If the cancer has invaded the deeper muscular layer of the stomach wall, the outermost plasma layer or reached the outer plasma membrane, regardless of the size of the cancer or the presence of metastasis, it is called progressive gastric cancer, which usually includes stage T2 to T4 gastric cancer. The goal of treatment for progressive gastric cancer is to achieve eradication or maximum tumor control, prolong patient survival, and improve quality of life.
For progressive gastric cancer that is initially evaluated for resectability, physicians generally follow the following process for diagnosis and treatment: refine relevant tests; preoperative treatment; determine surgical plan and perform surgery; postoperative treatment; and follow-up.
Perfecting the examination
Besides the usual physical examination and blood tests, before starting treatment, the doctor will perform a series of tests that are used to determine the benignity, location, and stage of gastric cancer.
Preoperative treatment
Not all progressive gastric cancers require immediate surgery. Depending on the depth of tumor invasion and whether there are lymph node metastases, doctors will consider whether neoadjuvant therapy should be administered before surgery. The goal of neoadjuvant therapy is to significantly reduce the size of the tumor and lower its pathologic stage, thereby reducing the difficulty of surgery, narrowing the scope of surgery, and reducing the chance of intraoperative dissemination of tumor cells, thereby increasing the likelihood of radical resection of the tumor. The treatments that physicians may use in neoadjuvant therapy include chemotherapy, radiotherapy, etc.
Identifying surgical options and performing surgery
For progressive gastric cancer that is initially evaluated as operable, physicians generally use a combination of treatments that are primarily surgical, with surgery being the primary treatment and currently the only way to cure gastric cancer.
The surgeon will determine the surgical approach based on a combination of factors, and currently D2 radical surgery is the standard procedure for progressive gastric cancer, meaning that in addition to a somewhat expanded resection of the gastric lesion, the lymph nodes are cleared to station 2 lymph nodes.
After gastric cancer surgery, systematic pathological diagnosis of the resected tissue is important to clarify the histologic type of gastric cancer, assess outcomes, and provide a basis for the development of targeted and individualized treatment plans. Detection of expression of targets such as HER2, or human epidermal growth factor receptor 2, can provide a basis for the selection of targeted therapy postoperatively.
Post-operative treatment
Radiotherapy
Patients with pathologic staging of T3 to T4 or positive lymph nodes after radical gastric cancer who did not undergo standard D2 radical surgery and did not have preoperative radiotherapy, physicians typically choose to administer concurrent radiotherapy postoperatively.
Chemotherapy
Postoperative patients usually require chemotherapy, and the treatment regimen is determined by the physician based on multiple factors, including the tumor condition and the patient’s systemic status. Adjuvant chemotherapy usually begins after the patient has largely recovered from surgery, usually 3 to 4 weeks after surgery, and is usually completed within 6 months with combination chemotherapy and no more than 1 year with single-agent chemotherapy.
For patients whose surgery did not result in radical resection, a multidisciplinary treatment team discussion is generally required to decide on a follow-up treatment plan.
Which patients should have post-operative adjuvant chemotherapy?
Patients with total gastrectomy who develop anemia are often advised by their physicians to take vitamin B12 and folic acid supplements. If granulocytopenia occurs with postoperative chemotherapy, your doctor will usually give leukocyte-raising drugs. For severe vomiting or other adverse reactions, doctors also give symptomatic treatment.
The purpose of follow-up is to monitor for disease recurrence or treatment-related adverse effects, assess improvement in nutritional status, and so on.
Usually, patients are followed up every 3 to 6 months for 3 years after surgical treatment, every 6 months for 3 to 5 years after surgery, and once a year after 5 years. Follow-ups include blood tests, imaging, etc. Gastroscopy is usually performed once a year.
For progressive gastric cancer, the physician usually adopts a comprehensive treatment, including surgery, chemotherapy, and radiotherapy in a planned and rational way according to the pathological type and clinical stage of the tumor, as well as the general condition and functional status of the patient’s organs. Patients must follow the doctor’s advice to receive standardized treatment and follow-up, which is conducive to a good outcome. (Coauthored by Songcheng Yin, Department of Gastrointestinal Oncology, The First Hospital of China Medical University)