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Cancer Medicine :: Gastric Cancer

Gastric Cancer(Stomach Cancer )

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For stomach cancer, the team of doctors may include a gastroenterologist (a doctor who specializes in the gastrointestinal tract, including the stomach and intestines), a surgeon, a medical oncologist, and a radiation oncologist.

Stomach cancer may be treated with surgery, radiation therapy, or chemotherapy. Descriptions of these common treatment options for stomach cancer are listed below. Often, a combination of these treatments is used. It can be difficult to cure stomach cancer because it is often not detected until it is at an advanced stage. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. A surgical oncologist is a doctor who specializes in treating cancer using surgery. The type of surgery will depend on the stage of the cancer.

In early stages (stages 0 or I), when the cancer is still contained within the stomach, treatment usually consists of surgery to remove the affected part of the stomach and nearby lymph nodes. For a very early stage (T1a) cancer, some doctors may recommend a non-surgical treatment called endoscopic mucosal resection (removal of the tumor with an endoscope).

If the cancer has spread to the outer stomach wall or to more than three lymph nodes (stages II or III), surgery plus either chemotherapy or radiation therapy may be used. The surgeon can perform a subtotal or partial gastrectomy (removal of part of the stomach) or a total gastrectomy (removal of all of the stomach). During a gastrectomy, the surgeon attaches the esophagus directly to the small intestine. In a partial gastrectomy, the surgeon connects the remaining part of the stomach to the esophagus or small intestine. After this surgery, the patient will only be able to eat a small amount of food at a time.

Gastrectomy is a major surgery and can have serious complications or side effects. One common side effect is a group of symptoms known as dumping syndrome, which includes cramps, nausea, diarrhea, and dizziness after eating. This happens when food enters the small intestine too fast. The doctor can suggest ways to avoid this and can prescribe medication to help control these symptoms. The symptoms usually disappear in a few months, but in some cases, they may be permanent. Patients who have their entire stomach removed will need regular injections of vitamin B12 because they will no longer be able to absorb this essential vitamin through their stomach.

Regional lymph nodes are often removed during surgery (lymphadenectomy) because the cancer may have spread to those lymph nodes. There is still debate as to how extensive the lymphadenectomy should be. In Europe and especially in Japan, more lymph nodes are routinely removed than in the United States.

When the cancer is diagnosed as Stage IV, surgery is typically not a primary treatment recommendation.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Patients with stomach cancer usually receive external-beam radiation therapy, which is radiation given from a machine outside the body. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells.

Side effects from radiation therapy include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Chemotherapy can be given by mouth (orally) or injection. The goal of chemotherapy can be to destroy cancer remaining after surgery, slow the tumor’s growth, or reduce cancer-related symptoms. It also may be combined with radiation therapy. Currently, there is no single standard chemotherapy treatment plan that is used worldwide. However, most chemotherapy treatments are based on the combination of at least two drugs, fluorouracil (5-FU, Adrucil) and cisplatin (Platinol). Newer drugs similar to 5-FU (such as capecitabine or Xeloda) and similar to cisplatin (such as oxaliplatin or Eloxatin) appear to be equivalent. Other drugs commonly used include docetaxel (Taxotere), paclitaxel (Taxol), irinotecan (Camptosar), and epirubicin (Ellence).

In addition, patients whose stomach tumors have too much of the protein HER2 (called HER2-positive cancer) may benefit from the addition of trastuzumab (Herceptin) to chemotherapy in advanced stomach cancer. For more information about targeted therapies, such as trastuzumab.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. 

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Palliative/supportive care

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Recurrent stomach cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic stomach cancer

If cancer has spread to another location in the body (called Stage IV), it is called metastatic cancer.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. 

The goal of treatment at this stage is typically to prolong life and increase the patient’s comfort since metastatic stomach cancer is not considered curable. Any treatment, including chemotherapy or radiation therapy, is considered palliative therapy. The role of surgery is limited, and the primary treatment is usually chemotherapy. It is important to note that studies indicate that the use of palliative chemotherapy can improve both the length and quality of life. 

Given the inability to cure metastatic stomach cancer, this diagnosis is stressful, and at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for stomach cancer are described in detail within the Treatment section.  Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery. Family members and friends often play an important role in the care of a person with stomach cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care.

After Treatment

After treatment for stomach cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

People who have had their entire stomach removed can feed themselves and live normally, but it is important for them to learn how to eat and take food in after this major surgery. Talk with your doctor about this type of rehabilitation.

People recovering from stomach cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about stomach cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Chemoprevention. This is the use of drugs or nutrients to lower a person’s risk of developing cancer. Preliminary research indicates that using antibiotics to treat people infected with Helicobacter pylori  can prevent changes to stomach cells that may lead to cancer.

Combination therapy. The combination of chemotherapy, radiation therapy, and surgery may reduce the chance that stomach cancer will return. Doctors may give chemotherapy before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). In addition, doctors may give combined radiation therapy and chemotherapy after surgery. Doctors are also exploring the possibility of giving both radiation therapy and chemotherapy before surgery, but this approach is usually given after surgery.

Newer chemotherapy treatments. Multidrug chemotherapy combinations are being increasingly used for people with stomach cancer and may modestly improve effectiveness. As outlined in Treatment, taxanes (a group of drugs that includes paclitaxel [Taxol] and docetaxel [Taxotere]), irinotecan (Camptosar), oxaliplatin (Eloxatin), and oral medications such as S-1 and capecitabine (Xeloda) are drugs that are being combined with other types of chemotherapy.

Targeted therapies. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells. Anti-angiogenesis therapy is a type of targeted therapy. It is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. Drugs that block the growth of new blood vessels are called antiangiogenic drugs. Other new drugs function by slowing or stopping the growth of stomach cancer, including the epidermal growth factor receptor (EGFR).

Examples of targeted therapies under large-scale investigation include cetuximab (Erbitux) and panitumumab (Vectibix). As discussed in Treatment, trastuzumab, a drug that targets HER2 (a specialized protein that controls cancer growth and spread), is approved for metastatic stomach cancer patients with a HER2-positive tumor. Bevacizumab (Avastin) failed to improve survival when combined with chemotherapy in a recently completed clinical trial. Another recently completed trial of panitumumab (Vectibix) also failed to improve survival when combined with chemotherapy. 

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current stomach cancer treatments in order to improve patients’ comfort and quality of life.

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