In recent years, new treatment approaches have been developed to treat gastric cancer.
Gastric cancer is relatively rare compared to other types of cancer, with about 28,000 new cases diagnosed in the United States annually. It mostly occurs in people over age 65, and it is more common in men than in women. More than 90 percent of gastric cancers are adenocarcinomas, meaning they start from cells located in the glands of the stomach.
Treatment Options by Stage
Stages 0 and IA Stages 0 and IA gastric cancers are treated by gastrectomy (surgical removal of part or all of the stomach) and lymphadenectomy (removal of the nearby lymph nodes). Typically, no additional therapy is needed.
Stages IB, II and III Stage IB, II or III gastric cancer is treated with a total or partial gastrectomy and lymphadenectomy. Chemotherapy or chemoradiation (chemotherapy plus radiation therapy) may be given before surgery to shrink the cancer, making it easier to remove.
Additionally, chemotherapy or chemoradiation is often given after surgery, especially if cancer is found in the removed lymph nodes.
People who are not able to undergo surgery are often treated with chemotherapy, radiation or chemoradiation.
Stage IV Treatments for stage IV gastric cancer are designed to shrink the tumor and help relieve symptoms. Options include surgery, chemotherapy, radiation, chemoradiation, targeted therapy and (in certain cases) immunotherapy.
When surgery is part of the treatment plan for gastric cancer, the approach depends on the stage of the cancer and other factors unique to the individual.
Subtotal (partial) gastrectomy. In a subtotal gastrectomy, the cancerous portion of the stomach is removed. Most often, a subtotal gastrectomy is performed if the cancer is in the lower portion of the stomach (near the intestines), although it may sometimes be performed if the cancer is in the upper portion of the stomach. Depending on the stage of the cancer, other organs or tissues close to the cancerous part of the stomach may also be removed, including the omentum (a layer of fatty tissue that covers the stomach and intestines), the spleen, or portions of the esophagus or small intestine.
A subtotal gastrectomy includes a step that allows the digestive tract to continue to function. If the lower portion of the stomach has been removed, the surgeon connects the upper portion to the small intestine. If the upper portion of the stomach has been removed, the surgeon attaches the lower portion to the esophagus.
Total gastrectomy. If the cancer has spread throughout the stomach, a total gastrectomy (the removal the entire stomach) is performed. Additionally, this type of surgery is often recommended if the cancer is located in the upper part of the stomach. In a total gastrectomy, the surgeon also removes the omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas and other nearby organs. The end of the esophagus is attached to part of the small intestine to allow food to continue to move through the intestinal tract.
People can sometimes have trouble taking in enough nutrition after a gastrectomy. A jejunostomy tube (J-tube) placed into the intestine at the time of surgery can help. The end of the J-tube remains outside the body, on the skin of the abdomen. Through this tube, liquid nutrition can be put directly into the intestine. A lymphadenectomy is performed at the same time as a subtotal or total gastrectomy.
Systemic (whole body) chemotherapy, designed to destroy cancer cells, has long been an important approach in the treatment of gastric cancer. Most systemic chemotherapy treatments for gastric cancer combine at least two drugs. In neoadjuvant (before surgery) treatment, common drug combinations include:
- Docetaxel, oxaliplatin and fluorouracil/leucovorin (FLOT)
- ECF (epirubicin, cisplatin and 5-FU)
- Docetaxel or paclitaxel plus either 5-FU or capecitabine
- Cisplatin plus either 5-FU or capecitabine
- Paclitaxel and carboplatin
The combination treatment ECF may also be given as an adjuvant (after surgery) treatment. A single drug, such as 5-FU or capecitabine, is sometimes used in adjuvant treatment.
Other chemotherapy drugs used to treat gastric cancer include etoposide and irinotecan.
Radiation therapy can be used to destroy small traces of cancer that could not be seen and removed during surgery.
A type of radiation called “external beam” is commonly used in the treatment of gastric cancer. External beam radiation uses a machine that directs a beam (or multiple beams) of radiation to the cancer. The use of CT (computerized tomography), MRI (magnetic resonance imaging) and PET (positron emission tomography) scans allows radiation oncologists to accurately target the cancer, helping to spare healthy tissues.
Targeted therapy focuses on specific molecules and cell mechanisms thought to be important for cancer cell survival and growth, taking advantage of what researchers have learned in recent years about how cancer cells grow.
The targeted therapies approved by the U.S. Food and Drug Administration (FDA) for the treatment of stage IV gastric cancer are:
- Trastuzumab (Herceptin). HER2, a growth-promoting protein found on the surface of some cancer cells, is present in approximately 20 percent of gastric cancers. Trastuzumab binds to and blocks the HER2 protein and is often added to chemotherapy for people whose cancer is HER2-positive. Trastuzumab is given intravenously (into a vein).
- Ramucirumab (Cyramza). VEGF (vascular endothelial growth factor) is a protein that contributes to blood vessel growth (angiogenesis), which can lead to the growth and spread of cancer. Ramucirumab blocks the action of VEGF and can be given by itself or added to chemotherapy. It is given intravenously.
Other targeted therapy drugs to treat gastric cancer are currently being studied in clinical trials.
Our immune system is constantly working to keep us healthy. It recognizes and fights against danger, such as infections, viruses and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer.
In September 2017, the FDA approved the immunotherapy pembrolizumab (Keytruda) to treat certain advanced gastric cancers. The approval applies to gastric cancers that have recurred (come back) or continued to grow after at least two previous chemotherapy regimens (courses of treatment). To be treated with pembrolizumab, the cancer cells must also test positive for the PD-L1 protein, a molecular “brake” that prevents the body’s immune system from attacking cancer cells.
Pembrolizumab, which is given intravenously, has also been approved to treat any type of cancer that has a genetic trait known as high microsatellite instability (MSI-H), which causes tumors to have a large number of genetic mutations. A small percentage of gastric cancers are MSI-H and can be treated with pembrolizumab.
Other immunotherapy approaches are currently being studied in clinical trials.
Treatment Side Effects
All cancer treatments can cause side effects. It’s important that you report any side effects that you experience to your health care team so they can help you manage them. Report them right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan. It’s important to remember that not all patients experience all side effects, and patients may experience side effects not listed here.
Side Effects of Chemotherapy
The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are used. They can include:
- Nausea or vomiting
- Hair loss
- Increased risk of infection (from having too few white blood cells)
- Easy bruising or bleeding
- Changes in memory or thinking
- Peripheral neuropathy (numbness or tingling in hands and feet)
Side Effects of Radiation
Changes to the skin are the most common side effects of radiation therapy; those changes can include dryness, swelling, peeling, redness and blistering. If a reaction occurs, contact your health care team so the appropriate treatment can be prescribed. It’s especially important to contact your health care team if there is any open skin or painful areas, as this could indicate an infection. Infections can be treated with an oral antibiotic or topical antibiotic cream.
Side Effects of Targeted Therapy
Targeted therapy drugs don’t have the same effect on the body as do chemotherapy drugs, but they can still cause side effects. Some of the potential side effects of the targeted therapies used to treat gastric cancer include headache, rashes, diarrhea, high blood pressure and problems with blood clotting and wound healing.
Side Effects of Immunotherapy
Immunotherapy travels through the bloodstream, helping to prompt what is called an “immune response.” Because immunotherapy can attack healthy cells as well as cancer cells, certain side effects may be experienced, including digestive tract symptoms, loss of appetite, fatigue and flu-like symptoms.
General Side Effects
There are certain side effects that may occur across different treatment approaches. The following tips and guidance may help you manage these side effects.
Managing Digestive Tract Symptoms
Nausea and vomiting
- Avoid food with strong odors, as well as overly sweet, greasy, fried, or highly seasoned food.
- Nibble on dry crackers or toast. These bland foods are easy on the stomach.
- Having something in your stomach when you take medication may help ease nausea.
- Many effective medications for nausea and vomiting have been developed in recent years; talk to your doctor about whether any may be right for you.
- Drink plenty of water. Ask your doctor about using drinks such as Gatorade which provide electrolytes as well as liquid. Electrolytes are body salts that must stay in balance for cells to work properly.
- Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, discuss it with your doctor or nurse.
- Choose foods that contain soluble fiber—for example beans, oat cereals, oranges, and flaxseeds. High-pectin foods such as peaches, apples, oranges, grapefruit, bananas, and apricots can also help to avoid diarrhea.
Loss of Appetite
- To help maintain your weight, eat small meals throughout the day. That’s an easy way to take in more protein and calories. Try to include protein in every meal.
- To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals and focus on liquids that have nutritional value.
- Be as physically active as you can. Sometimes, taking a short walk an hour or so before meals can help you feel hungry.
- Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna, or trail mix.
- If you are struggling to maintain your appetite, talk to your health care team about whether appetite-building medication could be right for you.
Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you.
There are a number of other tips for reducing fatigue:
• Take several short naps or breaks.
• Take short walks or do some light exercise, if possible.
• Try easier or shorter versions of the activities you enjoy.
• Ask your family or friends to help you with tasks you find difficult or tiring.
• Save your energy for things you find most important.
There are also prescription medications that may help, such as modafinil. Your health care team can provide guidance on whether medication is the right approach for your individual circumstances.
There are a number of options for pain relief, including prescription and over-the-counter medications. It’s important to talk to a member of your health care team before taking any over-the counter medication, to determine if they are safe and will not interfere with your treatments.
As you manage your lung cancer, it’s important to remember that you are a consumer of health care. The best way to make decisions about health care is to educate yourself about your diagnosis and the members of your health care team, including nurses, social workers and patient navigators.
Here are some tips for improving communication with your health care team:
Start a health care journal. Having a health care journal or notebook will allow you to keep all of your health information in one place. You may want to write down the names and contact information of the members of your health care team, as well as any questions for your doctor. Keep a diary of your daily experiences with cancer and treatment. You can separate your journal or notebook into different sections to help keep it organized.
Prepare a list of questions. Before your next medical appointment, write down your questions and concerns. Because your doctor may have limited time, you should ask your most important questions first, and be as specific and brief as possible.
Bring someone with you to your appointments. Even if you have a journal and a prepared list of questions or concerns, it’s always helpful to have support when you go to your appointments. The person who accompanies you can serve as a second set of ears. He or she may also think of questions to ask your doctor or remember details about your symptoms or treatment that you may have forgotten.
Write down your doctor’s answers. Taking notes will help you remember your doctor’s responses, advice and instructions. If you cannot write down the answers, ask the person who accompanies you to do that for you. If you have a mobile device, you can use it to take notes. Writing notes will help you review the information later.
Record your visit if your doctor allows it. Recording the conversation with your doctor gives you a chance to hear specific information again or share it with family members or friends.
Incorporate other health care professionals into your team. Your oncologist and oncology nurse are essential members of your health care team, but there are other health care professionals who can help you manage your diagnosis and treatment.
Make sure your oncologist knows of any other medical conditions you have, or any pain you are experiencing, so that they can consult with your primary care physician or your specialist if needed. Remember, there is no such thing as over-communication.
Frequently Asked Questions
Q: Are there gene mutations or inherited conditions that increase the risk of developing gastric cancer?
A: Certain gene mutations and some inherited conditions are considered risk factors for gastric cancer, including:
- BRCA1 and BRCA2. Although inherited mutations on the BRCA1 and BRCA2 genes are often associated with a higher risk of breast cancer, people who have inherited these genetic mutations are also at an increased risk for gastric cancer.
- Lynch syndrome. Lynch syndrome is a hereditary disorder caused by a mutation in a mismatch repair gene. Most commonly Lynch syndrome is associated with an increased risk for colon cancer, but also increases the risk of gastric and other cancers.
- Familial adenomatous polyposis (FAP). Often caused by mutations on the APC gene, FAP significantly increases a person’s risk of colorectal cancer and may also play a role in increasing the risk of developing gastric cancer.
- E-cadherin/CDH1. Though rare, people who inherit this genetic mutation have a significantly increased risk of developing gastric cancer in their lifetime.
Testing is available for gene mutations that make a person more likely to develop gastric cancer. A doctor or genetic counselor can help the individual and their family understand the test results.
Q: What is an endoscopic resection?
A: In an endoscopic resection, the surgeon passes an endoscope (a flexible tube with a lighted video camera on the end) into the stomach through the throat. Surgical tools are then passed through the endoscope to remove the cancer and part of the stomach wall around the cancer.
Endoscopic resection can sometimes be used to treat early-stage gastric cancers, where the risk of the cancer spreading to the lymph nodes is very low. This procedure is more common in countries where gastric cancer is more prevalent than it is in the United States and is often found at an earlier stage, due to more aggressive screening protocols in those countries.
If you are considering an endoscopic resection, your health care team can help you find a medical center that has experience with this technique.
Q: What is a treatment summary and why is important?
A: A treatment summary, sometimes called a “shadow chart,” is a document that you create and keep in your possession. Maintaining your own records allows you and your family members to have instant access to the specifics of your gastric cancer diagnosis and treatment. A treatment summary should include:
- Your name and date of birth
- Date of diagnosis
- Prescribed therapy/therapies; including dates started and stopped and dosages when appropriate
- Dates and types of post-diagnosis testing, and the results of these tests
- Other medications and supplements you are taking
- Names, affiliations and contact information of all members of your health care team.
Talk to your doctor or a member of your health care team about your intention to create a treatment summary, and ask what else they suggest be included. Take your treatment summary with you when you visit any doctor, not just your oncologist or gastroenterologist.