Selection and Management of Patients With Resectable Gastric or Gastroesophageal Junction Cancer Receiving Perioperative FLOT: A Modified Delphi Consensus Approach

Purpose Perioperative 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) is a guideline-recommended standard for patients with resectable gastric cancer or gastroesophageal junction adenocarcinoma globally. Guidance is limited on patient selection, nutritional optimization, and toxicity management within existing guidelines. This study aimed to develop an international consensus to address these management gaps. Methods A modified Delphi methodology, informed by the RAND/UCLA Appropriateness Method, was conducted virtually between March and August 2025. A multidisciplinary panel of 16 experts independently rated draft clinical statements across multiple domains. Responses were anonymized, with structured, iterative rounds of feedback and re-rating. Consensus was defined a priori as a median score of 7-9 (appropriate) or 1-3 (inappropriate) with a disagreement index ≤1.0. Results Consensus was reached on 66.3% of the statements. Experts agreed that patients aged >70 years should not be routinely excluded from perioperative FLOT but require comprehensive assessment; inclusion of Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 is appropriate, and ECOG PS 0-2 may be considered on a case-by-case basis. Adequate organ function, correction of baseline conditions, hepatitis B screening, and dihydropyrimidine dehydrogenase testing are appropriate before FLOT initiation. Universal baseline nutritional screening and support, proactive intervention for malnourished patients, and structured physical activity were endorsed. Surgical planning was supported through multidisciplinary input, with defined perioperative windows, individualized dosing, and flexibility in pre-/postoperative cycles. For toxicity management, the panel supported dose modification over drug omission, where possible. Conclusion This Delphi consensus provides expert-driven, practice-oriented advisories codifying fitness-based selection, nutrition-forward optimization, and pragmatic toxicity management. The resulting guidance builds on current standards and provides internationally applicable consensus statements to ultimately enhance patient care.