Treating Stomach Cancer

These cancers are still only in the inner lining layer of the stomach (the mucosa or submucosa) and are not thought to have grown deeper into the stomach wall or to have reached the lymph nodes.

Treatment options for very early-stage cancers might include:

• Surgery, either subtotal or total gastrectomy
• Endoscopic resection, either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)

Endoscopic resection is only likely to be an option for small, intestinal-type stomach cancers that are at very low risk of having spread any farther. In this procedure, the cancer and some layers of the stomach wall are removed through an endoscope passed down the throat. This is done more often in countries like Japan, where stomach cancer is often found early during screening. It’s rare to find stomach cancer this early in the United States, so this treatment isn’t used as often here. If it is done, it should be at a cancer center that has experience with this technique.

Whether further treatment is needed depends on the results of surgery (or endoscopic resection):

If the results show that all of the cancer has been removed, the person can usually be followed closely, without needing any further treatment.

If it’s not clear that all of the cancer has been removed after an endoscopic procedure, surgery will likely be recommended.

If it’s not clear that all of the cancer has been removed after surgery, chemotherapy and radiation are likely to be recommended. This combination is known as chemoradiation.

These cancers have grown deeper into the stomach wall and may have grown into nearby areas, but there are no signs they have grown into vital structures or spread to other parts of the body, so surgery might be an option to remove them.

It’s very important that all needed tests are done to stage these cancers accurately before surgery is attempted, so the doctors know the true extent of the cancer in the body. Trying to remove the cancer isn’t likely to be helpful if it has spread too far, and surgery can have serious side effects, so accurately staging these cancers helps ensure the potential benefits of surgery outweigh the potential downsides. Along with imaging tests like CT and PET scans, endoscopic ultrasound (EUS) and staging laparoscopy are often done before trying to remove the cancer. (See Tests for Stomach Cancer.)

Most people will get other treatments along with surgery, because it increases the chances of getting rid of the cancer completely. Treatment options might include:

• Chemotherapy, often along with an immunotherapy drug, followed by either a subtotal or total gastrectomy. Nearby lymph nodes (and possibly parts of nearby organs) are removed as well. This is followed by more chemotherapy/immunotherapy. Giving drug therapy before and after surgery is known as perioperative therapy.
• Surgery first, with either subtotal or total gastrectomy. Nearby lymph nodes (and possibly parts of nearby organs) are removed as well. Depending on the results of surgery, this might be followed by either chemotherapy or chemo plus radiation therapy (chemoradiation).
• Immunotherapy first, if the cancer cells have certain gene or protein changes such as high microsatellite instability (MSI-H) or a defect in a mismatch repair gene (dMMR), followed by surgery. This might be followed by more immunotherapy after surgery.

These cancers haven’t spread to distant parts of the body, but they can’t be removed (resected) completely with surgery.

Options for first-line treatment for these cancers might include:

• Chemotherapy alone
• Chemotherapy plus a targeted therapy drug, if the cancer cells have certain gene or protein changes such as high levels of HER2 or CLDN18.2
• Chemotherapy plus an immunotherapy drug, if the cancer cells have the PD-L1 protein
• Chemotherapy plus immunotherapy plus a targeted therapy drug (if the cancer cells have the PD-L1 protein and certain gene or protein changes)
• Chemotherapy plus radiation therapy (chemoradiation)
• Immunotherapy, if the cancer cells have high microsatellite instability (MSI-H) or a defect in a mismatch repair gene (dMMR)

The cancer is then reassessed after treatment. It’s very important that doctors know the extent of the cancer at this point. Along with imaging tests like CT and PET scans, other tests such as endoscopic ultrasound (EUS) or staging laparoscopy might be done. (See Tests for Stomach Cancer for more on these tests.)

If the cancer has shrunk enough, surgery to remove the cancer might be an option. This might be a subtotal gastrectomy (removal of part of the stomach) or total gastrectomy (removal of the entire stomach). Nearby lymph nodes (and possibly parts of nearby organs) are removed as well.

If the cancer is still unresectable, further treatment is aimed at controlling the cancer’s growth for as long as possible and preventing or relieving any problems it causes. This is similar to the treatment of metastatic cancer (described next).

Cancers that have spread to distant parts of the body can’t be removed completely. But treatment can often help keep the cancer under control and help prevent or relieve problems it might cause.

Treatments aimed at controlling the cancer’s growth

Treatment aimed at controlling the growth of the cancer might include:

• Chemotherapy alone
• Chemotherapy plus a targeted therapy drug, if the cancer cells have certain gene or protein changes such as high levels of HER2 or CLDN18.2
• Chemotherapy plus an immunotherapy drug, if the cancer cells have the PD-L1 protein
• Chemotherapy plus immunotherapy plus a targeted therapy drug (if the cancer cells have the PD-L1 protein and certain gene or protein changes)
• Chemotherapy plus radiation therapy (chemoradiation)
• Immunotherapy alone, if the cancer cells have high microsatellite instability (MSI-H) or a defect in a mismatch repair gene (dMMR)
• A targeted drug alone, if the cancer cells have certain changes such as an NTRK, BRAF, or RET gene change

If one type of treatment doesn’t work (or if it stops working), another type can often be tried.

Treatments to help prevent or relieve symptoms

Some types of palliative surgery, such as a gastric bypass (or, less often, a subtotal gastrectomy) might be helpful in some situations to keep the stomach and/or intestines from becoming blocked (obstructed) or to control bleeding.

Endoscopic procedures might also be used to help prevent or relieve symptoms, especially in people who can’t have (or don’t want) surgery. For example:

A laser beam directed through an endoscope (a long, flexible tube passed down the throat) can destroy parts of the tumor to stop it from blocking the passage of food through the stomach.

If needed, an endoscope can be used to place a stent (a hollow metal tube) where the esophagus and stomach meet to help keep it open and allow food to pass through. This can also be done at the junction of the stomach and the small intestine.

Stomach cancer (and its treatment) can often lead to problems eating, and getting adequate nutrition is often a concern. Some people might be helped by the placement of a feeding tube. If it is only needed for a short time, a thin tube can be passed down the nose and throat and into the stomach or intestine. If a feeding tube is needed for a longer time, a minor surgical procedure can be done to place the tube through the skin of the abdomen and into either the lower part of the stomach (a gastrostomy tube or G tube) or the small intestine (a jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

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

Even if treatments do not destroy or shrink the cancer, there are often ways to relieve pain, trouble eating, and other symptoms. It's important to tell your cancer care team right away about any symptoms you have, so they can be managed effectively.

For people who aren’t healthy enough for (or don’t want) major surgery

Sometimes, even when the cancer can be removed, a person might not be healthy enough for major surgery, or they might decide not to have it.

Treatment for these cancers is typically aimed at controlling the cancer growth for as long as possible and preventing or relieving any problems it causes. This is similar to the treatment of metastatic cancer (described above).

Preventing or relieving symptoms

Along with the treatments above, some people might be helped by treatments to prevent or relieve symptoms and complications from the cancer. See “Treatments to help prevent or relieve symptoms,” above.

Cancer that comes back after treatment is known as recurrent cancer. Treatment options for recurrent cancer depend on where the cancer recurs, what treatments a person has already had, and the person’s overall health and preferences.

Local recurrence: If the cancer comes back only near where the original cancer was, surgery and/or radiation therapy might be options, if a person is healthy enough. Chemotherapy, immunotherapy, or targeted therapy drugs might be part of treatment as well.

Distant recurrence: If the cancer recurrence is more widespread or is in a distant part of the body, or if a person isn’t healthy enough for surgery, treatment is similar to that for metastatic cancer (described above), in which the main goals are to control the cancer for as long as possible and to prevent or relieve any problems it might cause.

For people who are interested, clinical trials of newer treatments may be a good option.