Different medical guidelines define palliative care differently, so the recommended approach varies. Palliative care in a narrow sense refers only to end-of-life care for terminal cancer, while palliative care in a broad sense is a full spectrum of treatment including supportive care for patients with all stages of cancer. This article focuses on the palliative care approach proposed by the National Comprehensive Cancer Network (NCCN), which mainly includes systemic therapy, palliative supportive care, and clinical trials.
Systemic therapy
Surgery
Some patients who would not otherwise undergo radical resection may qualify for radical resection with preoperative adjuvant therapy, at which point radical resection may be performed.
For some non-radical resectable gastric cancers, physicians may also consider palliative gastrectomy for symptom relief (e.g., bleeding or obstruction). In this case, lymph node dissection is usually not required. For obstruction, the surgeon may also use a gastrointestinal anastomosis.
Chemotherapy, radiotherapy and concurrent radiotherapy
For some gastric cancers that are not temporarily resectable radically, doctors choose to administer chemotherapy, radiation therapy, or concurrent radiotherapy to shrink the tumor, reduce the stage, and sometimes reduce invasion of adjacent organs so that the tumor can be converted to be resected radically. After surgery, physicians often continue with chemotherapy.
For advanced gastric cancer where radical resection is not possible and the cancer has metastasized extensively, such as peritoneal metastases, the systemic treatment used is often palliative chemotherapy, radiation therapy, and radiotherapy to prolong life and improve quality of life.
Targeted therapy
Targeted therapy options in gastric cancer are currently limited, with trastuzumab [Trastuzumab, trade name Herceptin, only for HER2 (ie, human epidermal growth factor receptor 2)-positive tumors] and apatinib available for some advanced gastric or gastroesophageal junction adenocarcinomas.
Palliative supportive care
The goal of palliative supportive care is to prevent, reduce, and alleviate suffering, improve quality of life, and prolong the patient’s life as much as possible, primarily targeting symptoms and focusing on psychological and spiritual issues.
- For pain caused by cancer, doctors usually follow a “three-step approach”, giving non-opioid, weak opioid, and strong opioid medications in that order.
- For nausea and vomiting, if it is caused by obstruction due to tumor, it can usually be relieved by systematic anti-cancer treatment and antiemetics can sometimes play a role; if it is caused by treatment such as chemotherapy, doctors usually give antiemetics or change the treatment strategy.
- Bleeding is often secondary to tumor, tumor-related disease, and treatment. For acute bleeding, physicians usually stop the bleeding by endoscopy, and when endoscopy is ineffective, interventional embolization therapy or emergency surgery is considered to stop the bleeding. External radiation therapy (i.e., distant radiotherapy) has also been effective.
- For obstruction, physicians may choose gastrectomy, gastrointestinal anastomosis, placement of jejunal nutrition tubes, chemotherapy, and endoscopic placement of metal stents to relieve the obstruction.
Clinical trials
For patients for whom established treatment options are no longer applicable, doctors also encourage participation in clinical trials to try some of the newest treatments, such as immunotherapy.
Although palliative care is defined differently and approaches vary slightly, the goal is to improve the patient’s quality of life and prolong life as long as possible. Physicians will choose the appropriate palliative care strategy on a case-by-case basis.