Overview of treatment options for gastric cancer

by Specialist

There are many different treatments for patients with stomach cancer.

For patients with gastric cancer, there are a variety of different treatments. Some are standard treatments (treatments currently in use), while others are in clinical trials. A clinical trial is a scientific research method that aims to improve the current treatment or to obtain information about a new treatment. When the results of a clinical trial show that the new treatment is superior to the standard treatment, the new treatment may become the standard treatment. Patients may want to consider participating in clinical trials. Some clinical trials are only open to patients who have not yet started treatment.

Seven standard treatments currently in use:

Surgery

Surgery is a common treatment for patients with different stages of gastric cancer. The following types of surgery may be used:

  • Major gastrectomy: The portion of the stomach with the tumor, nearby lymph nodes, and a portion of other tissues and organs near the tumor are removed. The spleen may be removed. The spleen is an organ that produces lymphocytes, stores red blood cells and lymphocytes, filters blood, and destroys senescent blood cells. The spleen is located on the left side of the abdominal cavity, near the stomach.
  • Total gastrectomy: The entire stomach, adjacent lymph nodes, and parts of the esophagus, small intestine, and other tissues close to the tumor are removed. The spleen may be removed. The esophagus and small intestine are reconnected so that the patient can continue to eat and swallow.

    If the tumor is causing a blockage in the stomach and conventional surgery is not able to completely remove the tumor, then the following measures may be taken:

  • Intraluminal stent placement: The passage (such as an artery or esophagus) is kept open by implanting a stent (a small expandable tube). If the tumor blocks the entrance or exit of the stomach, a stent can be surgically placed at the esophage-gastric junction or the stomach-small intestine junction to allow the patient to eat normally.
  • Intraluminal laser therapy: An endoscope (a thin, tube-like instrument that emits light) with a laser emitter is inserted into the body. The laser is a high-intensity beam of light that can treat tumors like a scalpel.
  • Gastrojejunostomy: A procedure to remove a tumor in the stomach that is blocking the entrance to the small intestine. The stomach is connected to the jejunum (part of the small intestine) so that food and medicine can pass through the stomach into the small intestine.

    Endoscopic mucosal resection

    Endoscopic mucosal resection is the use of an endoscope to remove early tumors and precancerous lesions from the lining of the GI tract, thus avoiding surgery. An endoscope is a slender tube-like instrument with a light and lens that allows visualization of the interior of the GI tract. It also allows the use of tools to remove growths in the GI tract.

    Chemotherapy

    Chemotherapy is a treatment that uses drugs to inhibit the growth of cancer cells. The drugs can kill the cancer cells or stop them from dividing. When chemotherapy is given orally or by injecting drugs into a blood vessel or muscle, the drugs are able to get into the bloodstream and then reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is injected directly into the cerebrospinal fluid, into an organ or into a body cavity, such as the abdominal cavity, the drug will act primarily on cancer cells in these areas (local chemotherapy). The way chemotherapy is administered depends largely on the type of cancer being treated and the stage.

    One form of local chemotherapy for gastric cancer that is currently being investigated is intraperitoneal chemotherapy (IP). In intraperitoneal chemotherapy, anticancer drugs are delivered directly into the abdominal cavity (the space that holds the abdominal organs) through a thin tube.

    Heat-infused intraperitoneal chemotherapy (HIPEC) is a type of intraoperative gastric cancer treatment that is being studied. Heated chemotherapy drugs are delivered directly into the abdominal cavity after the surgeon has removed as much tumor tissue as possible.

    For more information, see approved drugs for gastric cancer.

    Radiation therapy

    Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or inhibit their growth. There are two types of radiation therapy:

  • Ex vivo radiation therapy uses a machine outside the body to send radiation to the tumor site.
  • In vivo radiation therapy involves sealing radioactive material in a needle, implanted particle, guide wire, or catheter and placing it directly into or near the cancer site.

    The type of radiation therapy used depends on the type and stage of the cancer. External radiation therapy is used to treat gastric cancer.

    Radiotherapy

    Radiotherapy therapy is a combination of chemotherapy and radiation therapy to improve the effectiveness of both. Radiotherapy after surgery can reduce the risk of cancer recurrence, which is called adjuvant therapy. And radiotherapy before surgery is currently being investigated to shrink tumors (i.e., neoadjuvant therapy).

    Targeted therapy

    Targeted therapy is a treatment that uses drugs or other substances to identify and attack specific cancer cells, and this treatment does not damage normal cells. Monoclonal antibodies and multikinase inhibitors are targeted therapies used to treat gastric cancer.

  • Monoclonal antibody therapy: This treatment uses antibodies that are produced in the laboratory by one type of immune system cell. These antibodies recognize substances on cancer cells or substances that encourage cancer cell growth. The antibodies attach to these substances and kill the cancer cells, inhibit the growth of the cancer cells, or stop the spread of the cancer cells. Monoclonal antibodies are given by injection. They can be used alone, or they can deliver drugs, toxins, or radioactive substances directly to cancer cells.

    There are different types of monoclonal antibody drugs:

  • Trastuzumab blocks the action of the growth factor protein HER2, which delivers growth signals to gastric cancer cells.
  • Remolimumab blocks the action of certain proteins, including vascular endothelial growth factor. This helps inhibit the growth of cancer cells and may kill them. It also stops the growth of new blood vessels that are needed for tumor growth.

    Trastuzumab and ramolutumab are used to treat stage IV gastric cancer and gastric cancer that cannot be surgically removed or has recurred.

  • Multikinase inhibitors: These are small molecule drugs that cross cell membranes and work inside cancer cells to block many of the protein signals needed for cancer cell growth and division. Some multikinase inhibitors also act as angiogenesis inhibitors. Angiogenesis inhibitors prevent the growth of new blood vessels needed for tumor growth.

    There are different types of multikinase inhibitor drugs:

  • Regofenib is a multikinase inhibitor and an angiogenesis inhibitor that blocks the action of multiple proteins in tumor cells. Regorafenib is being investigated for the treatment of stage IV gastric cancer and inoperable or recurrent gastric cancer.

    For more information, see Approved Drugs for Gastric Cancer.

    Immunotherapy

    Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also known as biologic therapy or biologic treatment.

    Immune checkpoint inhibitor therapy is a form of immunotherapy:

  • Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps control the body’s immune response. When PD-1 attaches to another protein called PDL-1 on cancer cells, it prevents T cells from killing cancer cells. PD-1 inhibitors attach to PDL-1, enabling T cells to kill cancer cells. Pabrolizumab is an immune checkpoint inhibitor.
    Immune checkpoint inhibitors. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help control the immune response. the binding of PD-L1 to PD-1 prevents T cells from killing tumor cells in the body (left). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows T cells to kill tumor cells (right).
    Immunotherapy uses the body’s immune system to fight cancer. This animation explains an immunotherapy that uses immune checkpoint inhibitors to treat cancer.

    For more information, see approved drugs for stomach cancer.

    A novel treatment is being validated in clinical trials.

    Information about clinical trials is available on the NCI website.

    Treatment for gastric cancer may have side effects.

    For information about side effects of cancer treatment, see the side effects page.

    Patients may want to consider participating in a clinical trial.

    For some patients, participating in a clinical trial may be the best option for treatment. Clinical trials are part of the cancer research process. The purpose of a clinical trial is to test whether a new treatment is safe, effective, or better than standard therapies.

    Many of the current standard therapies were identified based on earlier clinical trials. Patients who participate in clinical trials may receive standard therapies or be among the first to receive novel therapies.

    Patients who participate in clinical trials can also help improve future treatments for cancer. Even if clinical trials do not lead to effective new treatments, they can address important questions and help advance research.

    Patients can participate in clinical trials before, during, or after treatment.

    Some clinical trials are limited to patients who have not yet undergone treatment. And some other trial treatments are for patients whose cancer has not gotten better. There are also clinical trials that are used to test new ways to stop cancer from coming back or to reduce the side effects of cancer treatment.

    Clinical trials are being conducted in many parts of the country. Information about NCI-supported clinical trials can be found on the NCI’s Clinical Trials Search page. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

    Follow-up tests may be required.

    Some tests are repeated to diagnose the cancer or to clarify the stage of the cancer. Other tests are repeated to determine the effectiveness of treatment. The results of the tests will determine whether to continue or change or stop treatment.

    There are tests that need to be done from time to time after treatment ends. The results of the tests will show whether the disease has improved or whether the cancer has come back. These tests are often called follow-up tests or retests.

    Other tests that may be done:

  • Cancer embryonic antigen (CEA) test and CA19-9 test: A sample is examined to measure the amount of certain substances produced by organs, tissues, or tumor cells in the body. Elevated levels of certain substances in the body are often associated with specific types of cancer. These substances are called tumor markers. When carcinoembryonic antigen (CEA) and CA19-9 are higher than normal, it may mean that a recurrence of gastric cancer has occurred after treatment.