TO THE EDITOR: Macdonald’s editorial 1 is instructive and provides a great deal of depth and breadth on the subject of adjunctive therapy for gastric cancer. The issue raised is a subject of debate in the West and a resolution is not in sight. We want to emphasize three points that we believe are quite pertinent to this issue and need further discussion. The first point is related to the cross-study comparison of outcomes. It is quite likely that patient susceptibility (patient genetics) factors and carcinogenic forces that lead to the development of gastric cancer are different in different regions; however, the literature on this topic remains sparse and inconclusive. In addition to the assumption that Japanese gastric cancer is biologically different than western gastric cancer, the surgical techniques in the two regions are starkly different. This significantly limits the comparisons among studies. It may be safer to assume that western patients (such as those enrolled in the Intergroup 0116 trial 2 ) were simply grossly understaged for nodal stage. The median number of nodes examined in the ACTS-GC trial (Adjuvant Chemotherapy Trial of TS-1 for Gastric Cancer) 3 is likely to be considerably higher than in the Intergroup 0116 trial. There is a well-documented phenomenon of rampant nodal stage up-migration by carrying out a D2 dissection. 4 Finally, as more nodes are examined/removed, the better is the survival of patients with gastric cancer. 5 Thus, we argue that Western patients are understaged (and undertreated surgically) compared with Japanese patients who not only have adequate nodal staging but also potentially derive a survival benefit from the removal of negative nodes. We must consider these differences when comparing results across studies. Could we argue that a D2 dissection is better than D1 dissection? Yes and no. Yes, because you get proper nodal staging and you also remove more negative nodes and this seems to prolong survival. No, because the results of randomized trials in the West do not support D2 dissection, however none of the Western gastric cancer surgical trials was conducted ideally. The second point is regarding D2 dissection and its loose defini