochster, MD
	Associate Director (Clinical Research) Yale Cancer Center Professor of Medicine, Yale School of Medicine New Haven, Connecticut

Yes, actually I do. I believe that there is probably going to be a benefit. It’s just that when the trials are so heavily based in Asia, it’s a little harder to show benefit. I believe that’s based more on how they conduct their studies than on a biological difference.

	David H Ilson, MD, PhD
	Professor of Medicine, Weill Cornell Medical College Attending Physician, Memorial Hospital Memorial Sloan-Kettering Cancer Center New York, New York

Yes, I do believe anti-VEGF agents will play a significant role in the treatment of metastatic gastric cancer.

	John L Marshall, MD
	Chief, Hematology and Oncology Director, Ruesch Center for the Cure of GI Cancers Lombardi Comprehensive Cancer Center Georgetown University Washington, DC

The AVAGAST data certainly were unexciting. I’m on a “value kick” right now, so my enthusiasm is low for data sets with expensive drugs that you have to microanalyze. That to me means the study didn’t work.

	David P Ryan, MD
	Associate Chief of Hematology/Oncology Clinical Director of the Tucker Gosnell Center for Gastrointestinal Cancers Massachusetts General Hospital Boston, Massachusetts

I’m hopeful. I believe that a benefit probably does exist with anti-VEGF therapy for these patients in the United States who develop gastric or GE junction adenocarcinomas. I’m not using such an approach off protocol, though.

There were hints of promising results in the AVAGAST trial. I believe that future studies should not combine Asian gastric and GE junction cancers with Western gastric and GE junction cancers. I’m worried that there are 2 different biologies.

	Eric Van Cutsem, MD, PhD
	Professor of Medicine Digestive Oncology University Hospital Gasthuisberg/Leuven Leuven, Belgium

I am usually better at predicting the past than the future, so I will answer the question in a different manner. We hope we can find a population that benefits from bevacizumab because clearly some patients benefit from bevacizumab. We hope the same for ramucirumab, though I haven’t seen any data yet. I have to be optimistic.

	Alan P Venook, MD
	Professor of Clinical Medicine University of California, San Francisco San Francisco, California

AVAGAST was a negative study, though it was almost positive in that certain groups exhibited a benefit with bevacizumab. The authors put quite a spin on the results during the discussion at ASCO. The results of this study were recently published in the JCO.

With regard to ramucirumab, this agent is currently being evaluated in clinical trials, but I don't know if we can distinguish these antibodies.