Chemotherapy for Stomach Cancer

Chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein (through an IV line or central venous catheter) 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.

When is chemo used for stomach cancer?

Chemo might be used at different times to help treat stomach cancer:

• Chemo can be given before surgery for stomach cancer. This is known as neoadjuvant treatment. (Sometimes chemo is given along with radiation therapy, which is known as chemoradiation.) Neoadjuvant treatment can often 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 has been done to remove the cancer. This is called adjuvant treatment. The goal of adjuvant chemo is to kill any areas of cancer 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 may be especially helpful for cancers that could not be removed completely by surgery.
• Chemo may be given as the primary (main) treatment if the cancer has spread (metastasized) to distant parts of the body, or if it can't be removed for some other reason. Chemo may help shrink the cancer or slow its growth, which can relieve symptoms and help people 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.

Which chemo drugs are used for stomach cancer?

Many different chemo drugs can be used to treat stomach cancer, including:

• 5-FU (fluorouracil), often given along with leucovorin (folinic acid)
• Capecitabine
• Carboplatin
• Cisplatin
• Docetaxel
• Epirubicin
• Irinotecan
• Oxaliplatin
• Paclitaxel
• Trifluridine and tipiracil (Lonsurf), a combination drug in pill form

Most often, 2 or 3 of these drugs are combined (sometimes along with a targeted drug as well). But this depends on factors such as  the stage of the cancer, the person’s overall health, and whether chemo is combined with radiation therapy. 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.

For earlier stage cancers, some common drug combinations used before and/or after surgery include:

• Oxaliplatin plus 5-FU/leucovorin (FOLFOX), or oxaliplatin plus capecitabine (CAPOX)
• FLOT (5-FU/leucovorin, oxaliplatin, and docetaxel)
  
• Docetaxel or paclitaxel plus either 5-FU or capecitabine
• Cisplatin plus either 5-FU or capecitabine
• Paclitaxel and carboplatin

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

For advanced stomach cancer, many of the same combinations of drugs can be used, although doctors often prefer combinations of 2 drugs rather than 3 to try to reduce side effects. Some of the most commonly used combinations include:

• Oxaliplatin plus 5-FU/leucovorin (FOLFOX), or oxaliplatin plus capecitabine (CAPOX)
• Cisplatin plus either 5-FU or capecitabine
• Irinotecan plus 5-FU/leucovorin (FOLFIRI) 
• Paclitaxel plus either cisplatin or carboplatin
• Docetaxel plus cisplatin
• Epirubicin, either cisplatin or oxaliplatin, and either 5-FU or capecitabine
• Docetaxel, 5-FU, and either cisplatin, carboplatin, or oxaliplatin

If a person isn’t healthy enough to get a combination of chemo drugs, a single drug, such as 5-FU, capecitabine, docetaxel, or paclitaxel, might be used instead.

If one of these combinations (or a single drug) is no longer helpful, another drug or combination of drugs might be tried. 

Side effects of chemo

Chemo drugs attack cells in the body that are dividing quickly, which can lead to side effects. These depend on the type and dose of drugs, and the length of treatment. Side effects from chemo can include:

• Nausea and vomiting
• Loss of appetite
• Hair loss
• Diarrhea or constipation
• Mouth sores
• Increased chance of infection (from a shortage of white blood cells)
• Easy bleeding or bruising (from a shortage of platelets)
• Fatigue and shortness of breath (from a shortage of red blood cells)

These side effects usually 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 help with them. For example, you can be given drugs to prevent or reduce nausea and vomiting.

Some chemo drugs have specific side effects. Your treatment team can help you know which of these you might need to look out for.

Nerve damage (neuropathy): Cisplatin, oxaliplatin, docetaxel, and paclitaxel can damage nerves. 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 people. Oxaliplatin can also affect nerves in the throat, causing throat pain that is worse when trying to eat or drink cold liquids or foods.

Heart damage: Epirubicin and some other drugs can damage the heart 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.

Hand-foot syndrome can occur during treatment with capecitabine or 5-FU (when given as an infusion). This starts out as redness in the hands and feet, which can then progress to pain and sensitivity in the palms and soles. If it worsens, blistering, calluses, or skin peeling can occur, sometimes leading to painful sores. The best way to prevent severe hand-foot syndrome is to tell your doctor if you have early symptoms, such as redness or sensitivity, so that steps can be taken to keep things from getting worse.

Diarrhea is a common side effect with many chemo drugs, but it can be particularly bad with irinotecan. It needs to be treated right away — at the first sign of loose stools — to prevent severe dehydration. If you are getting a chemo drug that is likely to cause diarrhea, your doctor will give you instructions on what drugs to take and how often to take them to control this symptom.

Some chemo drugs can cause other side effects. Talk with your treatment team about what types of side effects you should watch for.