Stomach Cancer

General treatment information

Once your cancer has been diagnosed and staged, there is a lot to think about before you and your doctors choose a treatment plan. You may feel that you must make a decision quickly, but it is important to give yourself time to absorb the information you have just learned. Ask your cancer care team questions. You can find some good questions to ask in the section, “What should you ask your doctor about stomach cancer?”

The main treatments for stomach cancer are:

Surgery

Chemotherapy

Targeted therapy

Radiation therapy

Often the best approach uses 2 or more of these treatment methods.

You will want to weigh the benefits of each treatment against the possible risks and side effects. Your treatment options depend on many factors. The location and the stage (extent of spread) of the tumor are very important. In choosing your treatment plan, you and your cancer care team will also take your age, general state of health, and personal preferences into account.

It is important to have a team of doctors with different specialties involved in your care before plans for treating your stomach cancer are made. Most likely, your team will include:

A gastroenterologist: a doctor who specializes in treatment of diseases of the digestive system.

A surgical oncologist: a doctor who treats cancer with surgery.

A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy.

A radiation oncologist: a doctor who treats cancer with radiation therapy.

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, nutrition specialists, social workers, and other health professionals.

It is important that you understand the goal of your treatment — whether it is to try to cure your cancer or to keep the cancer under control or relieve symptoms — before starting treatment. If the goal of your treatment is a cure, you will also receive treatment to relieve symptoms and side effects. If a cure is not possible, treatment is aimed at keeping the cancer under control for as long as possible and relieving symptoms, such as trouble eating, pain, or bleeding.

If time permits, you may want to get a second opinion about your treatment options. A second opinion can provide you with more information and help you feel more confident about the treatment plan that you choose.

The next few sections describe the different types of treatment for stomach cancer. This is followed by a discussion of the most common treatment options based on the extent of the cancer.

Surgery for stomach cancer

Surgery is part of the treatment for many different stages of stomach cancer if it can be done. If a patient has a stage 0, I, II, or III cancer and is healthy enough, surgery (often along with other treatments) offers the only realistic chance for cure at this time.

Surgery may be done to remove the cancer and part or all of the stomach and some nearby lymph nodes, depending on the type and stage of stomach cancer. The surgeon will try to leave behind as much normal stomach as possible. Sometimes other organs will need to be removed as well.

Even when the cancer is too widespread to be removed completely, patients may be helped by surgery because it may help prevent bleeding from the tumor or prevent the stomach from being blocked by tumor growth. This type of surgery is called palliative surgery, meaning that it relieves or prevents symptoms but it is not expected to cure the cancer.

The type of operation usually depends on what part of the stomach the cancer is in and how much cancer is in the surrounding tissue. Different kinds of surgery can be used to treat stomach cancer:

Endoscopic mucosal resection

This procedure is done only for some very early-stage cancers, where the chance of spread to the lymph nodes is very low.

The operation does not require an incision in the skin. Instead, the surgeon passes an endoscope (a long, flexible tube with a small video camera on the end) down the throat and into the stomach. Surgical tools can be passed through the endoscope to remove the tumor and a small wedge of normal stomach wall around it.

This operation is not done as much in the United States as it is in Japan and some other countries, where stomach cancer is often detected early during screening. If you are going to have this surgery, it should be at a center that has experience with this technique.

Subtotal (partial) gastrectomy

This operation is often recommended if the cancer is only in the lower part of the stomach. It is also sometimes used for cancers that are only in the upper part of the stomach.

Only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine (the duodenum). The remaining section of stomach is then reattached. Some of the omentum, an apron-like layer of fatty tissue that covers the stomach and intestines, is removed as well, along with nearby lymph nodes, and possibly the spleen and parts of other nearby organs.

Eating is much easier after surgery if only part of the stomach is removed instead of the entire stomach.

Total gastrectomy

This operation is done if the cancer has spread throughout the stomach. It is also often advised if the cancer is in the upper part of the stomach, near the esophagus.

The surgeon removes the entire stomach, nearby lymph nodes, and omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs. The end of the esophagus is then attached to part of the small intestine. This allows food to move down the intestinal tract. But people who have had their stomach removed can only eat a small amount of food at a time. Because of this, they must eat more often.

Most subtotal and total gastrectomies are done through a large incision (cut) in the skin of the abdomen. Some centers are now studying the use of laparoscopic surgery for these operations, in which the surgeon operates through several smaller cuts in the abdomen.

Placement of a feeding tube

Some patients have trouble taking in enough nutrition after surgery for stomach cancer. Further treatment like chemotherapy with radiation can make this problem worse. To help with this, a tube can be placed into the intestine at the time of gastrectomy. The end of this tube, called a jejunostomy tube or J tube, remains outside of the skin on the abdomen. Through this, liquid nutrition can be put directly into the intestine to help prevent and treat malnutrition.

Lymph node removal

In either a subtotal or total gastrectomy, the nearby lymph nodes are removed.

This is a very important part of the operation. Many doctors feel that the success of the surgery is directly related to how many lymph nodes the surgeon removes.

In the United States, it is recommended that with a gastrectomy, nearby lymph nodes be removed (called a D1 lymphadenectomy) with the goal of removing at least 15 nodes. Surgeons in Japan have had very high success rates by doing a more extensive removal of the lymph nodes near the cancer (called a D2 lymphadenectomy).

Surgeons in Europe and the United States have not been able to equal the results of the Japanese surgeons. It is not clear if this is because Japanese surgeons are more experienced (stomach cancer is much more common in their country), because Japanese patients tend to have earlier stage disease (because they screen for stomach cancer) and are healthier, or if other factors play a role.

In any event, it takes a skilled surgeon who is experienced in stomach cancer surgery to remove all the lymph nodes successfully. Ask your surgeon about his or her experience in operating on stomach cancer. Studies have shown that the results are better when both the surgeon and the hospital have had extensive experience in treating patients with stomach cancer.

Palliative surgery for unresectable cancer

For people with unresectable stomach cancer, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.

Subtotal gastrectomy: For some people who are healthy enough for surgery, removing the part of the stomach with the tumor can help treat problems such as bleeding, pain, or blockage in the stomach, even if it does not cure the cancer. Because the goal of this surgery is not to cure the cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

Gastric bypass (gastrojejunostomy): Tumors in the lower part of the stomach may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (called the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

Endoscopic tumor ablation: In some cases, such as in people who are not healthy enough for surgery, an endoscope (a long, flexible tube passed down the throat) can be used to guide a laser beam to vaporize parts of the tumor. This can be done to stop bleeding or help relieve a blockage without surgery.

Stent placement: Another option to keep a tumor from blocking the opening at the beginning or end of the stomach is to use an endoscope to place a stent (a hollow metal tube) in the opening. This helps keep it open and allows food to pass through it. For tumors in the upper (proximal) stomach, the stent is placed where the esophagus and stomach meet. For tumors in the lower (distal) part of the stomach, the stent is placed at the junction of the stomach and the small intestine.

Feeding tube placement: Some people with stomach cancer are not able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the distal part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (known as a jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Possible complications and side effects of surgery

Surgery for stomach cancer is difficult and can have complications. These can include bleeding from the surgery, blood clots, and damage to nearby organs during the operation. Rarely, the new connections made between the ends of the stomach or esophagus and small intestine may leak.

Surgical techniques have improved in recent years, so only about 1% to 2% of people die from surgery for stomach cancer. This number is higher when the operation is more extensive, such as when all the lymph nodes are removed, but it is lower in the hands of highly skilled surgeons.

You will not be allowed to eat or drink anything for at least a few days after a total or subtotal gastrectomy. This is to give the digestive tract time to heal and to make sure there are no leaks in parts that have been sewn together during the operation.

You may develop side effects after you recover from surgery. These can include nausea, heartburn, abdominal pain, and diarrhea, particularly after eating. These side effects result from the fact that once part or all of the stomach is removed, food enters the intestines too quickly after eating. The side effects often get better over time, but in some people they can last for a long time. Your doctor might prescribe medicines to help with this.

Changes in your diet will be needed after a partial or total gastrectomy. The biggest change is that you will need to eat smaller, more frequent meals. The amount of stomach removed will affect how much you need to change the way you eat.

The stomach helps the body absorb some vitamins, so people who have had a subtotal or total gastrectomy may develop vitamin deficiencies. If certain parts of the stomach are removed, doctors routinely prescribe vitamin supplements, some of which can only be injected.

Before your surgery, ask your surgeon how much of the stomach he or she intends to remove. Some surgeons try to leave behind as much of the stomach as they can to allow patients to eat more normally afterward. The tradeoff is that the cancer might be more likely to come back. The extent of the surgery should be discussed with your doctor before it is done.

It cannot be stressed enough that you should make sure your surgeon is experienced in treating stomach cancer and able to perform the most up-to-date operations to reduce your risk of complications. 

Chemotherapy for stomach cancer

Chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein or given by mouth as pills. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful for cancer that has spread to organs beyond where it started.

Chemo can be used in different ways to help treat stomach cancer:

Chemo can be given before surgery for stomach cancer. This, known as neoadjuvant treatment, can shrink the tumor and possibly make surgery easier. It may also help keep the cancer from coming back and help patients live longer. For some stages of stomach cancer, neoadjuvant chemo is one of the standard treatment options. Often, chemo is then given again after surgery.

Chemo may be given after surgery to remove the cancer. This is called adjuvant treatment. The goal of adjuvant chemo is to kill any cancer cells that may have been left behind but are too small to see. This can help keep the cancer from coming back. Often, for stomach cancer, chemo is given with radiation therapy after surgery. This combination is called chemoradiation. This may be especially helpful for cancers that could not be removed completely by surgery.

Chemo may be given as the primary (main) treatment for stomach cancer that has spread (metastasized) to distant organs. It may help shrink the cancer or slow its growth, which can relieve symptoms for some patients and help them live longer.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each cycle typically lasts for a few weeks.

A number of chemo drugs can be used to treat stomach cancer, including:

5-FU (fluorouracil), often given along with leucovorin (folinic acid)

Capecitabine (Xeloda^®)

Carboplatin

Cisplatin

Docetaxel (Taxotere^®)

Epirubicin (Ellence^®)

Irinotecan (Camptosar^®)

Oxaliplatin (Eloxatin^®)

Paclitaxel (Taxol^®)

Depending on the situation (including the stage of the cancer, the person’s overall health, and whether chemo is combined with radiation therapy), these drugs may be used alone or combined with other chemotherapy or targeted drugs.

Some common drug combinations used when surgery is planned include:

ECF (epirubicin, cisplatin, and 5-FU),which may be given before and after surgery

Docetaxel or paclitaxel plus either 5-FU or capecitabine, combined with radiation as treatment before surgery

Cisplatin plus either 5-FU or capecitabine, combined with radiation as treatment before surgery

Paclitaxel and carboplatin, combined with radiation as treatment before surgery

When chemo is given with radiation after surgery, a single drug such as 5-FU or capecitabine may be used.

To treat advanced stomach cancer, ECF may also be used, but other combinations may also be helpful. Some of these include:

DCF (docetaxel, cisplatin and 5-FU)

Irinotecan plus cisplatin

Irinotecan plus 5-FU or capecitabine

Oxaliplatin plus 5-FU or capecitabine

Many doctors prefer to use combinations of 2 chemo drugs to treat advanced stomach cancer. Three-drug combinations can have more side effects, so they are usually reserved for people who are in very good health and who can be followed closely by their doctor.

Side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects. The type of side effect depends on the type of drugs, the amount taken, and the length of treatment. Short-term side effects common to most chemotherapy drugs can include:

Nausea and vomiting

Loss of appetite

Hair loss

Diarrhea

Mouth sores

Increased chance of infection (from a shortage of white blood cells)

Bleeding or bruising after minor cuts or injuries (from a shortage of platelets)

Fatigue and shortness of breath (from a shortage of red blood cells)

These side effects are usually short-term and go away once treatment is finished. For example, hair will usually grow back after treatment ends. Be sure to tell your cancer care team about any side effects you have because there are often ways to lessen them. For example, you can be given drugs to prevent or reduce nausea and vomiting.

Some chemotherapy drugs have specific side effects. You should be given specific information about each drug you are receiving and you should review it before you start treatment.

Neuropathy: Cisplatin, oxaliplatin, docetaxel, and paclitaxel can damage nerves outside the brain and spinal cord. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it may be long-lasting in some patients. Oxaliplatin can also affect nerves in the throat, causing throat pain that is worse when trying to eat or drink cold liquids or foods. This pain can lead to trouble swallowing or even breathing, and can last a few days after treatment.

Heart damage: Doxorubicin, epirubicin, and some other drugs may cause permanent heart damage if used for a long time or in high doses. For this reason, doctors carefully control the doses and use heart tests such as echocardiograms or MUGA scans to monitor heart function. Treatment with these drugs is stopped at the first sign of heart damage.

Low blood cell counts: This is a very common side effect of chemo.

Having a low white blood cell count can increase your risk of serious infection. If your white blood cell counts are very low during treatment, you can reduce your risk of infection by avoiding exposure to germs. During this time, your doctor may suggest that you:

Wash your hands often.

Avoid fresh, uncooked fruits and vegetables and other foods that might carry germs.

Avoid fresh flowers and plants because they may carry mold.

Make sure other people wash their hands before they come in contact with you.

Avoid large crowds and people who are sick (wearing a surgical mask offers some protection in these situations).

You might be given drugs known as growth factors, such as G-CSF (Neupogen^®) and GM-CSF (Leukine^®), to increase your white blood cell count and thus reduce the chance of infection while you are on chemo. You might also be given antibiotics before you have signs of infection or at the earliest sign that an infection may be developing.

If your platelet counts are low, you might be given drugs or platelet transfusions to help protect against bleeding. Likewise, shortness of breath and extreme fatigue caused by low red blood cell counts may be treated with drugs or with red blood cell transfusions.

Targeted therapies for stomach cancer

Chemotherapy (chemo) drugs target cells that divide rapidly, which is why they often work against cancer cells. But there are other aspects of cancer cells that make them different from normal cells. In recent years, researchers have developed new drugs to try to target these differences. Targeted drugs may work in some cases when standard chemo drugs don’t. They also tend to have fewer severe side effects than standard chemo drugs.

Trastuzumab

About 1 out of 5 of stomach cancers has too much of a growth-promoting protein called HER2/neu (or just HER2) on the surface of the cancer cells. Tumors with increased levels of HER2 are called HER2-positive.

Trastuzumab (Herceptin) is a monoclonal antibody, a man-made version of a very specific immune system protein, which targets the HER2 protein. Giving trastuzumab with chemo can help some patients with advanced, HER2-positive stomach cancer live longer than giving chemo alone.

This drug only works if the cancer cells have too much HER2, so samples of the patient’s tumor must be tested to look for HER2 before starting treatment . It is not used in people whose cancer is HER2-negative.

Trastuzumab is injected into a vein (IV). For stomach cancer it is given once every 2 or 3 weeks along with chemo. The best length of time to give it is not yet known.

The side effects of trastuzumab tend to be relatively mild. They can include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. These side effects occur less often after the first dose. This drug can also rarely lead to heart damage. The risk of heart damage is increased if trastuzumab is given with certain chemo drugs called anthracyclines, such as epirubicin (Ellence) or doxorubicin (Adriamycin).

Radiation therapy for stomach cancer

Radiation therapy uses high-energy rays or particles to kill cancer cells in a specific area of the body. Radiation can be used in different ways to help treat stomach cancer:

Before surgery for some cancers, radiation can be used along with chemo to try to shrink the tumor to make surgery easier.

After surgery, radiation therapy can be used to kill very small remnants of the cancer that cannot be seen and removed during surgery. Radiation therapy — especially when combined with chemo drugs such as 5-FU — may delay or prevent cancer recurrence after surgery and may help patients live longer.

Radiation therapy can be used to slow the growth and ease the symptoms of advanced stomach cancer, such as pain, bleeding, and eating problems.

External beam radiation therapy is the type of radiation therapy often used to treat stomach cancer. This treatment focuses radiation on the cancer from a machine outside the body.

Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is much stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — usually takes longer. Treatments are usually given 5 days a week over several weeks or months.

Side effects from radiation therapy for stomach cancer can include:

Skin problems (often like a sunburn) at the site where the radiation was aimed

Nausea and vomiting

Diarrhea

Fatigue

Low blood cell counts

These usually go away within several weeks after the treatment is finished. When radiation is given with chemotherapy, side effects are often worse. Please be sure to tell your doctor about any side effects you have, because there are often ways to relieve them.

Radiation might also damage nearby organs that are exposed to the beams. This could lead to problems such as heart or lung damage, or even an increased risk of another cancer later on. Doctors do everything they can to prevent this by using only the needed dose of radiation, carefully controlling where the beams are aimed, and shielding certain parts of the body from the radiation during treatment.

Treatment choices by type and stage of stomach cancer

Treatment of stomach cancer depends to a large degree on where the cancer started in the stomach and how far it has spread.

Stage 0

Because stage 0 cancers are limited to the inner lining layer of the stomach and have not grown into deeper layers, they can be treated by surgery alone. No chemotherapy or radiation therapy is needed.

Surgery with either subtotal gastrectomy (removal of part of the stomach) or total gastrectomy (removal of the entire stomach) is often the main treatment for these cancers. Nearby lymph nodes are removed as well.

Some small stage 0 cancers can be treated by endoscopic mucosal resection. In this procedure the cancer is removed through an endoscope passed down the throat. This is done more often in Japan, where stomach cancer is often detected early during screening. It is rare to find stomach cancer so early in the United States, so this treatment has not been used as much here. If it is done, it should be at a cancer center that has a great deal of experience with this technique.

Stage I

Stage IA: People with stage IA stomach cancer typically have their cancer removed by total or subtotal gastrectomy. The nearby lymph nodes are also removed. Endoscopic mucosal resection may rarely be an option for some small T1a cancers. No further treatment is usually needed after surgery.

Stage IB: The main treatment for this stage of stomach cancer is surgery (total or subtotal gastrectomy). Chemotherapy (chemo) or chemoradiation (chemo plus radiation therapy) may be given before surgery to try to shrink the cancer and make it easier to remove.

After surgery, patients whose lymph nodes (removed at surgery) show no signs of cancer spread are sometimes observed without further treatment, but the doctor might also recommend either chemoradiation or chemotherapy alone after surgery. Another option for patients who were treated with chemotherapy before surgery is to give them the same chemo (without radiation) after surgery.

If cancer is found in the lymph nodes, treatment with either chemoradiation, chemo alone, or a combination of the two is often recommended.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage II

The main treatment for stage II stomach cancer is surgery to remove all or part of the stomach, the omentum, and nearby lymph nodes. Many patients are treated with chemo or chemoradiation before surgery to try to shrink the cancer and make it easier to remove. Treatment after surgery may include chemo alone or chemoradiation.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage III

Surgery is the main treatment for patients with this stage disease (unless they have other medical conditions that make them too ill for it). Some patients may be cured by surgery (along with other treatments), while for others the surgery may be able to help control the cancer or help relieve symptoms.

Some people may get chemotherapy or chemoradiation before surgery to try to shrink the cancer and make it easier to remove. Patients who get chemo before surgery will probably get chemo after, as well. For patients who don’t get chemo before surgery and for those who have surgery but have some cancer left behind, treatment after surgery is usually chemoradiation.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage IV

Because stage IV stomach cancer has spread to distant organs, a cure is usually not possible. But treatment can often help keep the cancer under control and help relieve symptoms. This might include surgery, such as a gastric bypass or even a subtotal gastrectomy in some cases, to keep the stomach and/or intestines from becoming obstructed (blocked) or to control bleeding.

In some cases, a laser beam directed through an endoscope (a long, flexible tube passed down the throat) can destroy most of the tumor and relieve obstruction without surgery. If needed, a stent (a hollow metal tube) may be placed where the esophagus and stomach meet to help keep it open and allow food to pass through it. This can also be done at the junction of the stomach and the small intestine.

Chemotherapy and/or radiation therapy can often help shrink the cancer and relieve some symptoms as well as help patients live longer, but is usually not expected to cure the cancer. Combinations of chemo drugs are most commonly used, but which combination is best is not clear. The targeted drug trastuzumab (Herceptin) might be added to chemotherapy for patients whose tumors are HER2-positive.

Because these cancers can be hard to treat, new treatments being tested in clinical trials may benefit some patients.

Even if treatments do not destroy or shrink the cancer, there are ways to relieve pain and symptoms from the disease. Patients should tell their cancer care team about any symptoms or pain they have right way, so they can be managed effectively.

Nutrition is another concern for many patients with stomach cancer. Help is available ranging from nutritional counseling to placement of a tube into the small intestine to help provide nutrition for those who have trouble eating, if needed.

What happens after treatment for stomach cancer?

For some people with stomach cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives. 

In other people, the cancer may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care

If you have completed treatment, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you are having and may do exams and lab or imaging tests to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

Most doctors recommend careful follow-up, with a physical exam and review of symptoms every 3 to 6 months for the first few years, then at least yearly after that. Lab tests might also be done. Scans are not usually needed at each visit, but should be done if there are any suspicious symptoms or physical findings.

If you have had surgery, your health care team may suggest that you meet with a nutritionist, who can help you adjust to changes in your eating habits.

People who have had surgery — especially if they had the upper part of their stomach removed (in either a subtotal or total gastrectomy) — will probably need to have their vitamin blood levels tested regularly and may need to get vitamin supplements, which may include B12 injections. (The pill form of vitamin B12 isn’t absorbed if the upper part of the stomach has been removed.)

It is important to keep your health insurance during this time. Tests and doctor visits can cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

If treatment for stomach cancer stops working

If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it’s important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.

This is likely to be the hardest part of your battle with cancer — when you have been through many medical treatments and nothing’s working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment is not likely to improve your health or change your outcome or survival.

If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more treatment might have about a 1 in 100 chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.

No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.

Palliative care helps relieve symptoms, but is not expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose — the main goal of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using medicines to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve pain caused by cancer that has spread. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this is not the same as treatment to try to cure the cancer. 

At some point, you may benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn’t mean you can’t have treatment for the problems caused by your cancer or other health conditions. In hospice, the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice in our document, Hospice Care. You can read it online or call us to have a free copy mailed to you.

Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends — times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you’ve always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.

What’s new in stomach cancer research and treatment?

Research is always being done in the area of stomach cancer. In addition to looking for the causes and ways to prevent stomach cancer, scientists continue to look for better treatments.

Risk factors

Diet

Research has clearly shown that differences in diet are an important factor in explaining variations in stomach cancer risk around the world. Recent research in countries with relatively low stomach cancer risk has provided some insight into risk factors. Diets high in preserved meats and low in fresh fruits and vegetables have been linked with higher risk.

Helicobacter pylori infection

Recent studies have shown that certain types of H pylori (especially the cagA strains) are more strongly linked to stomach cancer. Some inherited traits related to blood groups may also affect whether someone infected with H pylori will develop cancer. Further research is needed to help doctors determine how to use this information to test which people might be at higher risk for developing stomach cancer.

Recent research has also studied the interaction of H pylori infection with other risk factors. For example, they have found that a healthy diet is especially important for reducing stomach cancer risk for people infected with H pylori.

Chemoprevention

Chemoprevention is the use of natural or man-made chemicals to lower the risk of developing cancer. Some types of chemicals might be useful in helping prevent stomach cancer.

Antioxidants

Many carcinogenic (cancer-causing) factors cause cells to form a type of chemical called a free radical. Free radicals can damage important parts of cells such as genes. Depending on how severe the damage is, the cells may die or they may become cancerous.

Antioxidants are a group of nutrients and other chemicals that can destroy free radicals or prevent them from forming. These nutrients include vitamin C, beta-carotene, vitamin E, and the mineral selenium. Studies that have looked at using dietary supplements to lower stomach cancer risk have had mixed results so far. There is some evidence that combinations of antioxidant supplements may reduce the risk of stomach cancer in people with poor nutrition to begin with. Further research in this area is needed.

Antibiotics

Studies are being done to see whether antibiotic treatment of people who are chronically infected by H pylori will help prevent stomach cancer. Some studies have found that treating this infection may prevent pre-cancerous stomach abnormalities, but more research is needed.

Although not truly chemoprevention, antibiotics may help prevent stomach cancer from recurring in some cases. Researchers have shown that antibiotics may lower the risk that the cancer will come back in another part of the stomach in people who have been treated with endoscopic mucosal resection for early stage stomach cancer. Unfortunately, in the United States stomach cancers are more often found at a later stage, so it’s not clear how useful these results might be here.

Non-steroidal anti-inflammatory drugs (including aspirin)

Some (but not all) studies have found that people who take non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen might have a lower risk of stomach cancer. More research is needed to better define this possible link. In the meantime, doctors generally don’t recommend taking these medicines just to try to lower your risk of cancer, as they can cause serious side effects in some people.

Staging

Sentinel lymph node mapping

Doctors are trying to identify the spread of stomach cancer to lymph nodes using this technique, which has proved very successful in melanoma and breast cancer.

In sentinel lymph node mapping, the surgeon injects a blue dye and/or a radioactive tracer substance into the cancer. These concentrate in the lymph nodes that would be the first site of cancer spread. Doctors can remove these lymph nodes and look for cancer. If no cancer is found in these lymph nodes, then the cancer is unlikely to have reached others, and a full lymph node removal might not be needed. If cancer is found in the sentinel lymph node(s), then all the lymph nodes would still need to be removed.

This technique has been shown to help find more lymph nodes to remove, and to find lymph nodes that are more likely to contain cancer cells. But this technique is still being studied in stomach cancer and is not yet ready for widespread use.

Treatment

Laparoscopic surgery

Laparoscopy is sometimes used to help stage (determine the extent of) stomach cancer. Doctors are now studying the use of laparoscopic (keyhole) surgery to remove small stomach cancers.

In this technique, the surgeon creates several small holes in the abdomen, each about an inch long. Special long, thin instruments are inserted into these holes. One of the instruments has a small video camera on the end. The others are used to cut, staple, or sew sections of the stomach. Often, the doctor maneuvers the instruments using robotic arms while sitting at a specially designed control panel inside the operating room. This is known as robotic-assisted laparoscopic surgery.

An advantage of this type of surgery is that it does not require a large incision in the abdomen, so recovery time is usually quicker. In one early study, laparoscopy seemed to be about as effective as standard surgery. Still, it is not widely used to treat stomach cancer in the United States, and more studies are needed to prove that it is as good as the standard approach.

Chemotherapy drugs and combinations

Some studies are testing new ways to combine drugs already known to be active against stomach cancer or other cancers. Newer chemotherapy (chemo) drugs are also being studied. For example, S-1 is an oral chemo drug related to 5-FU. This drug is commonly used for stomach cancer in some other parts of the world, but it is not yet available in the United States.

Other studies are testing the best ways to combine chemo with radiation therapy, targeted therapies, or immunotherapy. A good deal of effort is being directed at improving the results of surgery by adding chemo and/or radiation therapy either before or after surgery. Several clinical trials of this approach are in progress.

New ways of giving chemo are also being studied. For example, some doctors are looking at infusing chemo directly into the abdomen (intraperitoneal chemotherapy) to see if it might work better with fewer side effects.

Targeted therapies

Chemo drugs target cells that divide rapidly, which is why they work against cancer cells. But there are other aspects of cancer cells that make them different from normal cells. In recent years, researchers have developed new targeted drugs to try to exploit these differences. Targeted drugs sometimes work when standard chemo drugs don’t. They also tend to have less severe side effects than chemo drugs.

Drugs that block HER2: Some stomach cancers have too much of the HER2 protein on the surface of their cells, which helps them grow. Drugs that target this protein might help treat these cancers. Trastuzumab (Herceptin) is already approved for use against advanced stomach cancer. Other drugs that target HER2, such as lapatinib (Tykerb^®), pertuzumab (Perjeta^®), and trastuzumab emtansine (TDM-1) are now being studied in clinical trials.

Drugs that block EGFR: EGFR is another protein found on some stomach cancer cells that helps them grow. Drugs that block EGFR, such as cetuximab (Erbitux^®) and panitumumab (Vectibix^®) have shown some promise against stomach cancer in early studies and are now being tested in larger clinical trials. These drugs are already FDA-approved to treat some other cancers.

Other targeted drugs: Other drugs target different parts of cancer cells. Targeted drugs that are FDA-approved for other types of cancer and are now being studied against stomach cancer include everolimus (Afinitor^®) and sorafenib (Nexavar^®), among others.

Most of the research in this area is looking at combining targeted agents with chemotherapy or with each other.

Immunotherapy

Immunotherapy is an approach that uses drugs to try and help the body’s immune system fight the cancer.

A Korean study showed that combining chemotherapy with an immunotherapy called polyadenylic-polyuridylic acid (poly A:U) slowed stomach cancer from returning when given as adjuvant therapy after surgery. It also helped some patients live longer.