Treatment Choices Based on the Extent of Stomach Cancer

Treatment of stomach cancer (also known as gastric cancer) depends largely on where the cancer is in the stomach and how far it has spread. But other factors, such as a person’s age, overall health, and preferences, can be important as well.

Stomach cancer typically starts in the inner lining of the stomach. From there, it can grow and spread in different ways. It can grow through the wall of the stomach and into nearby organs. It might also spread to the nearby lymph nodes (bean-sized structures that help fight infections). As the cancer becomes more advanced, it can travel through the bloodstream or lymph system and spread (metastasize) to organs such as the liver, lungs, and bones, which can make it harder to treat.

Surgery to remove the cancer is typically part of treatment if it can be done, as it offers the best chance for long-term survival. But surgery might not be a good option if the cancer has spread widely or if a person isn’t healthy enough for it. Other treatments such as chemotherapy and radiation therapy are often part of treatment as well, either along with or instead of surgery. Newer treatments such as targeted drugs and immunotherapy might be helpful in some situations as well.

Because most people will get different types of treatment for their cancer, it’s important that a team of doctors review and discuss the best options for treatment. Stomach cancer isn’t common in the United States, and it can be challenging to treat, so it’s important that your cancer care team is experienced in treating stomach cancer.

While the AJCC TNM stage of the cancer can be important when deciding on treatment, doctors often divide stomach cancers into larger groups when determining the best treatment options. These include:

• Very early stage cancers. These cancers have not grown deeply into the wall of the stomach or spread outside the stomach. These cancers make up only a small portion of stomach cancers in the United States.
• Potentially resectable cancers. These cancers have grown deeper into the stomach wall and may have grown into nearby areas or lymph nodes. But these cancers aren’t thought to have spread to distant parts of the body, so surgery might still be an option to try to remove (resect) them completely.
• Unresectable local or regional cancers. These cancers have also grown deeper into the stomach wall and may have grown into nearby areas or lymph nodes. While the cancer hasn’t yet spread to distant parts of the body, it's unlikely it can all be removed with surgery. For example, the cancer might be too close to vital areas, or the person might not be healthy enough for major surgery.
• Metastatic cancers. These cancers have spread to distant parts of the body.

Very early stage cancers

These cancers are still only in the inner lining layer of the stomach and have not grown into deeper layers of the stomach wall.

Very early stage cancers can typically be treated by surgery, with either subtotal gastrectomy (removal of part of the stomach) or total gastrectomy (removal of the entire stomach). Nearby lymph nodes are removed as well.

Some small stage 0 cancers can be treated by endoscopic resection. In this procedure the cancer and some layers of the stomach wall are removed through an endoscope passed down the throat. This procedure is done more often in countries like 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 often here. If it is done, it should be at a cancer center that has experience with this technique.

If the results of surgery (or endoscopic resection) 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, chemotherapy and radiation are likely to be recommended. Another option might be a more extensive surgery to remove the cancer.

Potentially resectable cancers

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

It’s very important that all of the 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, other tests such as endoscopic ultrasound (EUS) or staging laparoscopy might be done before trying to remove the cancer. (See Tests for Stomach Cancer for more on these tests.)

Depending on the location and extent of the cancer, some people might get surgery as their first treatment, with either 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. Other people might get chemotherapy alone or chemo plus radiation therapy (known as chemoradiation) first to try to shrink the cancer and make the surgery easier.

After surgery, chemo (or chemoradiation, if it wasn’t used before surgery) might be given to try to kill any remaining cancer cells. This is especially true if it’s not clear that all of the cancer was removed, or if too few lymph nodes were removed during surgery. Another option if not all of the cancer was removed might be a more extensive operation.

Unresectable local or regional cancers

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

Options for the first line of treatment for these cancers might include chemotherapy alone, chemo plus immunotherapy, chemo plus immunotherapy plus the targeted drug trastuzumab (if the cancer tests positive for HER2 and for the PD-L1 protein), or chemo plus radiation therapy (chemoradiation).

The stage (extent) of the cancer is then reassessed after treatment. It’s very important that doctors know the true 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 with this treatment, surgery to remove the cancer might be an option at this point. 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 after the initial treatment, further treatment is 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 next).

Sometimes, even when the cancer is potentially resectable, 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 next).

Metastatic cancers

These cancers have spread to distant parts of the body, and they are very hard to cure. But treatment can often help keep the cancer under control and help prevent or relieve problems it might cause.

Treatment aimed at controlling the growth of the cancer might include chemotherapy alone, chemotherapy plus immunotherapy, or chemotherapy along with radiation therapy if a person is healthy enough. For people whose cancers test positive for HER2, the targeted drug trastuzumab can be added to the chemo, which might help it work better. If the cancer cells also test positive for the PD-L1 protein, another option is to add the immunotherapy drug pembrolizumab to the trastuzumab and chemo, as part of the first treatment.

If one type of chemo doesn’t work (or if it stops working), another type of chemo might be tried. Other options might include a targeted therapy drug or an immunotherapy drug.

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 with 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 benefit some patients.

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 about any symptoms you have right away, so they can be managed effectively.

Recurrent cancer

Cancer that comes back after initial 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.

If the cancer comes back only in one area near where the original cancer was, surgery might be an option to try to remove it, if a person is health enough for the operation.

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 growth 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 an option and could be considered.