Treatment options

Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team. 

Treatment for stomach cancer depends on: 

• the stage of the disease 
• the severity of symptoms 
• your wishes and preferences 
• your general health. 

Treatment may involve the following. 

Surgery

Surgery is usually the best option for many patients with stomach cancer, especially if the cancer is stage 1, 2 or 3^[3]. 

There are several kinds of surgery to treat stomach cancer. The type of surgery you have depends on where the cancer is in the stomach, whether the cancer has spread, and your age, medical history, nutritional needs and general health. 

Endoscopic resection

If the cancer is in the very early stages, a surgeon may be able to remove it using an endoscope. This is called an endoscopic resection. Endoscopic mucosal resection and endoscopic submucosal dissection are 2 types of endoscopic resection. 

There are no incisions (cuts) needed for this treatment, so you usually only need to stay in the hospital overnight. 

Gastrectomy

Surgery to remove all or part of the stomach is called a gastrectomy. The surgeon will remove as much of the tumour as possible, as well as some healthy tissue and lymph nodes to reduce the risk of the cancer coming back (recurring). The lymph nodes will be sent to a pathologist, to see if there are any cancer cells in them. 

There are 2 ways a gastrectomy may be performed, depending on the size of the tumour: 

• laparotomy, or open surgery, where a long cut is made in the upper part of the abdomen 
• laparoscopic surgery, or ‘keyhole’ surgery, where several small cuts are made in the abdomen and a laparoscope is used to guide the surgeon. 

There are 2 types of gastrectomy, depending on where the cancer is located: 

• partial gastrectomy, where only part of the stomach is removed, is performed when the cancer is in the lower part of the stomach; nearby fatty tissue and lymph nodes are also removed, while the upper stomach and oesophagus are usually left in place 
• total gastrectomy, where the whole stomach is removed, is performed when the cancer is in the upper or middle part of the stomach; nearby fatty tissue, lymph nodes, and parts of nearby organs (if necessary) are also removed. The surgeon will rejoin the oesophagus to the small intestine, and part of the small intestine will serve as the stomach. 

If the tumour cannot be completely removed by surgery but it is blocking the stomach, you may need^[4][5][6]: 

• endoluminal stent placement – a stent, which is a thin, flexible tube, is placed into passages (such as the oesophagus) to help keep them open 
• endoluminal laser therapy – an endoscope with a laser attached is used to burn away the cancer cells 
• gastrojejunostomy, or gastric bypass – the stomach is connected to part of the small intestine, to bypass the blockage. 

Feeding tube

Before or after stomach surgery, you may need a feeding tube placed into your small intestine to help you get the nutrition you need. The feeding tube can be placed through a nostril (called a nasojejunal tube) or through the skin of your abdomen (called a jejunostomy or J-tube). 

You will have the feeding tube until you are able to eat and drink normally. 

Chemotherapy

Along with surgery, some people may receive chemotherapy^[7]. For stomach cancer, chemotherapy may be used before surgery to reduce the tumour size and allow resection (neoadjuvant therapy) and/or after surgery to reduce the risk of cancer recurrence (adjuvant therapy). Chemotherapy is the main treatment for recurrent diseaseor to help control advanced stomach cancer.  

Radiation therapy

Radiation therapy for stomach cancer is used to control symptoms of pain, difficulty swallowing or bleeding^[8]. It may also be used before or after surgery, or in combination with chemotherapy (called chemoradiation). Chemoradiation can also be offeredwhen surgery is not an option. 

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells^[9][10][11]. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells.  

Some stomach cancers are HER2-positive, meaning they have abnormally high levels of the HER2 protein (a protein that causes cancer cells to grow uncontrollably). A medicine used for targeted therapy of HER2-positive stomach cancers is trastuzumab. This drug destroys, or slows the growth of, the HER2-positive cancer cells. Trastuzumab is usually given in combination with other chemotherapies. 

Another targeted therapy drug is ramucirumab, which reduces the bloody supply to a tumour to slow or stop its growth. 

Immunotherapy

Immunotherapy is a type of targeted therapy that uses medicines to stimulate the immune system to attack cancer cells. Immune checkpoint inhibitors are a type of immunotherapy. They block the proteins on immune system cells that stop these cells from attacking other cells in the body. This can help boost the immune system’s response against cancer cells. 

Along with chemotherapy, checkpoint inhibitors, such as nivolumab, are used as treatment for people with advanced stomach cancer that has high levels of the PD-L1 protein. Checkpoint inhibitors may also be used when chemotherapy hasn’t worked, or when the tumour has a high level of the marker MSI.  

Follow-up

After treatment, you might have regular visits with your doctor for physical examinations, blood tests, imaging scans, or an endoscopy, if needed. These show if your condition has changed or if the cancer has recurred (come back)^[12]. 

You should let your doctor know if you notice any symptoms between appointments. 

Recurrent cancer

Stomach cancer can recur (come back) after treatment. If stomach cancer has come back, the treatment you have will depend on the type of cancer, where it has spread, the type of treatments you have already had and your general health^[13][14]. Treatment options for recurrent stomach cancer include chemotherapy, radiation therapy, targeted therapy, immunotherapy or surgery. Some people have treatment to ease symptoms (called palliative care), which may include radiotherapy, chemotherapy, or other drug therapies.