At the recently concluded 97th Annual Meeting of the Japanese Gastric Cancer Association (JGCA 2025) in Nagoya, the surgical oncology team from The Affiliated Hospital of Qingdao University , led by Professor Yanbing Zhou, made a remarkable academic impression. Through keynote presentations, thematic reports, and poster discussions, they shared findings from four major clinical studies spearheaded by Chinese researchers—earning widespread praise from the international academic community. These achievements not only highlight the expertise and commitment of Chinese scholars but also signal China’s growing presence in global gastric cancer research.1. Robotic Gastrectomy Poised to Enhance Clinical Outcomes in Gastric Cancer Patients Undergoing Neoadjuvant Therapy
This year’s International Session at the JGCA 2025—titled “Current Status and Perspectives of Digital Innovation in Gastric Cancer Sciences Across Regions”—garnered significant global attention. As part of this high-level forum, Professor Yanbing Zhou delivered a featured presentation titled “A Multicenter, RCT Study of the Clinical Efficacy of Robotic and Laparoscopic Gastrectomy in Neoadjuvant Gastric Cancer (CLASS14, NCT06042998)”. The presentation centered on CLASS14, the world’s first international multicenter randomized controlled trial (RCT) led by Chinese researchers, designed to compare robotic and laparoscopic surgery in patients with gastric cancer who have received neoadjuvant chemotherapy.
Professor Zhou began by outlining the background, rationale, and methodology of the CLASS14 study. With the rapid advancement of medical technology, both laparoscopic and robotic gastrectomy have gained increasing prominence in the surgical management of gastric cancer. However, their comparative effectiveness specifically in the neoadjuvant setting remains a pressing question within the global surgical oncology community. In pursuit of more precise and effective treatment strategies, the research team designed this large-scale RCT involving 20 high-volume surgical centers across China, all with extensive experience in minimally invasive gastrointestinal surgery.
The trial enrolled patients who had received neoadjuvant chemotherapy for locally advanced gastric cancer and aimed to evaluate differences between robotic and laparoscopic surgery in terms of intraoperative safety, postoperative recovery, and long-term oncologic outcomes. The study was designed as a prospective, multicenter, open-label, randomized, non-inferiority trial, with a planned enrollment of 600 patients—300 per group—meeting strict inclusion and exclusion criteria. Primary and secondary endpoints include perioperative complications, postoperative recovery metrics, disease-free survival (DFS), and overall survival (OS).
According to Professor Zhou, the two surgical techniques present distinct characteristics in this patient population. For example, robotic surgery may demonstrate advantages in operative time, intraoperative blood loss, number of lymph nodes retrieved, conversion rates to open surgery, and other key intraoperative parameters. Additionally, robotic surgery may offer improved outcomes in terms of postoperative complications, quality of life, and long-term survival. These findings, once validated, are expected to serve as a robust scientific foundation for selecting the most suitable surgical strategy based on the individual patient profile.
The CLASS14 study received high praise from global surgical oncology leaders. Professor H.K. Yang, Secretary-General of the International Gastric Cancer Congress (IGCC), President of the Korea National Cancer Center, and Professor at Seoul National University Hospital, along with Professor Masanori Terashima of Shizuoka Cancer Center in Japan, both commended the study’s design and clinical relevance. They noted that CLASS14 could provide critical evidence-based support for the application of minimally invasive surgery in gastric cancer—especially in complex post-neoadjuvant settings where robotic systems may offer unique advantages. Furthermore, they emphasized that the study is likely to accelerate the standardization of minimally invasive techniques in gastric cancer surgery and become a pivotal reference for improving patient outcomes and prognoses through evidence-based surgical decision-making.
Professor Yanbing Zhou:
We had the privilege of participating in the international session at the 97th Annual Meeting of the Japanese Gastric Cancer Association (JGCA), where I presented a focused report on the CLASS14 trial. The study attracted widespread interest and received highly positive feedback from peers across the globe.
In China, there are nearly 500,000 new cases of gastric cancer annually, with the majority diagnosed at an advanced stage. Early gastric cancer accounts for only about 20%. Surgical outcomes in mid- and late-stage gastric cancer remain suboptimal. However, evidence now clearly shows that neoadjuvant therapy before surgery can effectively control tumor progression, improve the radical resection rate, and enhance oncologic outcomes in these patients.
This study builds on the foundational work led by Professor Lin Shen and Professor Jiafu Ji, who provided an important framework for us to move forward. While neoadjuvant therapy plays a key role in tumor control, it also brings systemic physiological stress to patients. It may impair gastrointestinal function, hematopoiesis, and even multiple organ systems—resulting in increased surgical risk. Patients may experience tissue edema, fibrosis, and malnutrition, all of which challenge surgeons during the perioperative period.
Today, minimally invasive surgery has become a standard approach in gastric cancer treatment. Many centers in China are now proficient in performing laparoscopic gastrectomy with lymphadenectomy. Robotic surgery, meanwhile, has made remarkable progress over the past decade in China. Both internationally imported systems like Da Vinci, and rapidly developing domestically engineered platforms, have given surgeons broader access to this technology.
In the context of neoadjuvant-treated patients, the CLASS14 trial raises a key clinical question: Can robotic surgery be performed safely and effectively in this specific population? We aim to validate the unique advantages of robotic systems and determine whether they can play a more important role for patients who have undergone chemotherapy prior to surgery.
This trial compares robotic and laparoscopic gastrectomy. Previous research has already demonstrated the benefits of laparoscopic over open surgery. In CLASS14, we conducted a multicenter randomized controlled trial (RCT), focusing on oncologic outcomes as the primary endpoint—particularly three-year disease-free survival (DFS). Secondary endpoints include three-year overall survival (OS), intraoperative metrics, postoperative complications, and recovery indicators. These outcomes will allow us to answer the core question: Is robotic surgery superior to traditional laparoscopy in this setting?
The study is progressing steadily with strong support from surgical experts nationwide. Our target sample size is 600 patients, evenly split between robotic and laparoscopic groups. So far, we have completed approximately half the cases, and we expect to complete recruitment by next year. At that point, we will be able to provide detailed reports and analyses on intraoperative performance, complication rates, and patient recovery.
Based on preliminary observations, robotic surgery has shown promising capabilities and appears to be a strong alternative to laparoscopy. We believe certain features of robotic systems simply cannot be replicated by either laparoscopy or open surgery, and these advantages may prove pivotal in optimizing treatment for patients receiving neoadjuvant chemotherapy.
Improving clinical outcomes for gastric cancer patients remains the core objective of our research. We look forward to completing this trial and sharing our findings with the broader medical community in the near future.
2. Prehabilitation Offers New Clinical Evidence for Improving Outcomes in Frail Elderly Patients Undergoing Gastric Cancer Surgery
As societies around the world face rapid aging, a host of medical and social challenges have emerged—among them, frailty, a common yet often overlooked clinical condition. Frailty is closely associated with diminished physiological reserve and an increased risk of postoperative complications, significantly affecting the recovery and long-term prognosis of elderly patients with gastric cancer. In recent years, the Enhanced Recovery After Surgery (ERAS) concept has gained wide acceptance in gastric cancer surgery, aiming to optimize perioperative care and promote faster recovery. However, ERAS alone may be insufficient to fully address the needs of frail elderly patients, particularly when it comes to restoring postoperative function and improving outcomes.
Prehabilitation, a proactive approach designed to enhance patients’ physiological resilience before surgery, has emerged as a promising complement to ERAS. This strategy combines multimodal interventions—including physical training, nutritional support, and psychological counseling—to boost treatment tolerance and optimize recovery. When integrated with ERAS, prehabilitation forms a comprehensive perioperative management model, with the potential to further reduce postoperative complications and improve quality of life.
At this year’s JGCA 2025 scientific workshop session themed “Best Practices in Perioperative Management for Elderly Patients in the Digital Innovation Era,” Professor Yanbing Zhou delivered a keynote lecture titled: “Supervised Home-Based Multimodal Prehabilitation to Improve the Clinical Outcomes of Frail Elderly Patients with Gastric Cancer: A Multicentre Randomized Controlled Trial (GISSG+2201, NCT05352802)”.
This multicenter RCT was conducted across 15 leading medical centers in China, enrolling a total of 368 eligible patients, who were randomized in a 1:1 ratio to either the prehabilitation group (PG) or the ERAS-only group (EG). Patients in the PG arm received a minimum of two weeks of supervised, home-based, multimodal prehabilitation—focused on physical exercise, nutrition, and psychological adjustment—alongside standard ERAS-based perioperative care. In contrast, patients in the EG arm received ERAS-only management without prehabilitation.
The primary endpoint was the rate of postoperative complications within 30 days after surgery. Secondary endpoints included changes in preoperative functional status, recovery progress, complications, and other short-term clinical outcomes such as ICU stay, duration of mechanical ventilation, and total length of hospitalization.
The findings were compelling:
- Compliance with prehabilitation reached 93.75%, demonstrating high feasibility.
- The postoperative complication rate was significantly lower in the PG group compared to the EG group (17.16% vs. 28.65%, P=0.011), with marked reductions in both Clavien-Dindo grade II complications and systemic complications (P=0.014 and P=0.016, respectively).
- Prehabilitation also led to measurable improvements in functional capacity, with PG patients showing a mean increase of 24 meters in the six-minute walk test (6MWT) compared to baseline (P<0.001). Notably, this improvement was still evident four weeks after surgery.
- Patients in the prehabilitation group also experienced lower postoperative inflammatory responses, better preoperative physiological status, and shorter ICU and hospital stays, as well as reduced mechanical ventilation time during the perioperative period.
Based on the outcomes of this multicenter RCT, the study concluded that supervised, home-based, multimodal prehabilitation significantly strengthens physiological reserves in frail elderly gastric cancer patients, reduces postoperative complications, and accelerates recovery. Compared with ERAS alone, this approach enhances surgical tolerance and recovery capacity, offering new clinical evidence for optimizing perioperative management in this high-risk population.
Professor Takeo Fukagawa (Department of Surgery, Teikyo University School of Medicine, Japan) and Professor Takeshi Ebina (Department of Gastrointestinal Surgery, Oita University, Japan), who chaired the session, commended the study for its timeliness and relevance in the context of global population aging. They emphasized the critical impact of frailty on perioperative recovery and long-term outcomes in elderly gastric cancer patients, and acknowledged the limitations of ERAS when used in isolation. This research, they noted, meaningfully advances the conversation by integrating prehabilitation into the ERAS framework. Overall, the study presents a clinically grounded and forward-looking solution for improving treatment outcomes in this vulnerable population.
Professor Yanbing Zhou ：
This study is a multicenter randomized controlled trial (RCT) initiated within the framework of the Shandong Gastrointestinal Research Collaborative Group, later joined by several additional high-volume centers across China. Our target population was frail, elderly patients with gastric cancer. As population aging accelerates, the majority of patients we now encounter are elderly individuals with declining physical resilience—often accompanied by organ dysfunction—posing new challenges for both chemotherapy and surgical treatment.
We proposed a forward-looking concept: before initiating treatment, we should conduct a comprehensive assessment of each patient, followed by a scientific and targeted intervention to improve their physical performance, functional capacity, and organ reserve. This led to our exploration of prehabilitation—a model that spans the entire treatment course, from diagnosis through chemotherapy and surgery. This concept, highly endorsed internationally in recent years, emphasizes proactive care rather than reactive management.
The prehabilitation model calls for early planning, integrating it into clinical pathways as a structured intervention. We believe this is especially relevant for frail elderly patients, as it enhances treatment tolerance, accelerates recovery, and improves cancer-related outcomes. By the end of last year, we had completed data collection, and during the International Session of the JGCA 2025, we officially presented the results. We also shared our findings in virtual forums with international experts.
What we found was encouraging. Patients undergoing prehabilitation showed marked improvements in physical function and greater surgical resilience. Their recovery was significantly faster, and the incidence of postoperative complications—particularly respiratory infections—was substantially reduced compared to traditional perioperative management. These results suggest that prehabilitation could potentially be translated into high-level evidence for clinical practice. Furthermore, hospital stays were shortened, and patients’ quality of life indicators improved, offering a strong foundation for adopting this approach in high-risk populations.
We hope our work will be recognized and embraced by professionals in the field and ultimately integrated into routine clinical practice for elderly gastric cancer patients.
Aging is progressing faster than anticipated. This is no longer just a clinical issue—it has become a national concern. The government has already acknowledged the far-reaching impact of population aging on healthcare, social services, and the broader economy. President Xi Jinping’s “Healthy China 2030” vision includes a specific focus on elderly healthcare.
Globally, there are successful models we can learn from. Take Japan, for example—60% to 70% of its population is elderly, and the government began addressing aging-related healthcare issues 10 to 20 years ago. Their approach—through coordinated efforts across government, healthcare institutions, and society—has led to timely and effective adjustments in clinical care and medical policy.
In our collaborations and discussions with Japanese experts, especially during the China–Japan Clinical Research Session, we received valuable guidance and constructive feedback that we consider worth implementing in China. Japan’s early and structured approach to aging can serve as a model for us.
What we now need in China is greater government support, along with proactive engagement from clinicians, hospital administrators, nurses, and health insurance providers. As frontline clinicians, our role is to generate high-quality data, clinical evidence, and real-world insights to inform and support policy decisions. And that means conducting our work with greater precision, rigor, and quality—to ensure this important effort can truly improve outcomes for our aging patient population.
Expert Profile
- Distinguished Professor, Qingdao University
- Chief Physician, Doctoral and Postdoctoral Supervisor
- President, Institute of Basic and Translational Research in Gastrointestinal Oncology, Qingdao University
- Vice President, International Hospital, Qingdao University
- Chair of the Department of Surgery and Director of Surgical Education, Qingdao University School of Medicine
- Chief of General Surgery, The Affiliated Hospital of Qingdao University
- Research Fellow in Surgical Oncology, Massachusetts General Hospital, Harvard Medical School
Professor Zhou is a leading figure in the National Key Clinical Specialty for General Surgery and heads the National Health Commission’s Surgical Skills Training Base. With extensive experience in laparoscopic and robotic surgery for gastrointestinal tumors, multidisciplinary treatment, perioperative care, and translational research, he has contributed significantly to advancing clinical practice.
He serves on the editorial board of Annals of Surgery (Chinese edition) and is a manuscript reviewer for high-impact journals such as Surgical Endoscopy, International Journal of Surgery, Science Bulletin, and Gastric Cancer. Professor Zhou is the leading PI of major clinical trials including CLASS14/16, HIPEC09, and GISSG series, and PI of CLASS13, HIPEC01, RESOLVE, and INTRIGUE trials.
- MD, Postdoctoral Fellow at New York University
- Associate Chief of Gastrointestinal Surgery and Deputy Director of Medical Affairs, The Affiliated Hospital of Qingdao University
- Member of the 20th Cohort of the Central Government’s Doctoral Service Program
Academic Positions: Dr. Cao holds numerous professional roles, including committee positions within the Chinese Medical Association, Chinese Medical Doctor Association, Chinese Anti-Cancer Association, and several provincial-level medical societies. His expertise spans perioperative nutrition, emergency GI surgery, enhanced recovery after surgery (ERAS), and colorectal cancer surgery. He also serves as Chair of the ERAS Committee for the Shandong Medical Workers’ Association and Vice Chair of multiple gastrointestinal and surgical committees in Shandong Province.
- MD, Attending Surgeon, Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University
Dr. Meng has published multiple first-author papers in top-tier journals such as Gastric Cancer, EJSO, and Surgical Endoscopy, as well as leading Chinese medical journals. He has contributed to over 20 SCI-indexed and national journal publications. His research has been selected for oral or special presentations at the 94th, 96th, and 97th JGCA Annual Meetings, the 15th World Congress on Gastric Cancer, and the 17th National Conference on Parenteral and Enteral Nutrition. He also serves as a reviewer for journals including BMC Geriatrics, BMC Surgery, and Scientific Reports.
