General Information About Gastric Cancer

KEY POINTS

  • Gastric cancer is a disease in which malignant (cancer) cells form in the lining of the stomach.
  • Age, diet, and stomach disease can affect the risk of developing gastric cancer.
  • Symptoms of gastric cancer include indigestion and stomach discomfort or pain.
  • Tests that examine the stomach and esophagus are used to detect (find) and diagnose gastric cancer.
  • Certain factors affect prognosis (chance of recovery) and treatment options.

Gastric cancer is a disease in which malignant (cancer) cells form in the lining of the stomach.

The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients (vitaminsminerals,carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body. Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine.

ENLARGEGastrointestinal (digestive) system anatomy; drawing shows the esophagus, liver, stomach, small intestine, and large intestine.
The esophagus and stomach are part of the upper gastrointestinal (digestive) system.

The wall of the stomach is made up of 3 layers of tissue: the mucosal (innermost) layer, the muscularis (middle) layer, and the serosal (outermost) layer. Gastric cancer begins in the cells lining the mucosal layer and spreads through the outer layers as it grows.

Stromal tumors of the stomach begin in supporting connective tissue and are treated differently from gastric cancer. See the PDQ summary on Gastrointestinal Stromal Tumors Treatment for more information.

For more information about cancers of the stomach, see the following PDQ summaries:

Age, diet, and stomach disease can affect the risk of developing gastric cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for gastric cancer include the following:

  • Eating a diet high in salted, smoked foods and low in fruits and vegetables.
  • Eating foods that have not been prepared or stored properly.
  • Being older or male.
  • Smoking cigarettes.
  • Having a mother, father, sister, or brother who has had stomach cancer.

Symptoms of gastric cancer include indigestion and stomach discomfort or pain.

These and other signs and symptoms may be caused by gastric cancer or by other conditions.

In the early stages of gastric cancer, the following symptoms may occur:

  • Indigestion and stomach discomfort.
  • A bloated feeling after eating.
  • Mild nausea.
  • Loss of appetite.
  • Heartburn.

In more advanced stages of gastric cancer, the following signs and symptoms may occur:

Check with your doctor if you have any of these problems.

Tests that examine the stomach and esophagus are used to detect (find) and diagnose gastric cancer.

The following tests and procedures may be used:

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
  • Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • Upper endoscopy : A procedure to look inside the esophagus, stomach, andduodenum (first part of the small intestine) to check for abnormal areas. Anendoscope (a thin, lighted tube) is passed through the mouth and down the throat into the esophagus.ENLARGEUpper endoscopy; shows endoscope inserted through the mouth and esophagus and into the stomach. Inset shows patient on table having an upper endoscopy.
    Upper endoscopy. A thin, lighted tube is inserted through the mouth to look for abnormal areas in the esophagus, stomach, and first part of the small intestine.
  • Barium swallow : A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.ENLARGEBarium swallow for stomach cancer; drawing shows barium liquid flowing through the esophagus and into the stomach.
    Barium swallow for stomach cancer. The patient swallows barium liquid and it flows through the esophagus and into the stomach. X-rays are taken to look for abnormal areas.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Biopsy : The removal of cells or tissues so they can be viewed under a microscopeto check for signs of cancer. A biopsy of the stomach is usually done during the endoscopy.

    The sample of tissue may be checked to measure how many HER2 genes there are and how much HER2 protein is being made. If there are more HER2 genes or higher levels of HER2 protein than normal, the cancer is called HER2 positive. HER2-positive gastric cancer may be treated with a monoclonal antibody that targets the HER2 protein.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of the cancer (whether it is in the stomach only or has spread to lymph nodes or other places in the body).
  • The patient’s general health.

When gastric cancer is found very early, there is a better chance of recovery. Gastric cancer is often in an advanced stage when it is diagnosed. At later stages, gastric cancer can be treated but rarely can be cured. Taking part in one of the clinical trialsbeing done to improve treatment should be considered. Information about ongoing clinical trials is available from the NCI website.

Stages of Gastric Cancer

KEY POINTS

  • After gastric cancer has been diagnosed, tests are done to find out if cancer cells have spread within the stomach or to other parts of the body.
  • There are three ways that cancer spreads in the body.
  • Cancer may spread from where it began to other parts of the body.
  • The following stages are used for gastric cancer:
    • Stage 0 (Carcinoma in Situ)
    • Stage I
    • Stage II
    • Stage III
    • Stage IV

After gastric cancer has been diagnosed, tests are done to find out if cancer cells have spread within the stomach or to other parts of the body.

The process used to find out if cancer has spread within the stomach or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • CEA (carcinoembryonic antigen) assay: Tests that measure the level of CEA in theblood. This substance is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of gastric cancer or other conditions.
  • Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues ororgans and make echoes. The echoes form a picture of body tissues called asonogram. This procedure is also called endosonography.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • PET scan (positron emission tomography scan): A procedure to find malignanttumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cellsbreak away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if gastric cancer spreads to the liver, the cancer cells in the liver are actually gastric cancer cells. The disease is metastatic gastric cancer, not liver cancer.

The following stages are used for gastric cancer:

Stage 0 (Carcinoma in Situ)

In stage 0abnormal cells are found in the inside lining of the mucosa (innermost layer) of the stomach wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I

In stage Icancer has formed in the inside lining of the mucosa (innermost layer) of thestomach wall. Stage I is divided into stage IA and stage IB, depending on where the cancer has spread.

Stage II

Stage II gastric cancer is divided into stage IIA and stage IIB, depending on where thecancer has spread.

  • Stage IIA: Cancer:
    • has spread to the subserosa (layer of tissue next to the serosa) of the stomachwall; or
    • has spread to the muscle layer of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or
    • may have spread to the submucosa (layer of tissue next to the mucosa) of the stomach wall and is found in 3 to 6 lymph nodes near the tumor.
  • Stage IIB: Cancer:
    • has spread to the serosa (outermost layer) of the stomach wall; or
    • has spread to the subserosa (layer of tissue next to the serosa) of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or
    • has spread to the muscle layer of the stomach wall and is found in 3 to 6 lymph nodes near the tumor; or
    • may have spread to the submucosa (layer of tissue next to the mucosa) of the stomach wall and is found in 7 or more lymph nodes near the tumor.

Stage III

Stage III gastric cancer is divided into stage IIIA, stage IIIB, and stage IIIC, depending on where the cancer has spread.

Stage IV

In stage IVcancer has spread to distant parts of the body.

Treatment Option Overview

KEY POINTS

  • There are different types of treatment for patients with gastric cancer.
  • Five types of standard treatment are used:
    • Surgery
    • Chemotherapy
    • Radiation therapy
    • Chemoradiation
    • Targeted therapy
  • New types of treatment are being tested in clinical trials.
  • Patients may want to think about taking part in a clinical trial.
  • Patients can enter clinical trials before, during, or after starting their cancer treatment.
  • Follow-up tests may be needed.

There are different types of treatment for patients with gastric cancer.

Different types of treatments are available for patients with gastric cancer. Some treatments are standard (the currently used treatment), and some are being tested inclinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

Surgery is a common treatment of all stages of gastric cancer. The following types of surgery may be used:

  • Subtotal gastrectomy: Removal of the part of the stomach that contains cancer, nearby lymph nodes, and parts of other tissues and organs near the tumor. Thespleen may be removed. The spleen is an organ in the upper abdomen that filters the blood and removes old blood cells.
  • Total gastrectomy: Removal of the entire stomach, nearby lymph nodes, and parts of the esophagussmall intestine, and other tissues near the tumor. The spleen may be removed. The esophagus is connected to the small intestine so the patient can continue to eat and swallow.

If the tumor is blocking the stomach but the cancer cannot be completely removed by standard surgery, the following procedures may be used:

  • Endoluminal stent placement: A procedure to insert a stent (a thin, expandable tube) in order to keep a passage (such as arteries or the esophagus) open. For tumors blocking the passage into or out of the stomach, surgery may be done to place a stent from the esophagus to the stomach or from the stomach to the small intestine to allow the patient to eat normally.
  • Endoluminal laser therapy: A procedure in which an endoscope (a thin, lighted tube) with a laser attached is inserted into the body. A laser is an intense beam of light that can be used as a knife.
  • Gastrojejunostomy: Surgery to remove the part of the stomach with cancer that is blocking the opening into the small intestine. The stomach is connected to thejejunum (a part of the small intestine) to allow food and medicine to pass from the stomach into the small intestine.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavitysuch as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

See Drugs Approved for Stomach (Gastric) Cancer for more information.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types ofradiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

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

Chemoradiation

Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both. Chemoradiation given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Chemoradiation given before surgery, to shrink the tumor (neoadjuvant therapy), is being studied.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibodytherapy is a type of targeted therapy used in the treatment of gastric cancer.

Monoclonal antibody therapy uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. For stage IV gastric cancerand gastric cancer that has recurred, monoclonal antibodies, such as trastuzumab orramucirumab, may be given. Trastuzumab blocks the effect of the growth factor proteinHER2, which sends growth signals to gastric cancer cells. Ramucirumab blocks the effect of the protein VEGF and may prevent the growth of new blood vessels that tumors need to grow.

See Drugs Approved for Stomach (Gastric) Cancer for more information.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI website.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options by Stage

Stage 0 (Carcinoma in Situ)

Treatment of stage 0 is usually surgery (total or subtotalgastrectomy).

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage 0 gastric cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage I Gastric Cancer

Treatment of stage I gastric cancer may include the following:

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage I gastric cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage II Gastric Cancer

Treatment of stage II gastric cancer may include the following:

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage II gastric cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage III Gastric Cancer

Treatment of stage III gastric cancer may include the following:

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage III gastric cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage IV and Recurrent Gastric Cancer

Treatment of stage IV or recurrent gastric cancer may include the following:

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage IV gastric cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

 

What is stomach cancer?

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body. To learn more about how cancers start and spread, see What Is Cancer?

Stomach cancer, also called gastric cancer, is a cancer that starts in the stomach. To understand stomach cancer, it helps to know about the normal structure and function of the stomach.

The stomach

After food is chewed and swallowed, it enters the esophagus, a tube that carries food through the neck and chest to the stomach. The esophagus joins the stomach at thegastroesophageal (GE) junction, which is just beneath the diaphragm (the thin sheet of breathing muscle under the lungs). The stomach is a sac-like organ that holds food and starts to digest it by secreting gastric juice. The food and gastric juice are mixed and then emptied into the first part of the small intestine called the duodenum.

Some people use the word stomach to refer to the area of the body between the chest and the pelvic area. The medical term for this area is the abdomen. For instance, some people with pain in this area would say they have a “stomachache,” when in fact the pain could be coming from the appendix, small intestine, colon (large intestine), or other organs in the area. Doctors would call this symptom abdominal pain, because the stomach is only one of many organs in the abdomen.

Stomach cancer should not be confused with other cancers that can occur in the abdomen, like cancer of the colon (large intestine)liverpancreas, or small intestinebecause these cancers may have different symptoms, different outlooks, and different treatments.

Parts of the stomach

The stomach has 5 parts:

  • Cardia: The first portion (closest to the esophagus)
  • Fundus: The upper part of the stomach next to the cardia.
  • Body (corpus): The main part of the stomach, between the upper and lower parts
  • Antrum: The lower portion (near the intestine), where the food is mixed with gastric juice
  • Pylorus: The last part of the stomach, which acts as a valve to control emptying of the stomach contents into the small intestine.

The first 3 parts of the stomach (cardia, fundus, and body) are sometimes called theproximal stomach. Some cells in these parts of the stomach make acid and pepsin (a digestive enzyme), the parts of the gastric juice that help digest food. They also make a protein called intrinsic factor, which the body needs to absorb vitamin B12.

The lower 2 parts (antrum and pylorus) are called the distal stomach. The stomach has 2 curves, which form its inner and outer borders. They are called the lesser curvature andgreater curvature, respectively.

Other organs next to the stomach include the colon, liver, spleen, small intestine, and pancreas.

The stomach wall has 5 layers:

  • The innermost layer is the mucosa. This is where stomach acid and digestive enzymes are made. Most stomach cancers start in this layer.
  • Next is a supporting layer called the submucosa.
  • Outside of this is the muscularis propria, a thick layer of muscle that moves and mixes the stomach contents.
  • The outer 2 layers, the subserosa and the outermost serosa, wrap the stomach.

The layers are important in determining the stage (extent) of the cancer and in helping to determine a person’s prognosis (outlook). As a cancer grows from the mucosa into deeper layers, the stage becomes more advanced and the prognosis is not as good.

Development of stomach cancer

Stomach cancers tend to develop slowly over many years. Before a true cancer develops, pre-cancerous changes often occur in the inner lining (mucosa) of the stomach. These early changes rarely cause symptoms and therefore often go undetected.

Cancers starting in different sections of the stomach may cause different symptoms and tend to have different outcomes. The cancer’s location can also affect the treatment options. For example, cancers that start at the GE junction are staged and treated the same as cancers of the esophagus. A cancer that starts in the cardia of the stomach but then grows into the GE junction is also staged and treated like a cancer of the esophagus. (For more information, see Esophagus Cancer.)

Stomach cancers can spread (metastasize) in different ways. They can grow through the wall of the stomach and invade nearby organs. They can also spread to the lymph vessels and nearby lymph nodes. Lymph nodes are bean-sized structures that help fight infections. The stomach has a very rich network of lymph vessels and nodes. As the stomach cancer becomes more advanced, it can travel through the bloodstream and spread to organs such as the liver, lungs, and bones. If cancer has spread to the lymph nodes or to other organs, the patient’s outlook is not as good.

Types of stomach cancers

Different types of stomach cancer include:

Adenocarcinoma

About 90% to 95% of cancers of the stomach are adenocarcinomas. When the termstomach cancer or gastric cancer is used, it almost always refers to an adenocarcinoma. These cancers develop from the cells that form the innermost lining of the stomach (known as the mucosa).

Lymphoma

These are cancers of the immune system tissue that are sometimes found in the wall of the stomach. About 4% of stomach cancers are lymphomas. The treatment and outlook depend on the type of lymphoma. For more detailed information, see Non-Hodgkin Lymphoma.

Gastrointestinal stromal tumor (GIST)

These are rare tumors that start in very early forms of cells in the wall of the stomach called interstitial cells of Cajal. Some of these tumors are non-cancerous (benign); others are cancerous. Although GISTs can be found anywhere in the digestive tract, most are found in the stomach. For more information, see Gastrointestinal Stromal Tumor (GIST).

Carcinoid tumor

These are tumors that start in hormone-making cells of the stomach. Most of these tumors do not spread to other organs. About 3% of stomach cancers are carcinoid tumors. These tumors are discussed in more detail in Gastrointestinal Carcinoid Tumors.

Other cancers

Other types of cancer, such as squamous cell carcinoma, small cell carcinoma, and leiomyosarcoma, can also start in the stomach, but these cancers are very rare.

The information in the remainder of this document refers only to adenocarcinoma of the stomach.

What are the risk factors for stomach cancer?

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

But risk factors don’t tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may have few or no known risk factors.

Scientists have found several risk factors that make a person more likely to get stomach cancer. Some of these can be controlled, but others cannot.

Gender

Stomach cancer is more common in men than in women.

Age

There is a sharp increase in stomach cancer rates in people over the age of 50. Most people diagnosed with stomach cancer are between their late 60s and 80s.

Ethnicity

In the United States, stomach cancer is more common in Hispanic Americans, African Americans, and Asian/Pacific Islanders than it is in non-Hispanic whites.

Geography

Worldwide, stomach cancer is more common in Japan, China, Southern and Eastern Europe, and South and Central America. This disease is less common in Northern and Western Africa, South Central Asia, and North America.

Helicobacter pylori infection

Infection with Helicobacter pylori (H pylori) bacteria seems to be a major cause of stomach cancer, especially cancers in the lower (distal) part of the stomach. Long-term infection of the stomach with this germ may lead to inflammation (called chronic atrophic gastritis) and pre-cancerous changes of the inner lining of the stomach. (See “Do we know what causes stomach cancer?”)

People with stomach cancer have a higher rate of H pylori infection than people without this cancer. H pylori infection is also linked to some types of lymphoma of the stomach. Even so, most people who carry this germ in their stomach never develop cancer.

Stomach lymphoma

People who have had a certain type of lymphoma of the stomach known as mucosa-associated lymphoid tissue (MALT) lymphoma have an increased risk of getting adenocarcinoma of the stomach. This is probably because MALT lymphoma of the stomach is caused by infection with H pylori bacteria.

Diet

An increased risk of stomach cancer is seen in people with diets that have large amounts of smoked foods, salted fish and meat, and pickled vegetables. Nitrates and nitrites are substances commonly found in cured meats. They can be converted by certain bacteria, such as H pylori, into compounds that have been shown to cause stomach cancer in lab animals.

On the other hand, eating lots of fresh fruits and vegetables appears to lower the risk of stomach cancer. (See “Can stomach cancer be prevented?”)

Tobacco use

Smoking increases stomach cancer risk, particularly for cancers of the upper portion of the stomach near the esophagus. The rate of stomach cancer is about doubled in smokers.

Being overweight or obese

Being overweight or obese is a possible cause of cancers of the cardia (the upper part of the stomach nearest the esophagus), but the strength of this link is not yet clear.

Previous stomach surgery

Stomach cancers are more likely to develop in people who have had part of their stomach removed to treat non-cancerous diseases such as ulcers. This might be because the stomach makes less acid, which allows more nitrite-producing bacteria to be present. Reflux (backup) of bile from the small intestine into the stomach after surgery might also add to the increased risk. These cancers typically develop many years after the surgery.

Pernicious anemia

Certain cells in the stomach lining normally make a substance called intrinsic factor (IF)that we need to absorb vitamin B12 from foods. People without enough IF may end up with a vitamin B12 deficiency, which affects the body’s ability to make new red blood cells and can cause other problems as well. This condition is called pernicious anemia. Along with anemia (too few red blood cells), people with this disease have an increased risk of stomach cancer.

Menetrier disease (hypertrophic gastropathy)

In this condition, excess growth of the stomach lining causes large folds in the lining and leads to low levels of stomach acid. Because this disease is very rare, it is not known exactly how much this increases the risk of stomach cancer.

Type A blood

Blood type groups refer to certain substances that are normally present on the surface of red blood cells and some other types of cells. These groups are important in matching blood for transfusions. For unknown reasons, people with type A blood have a higher risk of getting stomach cancer.

Inherited cancer syndromes

Some inherited conditions may raise a person’s risk of stomach cancer.

Hereditary diffuse gastric cancer

This inherited syndrome greatly increases the risk of developing stomach cancer. This condition is rare, but the lifetime stomach cancer risk among affected people is about 70% to 80%. Women with this syndrome also have an increased risk of getting a certain type ofbreast cancer. This condition is caused by mutations (defects) in the CDH1 gene.

Hereditary non-polyposis colorectal cancer (HNPCC)

HNPCC, also known as Lynch syndrome, is an inherited genetic disorder that increases the risk of colorectal cancer. People with this syndrome also have an increased risk of getting stomach cancer (as well as some other cancers). In most cases, this disorder is caused by a defect in either the MLH1 or MSH2 gene, but other genes can cause HNPCC, including MLH3MSH6TGFBR2PMS1, and PMS2.

Familial adenomatous polyposis (FAP)

In FAP syndrome, people get many polyps in the colon, and sometimes in the stomach and intestines as well. People with this syndrome are at greatly increased risk of gettingcolorectal cancer and have a slightly increased risk of getting stomach cancer. It is caused by mutations in the APC gene.

BRCA1 and BRCA2

People who carry mutations of the inherited breast cancer genes BRCA1 or BRCA2 may also have a higher rate of stomach cancer.

Li-Fraumeni syndrome

People with this syndrome have an increased risk of several types of cancer, including developing stomach cancer at a relatively young age. Li-Fraumeni syndrome is caused by a mutation in the TP53 gene.

Peutz-Jeghers syndrome (PJS)

People with this condition develop polyps in the stomach and intestines, as well as in other areas including the nose, the airways of the lungs, and the bladder. The polyps in the stomach and intestines are a special type called hamartomas. They can cause problems like bleeding or blockage of the intestines. PJS can also cause dark freckle-like spots on the lips, inner cheeks and other areas. People with PJS have an increased risk of cancers of the breast, colon, pancreas, stomach, and several other organs. This syndrome is caused by mutations in the gene STK1.

A family history of stomach cancer

People with first-degree relatives (parents, siblings, or children) who have had stomach cancer are more likely to develop this disease.

Some types of stomach polyps

Polyps are non-cancerous growths on the lining of the stomach. Most types of polyps (such as hyperplastic polyps or inflammatory polyps) do not seem to increase a person’s risk of stomach cancer, but adenomatous polyps – also called adenomas – can sometimes develop into cancer.

Epstein-Barr virus (EBV) infection

Epstein-Barr virus causes infectious mononucleosis (also called mono). Almost all adults have been infected with this virus at some time in their lives, usually as children or teens.

EBV has been linked to some forms of lymphoma. It is also found in the cancer cells of about 5% to 10% of people with stomach cancer. These people tend to have a slower growing, less aggressive cancer with a lower tendency to spread. EBV has been found in some stomach cancer cells, but it isn’t yet clear if this virus actually causes stomach cancer.

Certain occupations

Workers in the coal, metal, and rubber industries seem to have a higher risk of getting stomach cancer.

Common variable immune deficiency (CVID)

People with CVID have an increased risk of stomach cancer. The immune system of someone with CVID can’t make enough antibodies in response to germs. People with CVID have frequent infections as well as other problems, including atrophic gastritis and pernicious anemia. They are also more likely to get gastric lymphoma and stomach cancer.


Can stomach cancer be found early?

Screening is testing for a disease, such as cancer, in people without symptoms. In countries such as Japan, where stomach cancer is very common, mass screening of the population has helped find many cases at an early, curable stage. This may have reduced the number of people who die of this disease, but this has not been proven.

Studies in the United States have not found that routine screening in people at average risk for stomach cancer is useful, because this disease is not that common. On the other hand, people with certain stomach cancer risk factors may benefit from screening. If you have any questions about your stomach cancer risk or about the benefits of screening, please ask your doctor.

Some of the tests that could be used for screening, such as upper endoscopy, are described in the section “How is stomach cancer diagnosed?

Because routine screening for stomach cancer is not done in the United States, most people with this disease are not diagnosed until they have certain signs and symptomsthat point to the need for medical tests.

Can stomach cancer be prevented?

There is no sure way to prevent stomach cancer, but there are things you can do that could lower your risk.

Diet, nutrition, body weight, and physical activity

The dramatic decline of stomach cancer in the past several decades is thought to be a result of people reducing many of the known dietary risk factors. This includes greater use of refrigeration for food storage rather than preserving foods by salting, pickling, and smoking. To help reduce your risk, avoid a diet that is high in smoked and pickled foods and salted meats and fish.

A diet high in fresh fruits and vegetables can also lower stomach cancer risk. Citrus fruits (such as oranges, lemons, and grapefruit) may be especially helpful, but grapefruit and grapefruit juice can change the blood levels of certain drugs you take, so it’s important to discuss this with your health care team before adding grapefruit to your diet.

The American Cancer Society recommends that people eat a healthy diet, with an emphasis on plant foods. This includes eating at least 2½ cups of vegetables and fruits every day. Choosing whole-grain breads, pastas, and cereals instead of refined grains, and eating fish, poultry, or beans instead of processed meat and red meat may also help lower your risk of cancer.

Studies that have looked at using dietary supplements to lower stomach cancer risk have had mixed results so far. Some studies have suggested that combinations of antioxidant supplements (vitamins A, C, and E and the mineral selenium) might reduce the risk of stomach cancer in people with poor nutrition to begin with. But most studies looking at people who have good nutrition have not found any benefit to adding vitamin pills to their diet. Further research in this area is needed.

Although some small studies suggested that drinking tea, particularly green tea, may help protect against stomach cancer, most large studies have not found such a link.

Being overweight or obese may add to the risk of stomach cancer. On the other hand, being physically active may help lower your risk.

The American Cancer Society recommends maintaining a healthy weight throughout life by balancing calorie intake with physical activity. Aside from possible effects on the risk of stomach cancer, losing weight and being active may also have an effect on the risk of several other cancers and health problems. The full recommendations can be found in theAmerican Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention.

Avoiding tobacco use

Tobacco use can increase the risk of cancers of the proximal stomach (the portion of the stomach closest to the esophagus). Tobacco use increases the risk for many other types of cancer and is responsible for about one-third of all cancer deaths in the United States. If you don’t use tobacco, please don’t start. If you already do and want help quitting, call the American Cancer Society at 1-800-227-2345.

Treating H pylori infection

It is not yet clear whether people whose stomach linings are chronically infected with the H pylori bacteria but who do not have any symptoms should be treated with antibiotics. This is a topic of current research. Some early studies have suggested that giving antibiotics to people with H pylori infection may lower the number of pre-cancerous lesions in the stomach and may reduce the risk of developing stomach cancer. But not all studies have found this. More research is needed to be sure that this is a way to prevent stomach cancer in people with H pylori infection.

If your doctor thinks you might have H pylori infection, there are several ways to test for this:

  • The simplest way is a blood test that looks for antibodies to H pylori. Antibodies are proteins the body’s immune system makes in response to an infection. A positive H pylori antibody test result can mean either that you are infected with H pylori or that you had an infection in the past that is now cleared.
  • Another approach is to have an endoscopy procedure (see the section “How is stomach cancer diagnosed?”) to take a biopsy sample of the stomach lining. This sample can be used for chemical tests for this kind of bacteria. Doctors can also identify H pylori in biopsy samples viewed under a microscope. The biopsy sample can also be cultured (placed in a substance that promotes bacterial growth) to see if H pylori grows out of the sample.
  • There is also a special breath test for the bacteria. For this test, you drink a liquid containing urea. If H pylori is present, it will chemically change the urea. A sample of your breath is then tested for these chemical changes.

Aspirin use

Using aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, seems to lower the risk of stomach cancer. These medicines can also lower the risk of developing colon polyps and colon cancer. But they can also cause serious (and even life-threatening) internal bleeding and other potential health risks in some people.

Most doctors consider any reduced cancer risk an added benefit for patients who take these drugs for other reasons, such as to treat arthritis. But doctors do not routinely recommend taking NSAIDs specifically to prevent stomach cancer. Studies have not yet determined for which patients the benefits of lowering cancer risk would outweigh the risks of bleeding complications.

For people at greatly increased risk

Only a small percentage of stomach cancers are caused by hereditary diffuse gastric cancer syndrome. But it is very important to recognize it, because most people who inherit this condition eventually get stomach cancer. A personal history of invasive lobular breast cancer before age 50 as well as having close family members who have had stomach cancer suggests that they might be at risk for having this syndrome. These people can talk to a genetics professional about getting genetic testing. If the testing shows the person has a mutation (abnormal change) in the CDH1 gene, many doctors will recommend they have their stomach removed before the cancer develops.

Stomach Cancer

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EARLY DETECTION, DIAGNOSIS, AND STAGING TOPICS

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Can stomach cancer be found early?

Signs and symptoms of stomach cancer

Unfortunately, early-stage stomach cancer rarely causes symptoms. This is one of the reasons stomach cancer is so hard to detect early. The signs and symptoms of stomach cancer can include:

  • Poor appetite
  • Weight loss (without trying)
  • Abdominal (belly) pain
  • Vague discomfort in the abdomen, usually above the navel
  • A sense of fullness in the upper abdomen after eating a small meal
  • Heartburn or indigestion
  • Nausea
  • Vomiting, with or without blood
  • Swelling or fluid build-up in the abdomen
  • Low red blood cell count (anemia)

Most of these symptoms are more likely to be caused by things other than cancer, such as a stomach virus or an ulcer. They may also occur with other types of cancer. But people who have any of these problems, especially if they don’t go away or get worse, should check with their doctor so the cause can be found and treated.

Since symptoms of stomach cancer often do not appear until the disease is advanced, only about 1 in 5 stomach cancers in the United States is found at an early stage, before it has spread to other areas of the body.


How is stomach cancer diagnosed?

Stomach cancers are usually found when a person goes to the doctor because of signs or symptoms they are having. The doctor will take a history and examine the patient. If stomach cancer is suspected, tests will be needed to confirm the diagnosis.

Medical history and physical exam

When taking your medical history, the doctor will ask you questions about your symptoms (eating problems, pain, bloating, etc.) and possible risk factors to see if they might suggest stomach cancer or another cause. The physical examgives your doctor information about your general health, possible signs of stomach cancer, and other health problems. In particular, the doctor will feel your abdomen for any abnormal changes.

If your doctor thinks you might have stomach cancer or another type of stomach problem, he or she will refer you to a gastroenterologist, a doctor who specializes in diseases of the digestive tract, who will examine you and do further testing.

Upper endoscopy

Upper endoscopy (also called esophagogastroduodenoscopy or EGD) is the main test used to find stomach cancer. It may be used when someone has certain risk factors or when signs and symptoms suggest this disease may be present.

During this test, the doctor passes an endoscope, which is a thin, flexible, lighted tube with a small video camera on the end, down your throat. This lets the doctor see the lining of your esophagus, stomach, and first part of the small intestine. If abnormal areas are seen, biopsies (tissue samples) can be taken using instruments passed through the endoscope. The tissue samples are sent to a lab, where they are looked at under a microscope to see if cancer is present.

When seen through an endoscope, stomach cancer can look like an ulcer, a mushroom-shaped or protruding mass, or diffuse, flat, thickened areas of mucosa known as linitis plastica. Unfortunately, the stomach cancers in hereditary diffuse gastric cancer syndrome often cannot be seen during endoscopy.

Endoscopy can also be used as part of a special imaging test known as endoscopic ultrasound, which is described below.

This test is usually done after you are given medication to make you sleepy (sedation). If sedation is used, you will need someone to take you home (not just a cab).

Endoscopic ultrasound

Ultrasound uses sound waves to produce images of organs such as the stomach. During a standard ultrasound, a wand-shaped probe called a transducer is placed on the skin. It gives off sound waves and detects the echoes as they bounce off internal organs. The pattern of echoes is processed by a computer to produce a black and white image on a screen.

In endoscopic ultrasound (EUS), a small transducer is placed on the tip of an endoscope. While you are sedated, the endoscope is passed down the throat and into the stomach. This lets the transducer rest directly on the wall of the stomach where the cancer is. It lets the doctor look at the layers of the stomach wall, as well as the nearby lymph nodes and other structures just outside the stomach. The picture quality is better than a standard ultrasound because of the shorter distance the sound waves have to travel.

EUS is most useful in seeing how far a cancer may have spread into the wall of the stomach, to nearby tissues, and to nearby lymph nodes. It can also be used to help guide a needle into a suspicious area to get a tissue sample (EUS-guided needle biopsy).

Biopsy

Your doctor may suspect cancer if an abnormal-looking area is seen on endoscopy or an imaging test, but the only way to tell for sure if it is really cancer is by doing a biopsy. During a biopsy, the doctor removes a sample of the abnormal area.

Biopsies to check for stomach cancer are most often obtained during upper endoscopy. If the doctor sees any abnormal areas in the stomach lining during the endoscopy, instruments can be passed down the endoscope to biopsy them.

Some stomach cancers are deep within the stomach wall, which can make them hard to biopsy with standard endoscopy. If the doctor suspects cancer might be deeper in the stomach wall, endoscopic ultrasound can be used to guide a thin, hollow needle into the wall of the stomach to get a biopsy sample.

Biopsies may also be taken from areas of possible cancer spread, such as nearby lymph nodes or suspicious areas in other parts of the body.

Testing biopsy samples

Biopsy samples are sent to a lab to be looked at under a microscope. The samples are checked to see if they contain cancer, and if they do, what kind it is (for example, adenocarcinoma, carcinoid, gastrointestinal stromal tumor, or lymphoma).

If a sample contains adenocarcinoma cells, it may be tested to see if it has too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). The HER2/neugene instructs the cells to make this protein. Tumors with increased levels of HER2/neu are called HER2-positive.

Stomach cancers that are HER2-positive can be treated with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin®). See the section “Targeted therapies for stomach cancer” for more information.

The biopsy sample may be tested in 2 different ways:

  • Immunohistochemistry (IHC): In this test, special antibodies that stick to the HER2/neu protein are applied to the sample, which cause cells to change color if many copies are present. This color change can be seen under a microscope. The test results are reported as 0, 1+, 2+, or 3+.
  • Fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.

Often the IHC test is used first.

  • If the results are 0 or 1+, the cancer is HER2-negative. People with HER2-negative tumors are not treated with drugs (like trastuzumab) that target HER2.
  • If the test comes back 3+, the cancer is HER2-positive. Patients with HER2-positive tumors may be treated with drugs like trastuzumab.
  • When the result is 2+, the HER2 status of the tumor is not clear. This often leads to testing the tumor with FISH.

See Testing Biopsy and Cytology Specimens for Cancer to learn more about different types of biopsies and tests, how the tissue is used in the lab to diagnose cancer, and what the results will tell you.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including:

  • To help find out whether a suspicious area might be cancerous
  • To learn how far cancer may have spread
  • To help determine if treatment has been effective

Upper gastrointestinal (GI) series

This is an x-ray test to look at the inner lining of the esophagus, stomach, and first part of the small intestine. This test is used less often than endoscopy to look for stomach cancer or other stomach problems, as it may miss some abnormal areas and does not allow the doctor to take biopsy samples. But it is less invasive than endoscopy, and it might be useful in some situations.

For this test, the patient drinks a white chalky solution containing a substance calledbarium. The barium coats the lining of the esophagus, stomach, and small intestine. Several x-ray pictures are then taken. Because x-rays can’t pass through the coating of barium, this will outline any abnormalities of the lining of these organs.

A double-contrast technique may be used to look for early stomach cancer. With this technique, after the barium solution is swallowed, a thin tube is passed into the stomach and air is pumped in. This makes the barium coating very thin, so even small abnormalities will show up.

Computed tomography (CT or CAT) scan

The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into images of slices of the part of your body being studied.

Before the test, you may be asked to drink 1 or 2 pints of a contrast solution and/or receive an intravenous (IV) line through which a contrast dye is injected. This helps better outline structures in your body.

The IV contrast can cause some flushing (redness and warm feeling). Some people are allergic and get hives, or rarely have more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.

CT scans show the stomach fairly clearly and often can confirm the location of the cancer. CT scans can also show the organs near the stomach, such as the liver, as well as lymph nodes and distant organs where cancer might have spread. The CT scan can help determine the extent (stage) of the cancer and whether surgery may be a good treatment option.

CT-guided needle biopsy: CT scans can also be used to guide a biopsy needle into a suspected area of cancer spread. The patient remains on the CT scanning table while a doctor moves a biopsy needle through the skin toward the mass. CT scans are repeated until the needle is within the mass. A fine-needle biopsy sample (tiny fragment of tissue) or a core-needle biopsy sample (a thin cylinder of tissue) is then removed and looked at under a microscope.

Magnetic resonance imaging (MRI) scan

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material might be injected just as with CT scans, but this is used less often.

Most doctors prefer to use CT scans to look at the stomach. But an MRI may sometimes provide more information. MRIs are often used to look at the brain and spinal cord.

MRI scans take longer than CT scans, often up to an hour. You may have to lie inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Special, open MRI machines can help with this if needed, although the images may not be as sharp in some cases. The MRI machine makes loud buzzing noises that you may find disturbing. Some places provide headphones to block this noise out.

Positron emission tomography (PET) scan

In this test, radioactive substance (usually a type of sugar related to glucose, known as FDG) is injected into a vein. (The amount of radioactivity used is very low and will pass out of the body over the next day or so.) Because cancer cells are growing faster than normal cells, they use sugar much faster, so they take up the radioactive material. After about an hour, you are moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body.

PET is sometimes useful if your doctor thinks the cancer might have spread but doesn’t know where. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about the whole body. Although PET scans can be useful for finding areas of cancer spread, they aren’t always helpful in certain kinds of stomach cancer because these types don’t take up glucose very much.

Some machines can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT. PET/CT may be more helpful than PET alone for stomach cancer. This can help show if the cancer has spread beyond the stomach to other parts of the body, in which case surgery might not be a good treatment.

Chest x-ray

This test can help find out if the cancer has spread to the lungs. It might also determine if there are any serious lung or heart diseases present. This test is not needed if a CT scan of the chest has been done.

You can read more about imaging tests in Imaging (Radiology) Tests.

Other tests

Laparoscopy

If this procedure is done, it is usually only after stomach cancer has already been found. Although CT or MRI scans can create detailed pictures of the inside of the body, they can miss some tumors, especially if they are very small. Doctors might do a laparoscopy before any other surgery to help confirm a stomach cancer is still only in the stomach and can be removed completely with surgery. It may also be done before chemotherapy and/orradiation if these are planned before surgery.

This procedure is done in an operating room with the patient under general anesthesia (in a deep sleep). A laparoscope (a thin, flexible tube) is inserted through a small surgical opening in the patient’s side. The laparoscope has a small video camera on its end, which sends pictures of the inside of the abdomen to a TV screen. Doctors can look closely at the surfaces of the organs and nearby lymph nodes, or even take small samples of tissue. If it doesn’t look like the cancer has spread, sometimes the doctor will “wash” the abdomen with saline (salt water). The fluid (called peritoneal washings) is then removed and checked to see if it contains cancer cells. If it does, the cancer has spread, even if the spread couldn’t be seen.

Sometimes laparoscopy is combined with ultrasound to give a better picture of the cancer.

Lab tests

When looking for signs of stomach cancer, a doctor may order a blood test called acomplete blood count (CBC) to look for anemia (which could be caused by the cancer bleeding into the stomach). A fecal occult blood test may be done to look for blood in stool (feces) that isn’t visible to the naked eye.

The doctor might recommend other tests if cancer is found, especially if you are going to have surgery. For instance, blood tests will be done to make sure your liver and kidney functions are normal and that your blood clots normally. If surgery is planned or you are going to get medicines that can affect the heart, you may also have an electrocardiogram (EKG) and echocardiogram (an ultrasound of the heart) to make sure your heart is functioning well.

How is stomach cancer staged?

The stage of a cancer is a description of how far the cancer has spread. The stomach cancer’s stage is an important factor in choosing treatment options and predicting a patient’s outlook (prognosis).

There are actually 2 types of stages for stomach cancer.

The clinical stage of the cancer is the doctor’s best estimate of the extent of the cancer, based on the results of physical exams, endoscopy, biopsies, and any imaging tests (such as CT scans) that have been done. These exams and tests are described in the section “How is stomach cancer diagnosed?

If surgery is done, the pathologic stage can be determined using the same test results used for the clinical stage, plus what is found from tissues removed during surgery.

The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates. Because the pathologic stage is based on what was found at surgery, it can more accurately predict the patient’s outlook. The staging described here is the pathologic stage.

A staging system is a way for members of the cancer care team to describe the extent of a cancer’s spread. The system most often used to stage stomach cancer in the United States is the American Joint Commission on Cancer (AJCC) TNM system. The TNM system for staging contains 3 key pieces of information:

  • T describes the extent of the primary tumor (how far it has grown into the wall of the stomach and into nearby organs).
  • N describes the spread to nearby (regional) lymph nodes.
  • indicates whether the cancer has metastasized (spread) to distant parts of the body. The most common sites of distant spread of stomach cancer are the liver, the peritoneum (the lining of the space around the digestive organs), and distant lymph nodes. Less common sites of spread include the lungs and brain.

Numbers or letters appear after T, N, and M to provide more details about each of these factors:

  • The numbers 0 through 4 indicate increasing severity.
  • The letter X means “cannot be assessed” because the information is not available.
  • The letters “is” refer to carcinoma in situ, which means the tumor is only in the top layer of mucosa cells and has not yet invaded deeper layers of tissue.

This system is for staging all stomach cancers except those starting in either the gastroesophageal junction (where the stomach and the esophagus meet) or in the cardia (the first part of the stomach) and growing into the gastroesophageal junction. Those cancers are staged (and often treated) like cancers of the esophagus. (See Esophagus Cancer)

T categories of stomach cancer

Nearly all stomach cancers start in the innermost layer of the stomach wall (the mucosa). The T category describes how far through the stomach’s 5 layers the cancer has invaded.

  • The innermost layer is the mucosa. The mucosa has 3 parts: epithelial cells, which lie on top of a layer of connective tissue (the lamina propria), which is on top of a thin layer of muscle (the muscularis mucosa).
  • Under the mucosa is a supporting layer called the submucosa.
  • Below this is the muscularis propria, a thick layer of muscle that moves and mixes the stomach contents.
  • The next 2 layers, the subserosa and the outermost serosa, act as wrapping layers for the stomach.

TX: The main (primary) tumor cannot be assessed.

T0: No signs of a main tumor can be found.

Tis: Cancer cells are only in the top layer of cells of the mucosa (innermost layer of the stomach) and have not grown into deeper layers of tissue such as the lamina propria or muscularis mucosa. This stage is also known as carcinoma in situ.

T1: The tumor has grown from the top layer of cells of the mucosa into the next layers below such as the lamina propria, the muscularis mucosa, or submucosa.

  • T1a: The tumor is growing into the lamina propria or muscularis mucosa.
  • T1b: The tumor has grown through the lamina propria and muscularis mucosa and into the submucosa.

T2: The tumor is growing into the muscularis propria layer.

T3: The tumor is growing into the subserosa layer.

T4: The tumor has grown into the serosa and may be growing into a nearby organ (spleen, intestines, pancreas, kidney, etc.) or other structures such as major blood vessels.

  • T4a: The tumor has grown through the stomach wall into the serosa, but the cancer hasn’t grown into any of the nearby organs or structures.
  • T4b: The tumor has grown through the stomach wall and into nearby organs or structures.

N categories of stomach cancer

NX: Nearby (regional) lymph nodes cannot be assessed.

N0: No spread to nearby lymph nodes.

N1: The cancer has spread to 1 to 2 nearby lymph nodes.

N2: The cancer has spread to 3 to 6 nearby lymph nodes.

N3: The cancer has spread 7 or more nearby lymph nodes.

  • N3a: The cancer has spread to 7 to 15 nearby lymph nodes.
  • N3b: The cancer has spread to 16 or more nearby lymph nodes.

M categories of stomach cancer

M0: No distant metastasis (the cancer has not spread to distant organs or sites, such as the liver, lungs, or brain).

M1: Distant metastasis (the cancer has spread to organs or lymph nodes far away from the stomach).

TNM stage grouping

Once the T, N, and M categories have been determined, this information is combined and expressed as a stage, using the number 0 (zero) and the Roman numerals I through IV. This is known as stage grouping. Some stages are split into substages, indicated by letters.

Stage 0: Tis, N0, M0

This is stomach cancer in its earliest stage. It has not grown beyond the inner layer of cells that line the stomach (Tis). The cancer has not spread to any lymph nodes (N0) or anywhere else (M0). This stage is also known as carcinoma in situ.

Stage IA: T1, N0, M0

The cancer has grown beneath the top layer of cells in the mucosa into tissue below, such as the connective tissue (lamina propria), the thin muscle layer (muscularis mucosa), or the submucosa (T1). The cancer has not spread to any lymph nodes (N0) or anywhere else (M0).

Stage IB: Any of the following:

T1, N1, M0: The cancer has grown into the layer of connective tissue (lamina propria), and may have grown into the thin layer of muscle beneath it (muscularis mucosa) or deeper into the submucosa (T1). Cancer has also spread to 1 or 2 lymph nodes near the stomach (N1), but not to any distant tissues or organs (M0).

OR

T2, N0, M0: The cancer has grown into the main muscle layer of the stomach wall, called the muscularis propria (T2). It has not spread to nearby lymph nodes (N0) or to any distant tissues or organs (M0).

Stage IIA: Any of the following:

T1, N2, M0: The cancer has grown beneath the top layer of cells of the mucosa into the layer of connective tissue (lamina propria), thin muscle layer (muscularis mucosa), or the submucosa (T1). It has spread to 3 to 6 nearby lymph nodes (N2). It has not spread to distant sites (M0).

OR

T2, N1, M0: The cancer has grown into the main muscle layer of the stomach called the muscularis propria (T2). It has spread to 1 or 2 nearby lymph nodes (N1), but has not spread to distant sites (M0).

OR

T3, N0, M0: The cancer has grown through the main muscle layer into the subserosa, but has not grown through all the layers to the outside the stomach (T3). It has not spread to any nearby lymph nodes (N0) or to distant tissues or organs (M0).

Stage IIB: Any of the following:

T1, N3, M0: The cancer has grown beneath the top layer of cells of the mucosa into the layer of connective tissue (lamina propria), the thin muscle layer, or the submucosa (T1). It has spread to 7 or more nearby lymph nodes (N3). It has not spread to distant tissues or organs (M0).

OR

T2, N2, M0: The cancer has grown into the main muscle layer, called the muscularis propria (T2). It has spread to 3 to 6 nearby lymph nodes (N2), but it has not spread to distant tissues or organs (M0).

OR

T3, N1, M0: The cancer has grown into the subserosa layer, but not through all the layers to the outside of the stomach (T3). It has spread to 1 or 2 nearby lymph nodes (N1), but has not spread to distant tissues or organs (M0).

OR

T4a, N0, M0: The cancer has grown completely through all the layers of stomach wall into the outer covering of the stomach (the serosa), but it has not grown into nearby organs or tissues, such as the spleen, intestines, kidneys, or pancreas (T4a). It has not spread to any nearby lymph nodes (N0) or distant sites (M0).

Stage IIIA: Any of the following:

T2, N3, M0: The cancer has grown into the main muscle layer, called the muscularis propria (T2). It has spread to 7 or more nearby lymph nodes (N3), but has not spread to distant tissues or organs (M0).

OR

T3, N2, M0: The cancer has grown into the subserosa layer, but not through all the layers to the outside of the stomach (T3). It has spread to 3 to 6 nearby lymph nodes (N2), but it has not spread to distant tissues or organs (M0).

OR

T4a, N1, M0: The cancer has grown completely through all the layers of the stomach wall into the outer covering of the stomach (the serosa), but it has not grown into nearby organs or tissues (T4a). It has spread to 1 or 2 nearby lymph nodes (N1), but it has not spread to distant sites (M0).

Stage IIIB: Any of the following:

T3, N3, M0: The cancer has grown into the subserosa layer, but not through all the layers to the outside of the stomach (T3). It has spread to 7 or more nearby lymph nodes (N2), but it has not spread to distant sites (M0).

OR

T4a, N2, M0: The cancer has grown completely through all the layers of the stomach wall into the serosa (the outer covering of the stomach), but it has not grown into nearby organs or tissues (T4a). It has spread to 3 to 6 nearby lymph nodes (N2), but it has not spread to distant sites (M0).

OR

T4b, N0 or N1, M0: The cancer has grown through the stomach wall and into nearby organs or structures such as the spleen, intestines, liver, pancreas, or major blood vessels (T4b). It may also have spread to up to 2 nearby lymph nodes (N0 or N1). It has not spread to distant sites (M0).

Stage IIIC: Any of the following:

T4a, N3, M0: The cancer has grown completely through all the layers of the stomach wall into the serosa, but it has not grown into nearby organs or tissues (T4a). It has spread to 7 or more nearby lymph nodes (N3), but it has not spread to distant sites (M0).

OR

T4b, N2 or N3, M0: The cancer has grown through the stomach wall and into nearby organs or structures such as the spleen, intestines, liver, pancreas, or major blood vessels (T4b). It has spread to 3 or more nearby lymph nodes (N2 or N3). It has not spread to distant sites (M0).

Stage IV: Any T, any N, M1

The cancer has spread to distant organs such as the liver, lungs, brain, or bones (M1).

If you have any questions about the stage of your disease, ask your doctor to explain this to you. The stage of a stomach cancer is an important factor, but it is not the only factor in considering treatment options and in predicting outlook for survival.

Resectable vs. unresectable cancer

The AJCC staging system provides a detailed summary of how far a stomach cancer has spread. But for treatment purposes, doctors are often more concerned about whether the tumor can be removed (resected) with surgery.

  • Resectable cancers are those the doctor believes can be completely removed during surgery.
  • Unresectable cancers can’t be removed completely. This might be because the tumor has grown too far into nearby organs or lymph nodes, it has grown too close to major blood vessels, it has spread to distant parts of the body, or the person is not healthy enough for surgery.

There is no distinct dividing line between resectable and unresectable in terms of the TNM stage of the cancer, but earlier stage cancers are more likely to be resectable.


Survival rates for stomach cancer, by stage

Survival rates are often used by doctors as a standard way of discussing a person’s prognosis (outlook). Some people with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. If you do not want to read about the survival statistics for stomach cancer, stop reading here and skip to the next section.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many of these people live much longer than 5 years (and many are cured).

To get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a better outlook for people now being diagnosed with stomach cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person’s case. Many other factors may affect a person’s outlook, such as their general health, the location of the cancer in the stomach, the treatment received, and how well the cancer responds to treatment. Your doctor can tell you how these survival rates may apply to you.

The survival rates that follow come from the National Cancer Institute’s SEER database and were published in 2010 in the 7th edition of the AJCC Staging Manual. They are based on people diagnosed with stomach cancer and treated with surgery between 1991 and 2000. Survival rates for patients not treated with surgery are likely to be lower. It is also important to note that these are observed survival rates. People with cancer can die of other things, and these rates do not take that into account.

The rates below are based on the stage of the cancer at the time of diagnosis. When looking at survival rates, it’s important to understand that the stage of a cancer does not change over time, even if the cancer progresses. A cancer that comes back or spreads is still referred to by the stage it was given when it was first found and diagnosed, but more information is added to explain the current extent of the cancer.

The 5-year survival rates by stage for stomach cancer treated with surgery are as follows:

    Stage

    5 year
    observed
    survival

    Stage IA

    71%

    Stage IB

    57%

    Stage IIA

    46%

    Stage IIB

    33%

    Stage IIIA

    20%

    Stage IIIB

    14%

    Stage IIIC

    9%

    Stage IV

    4%

The overall 5-year relative survival rate of all people with stomach cancer in the United States is about 29%. The 5-year relative survival rate compares the observed survival of people with stomach cancer to that expected for people without stomach cancer. Since some people may die from other causes, this is a better way to see the impact of cancer on survival.

This survival rate has improved gradually over the last 30 years. One reason the overall survival rate is poor in the United States is that most stomach cancers are diagnosed at an advanced rather than an early stage. The stage of the cancer has a major effect on a patient’s prognosis (outlook for survival).

How is stomach cancer treated?

General treatment information

Once your cancer has been diagnosed and staged, there is a lot to think about before you and your doctors choose a treatment plan. You may feel that you must make a decision quickly, but it is important to give yourself time to absorb the information you have just learned. Ask your cancer care team questions. You can find some good questions to ask in the section “What should you ask your doctor about stomach cancer?

The main treatments for stomach cancer are:

Often the best approach uses 2 or more of these treatment methods.

You will want to weigh the benefits of each treatment against the possible risks and side effects. Your treatment options depend on many factors. The location and the stage (extent of spread) of the tumor are very important. In choosing your treatment plan, you and your cancer care team will also take your age, general state of health, and personal preferences into account.

It is important to have a team of doctors with different specialties involved in your care before plans for treating your stomach cancer are made. Most likely, your team will include:

  • A gastroenterologist: a doctor who specializes in treatment of diseases of the digestive system.
  • A surgical oncologist: a doctor who treats cancer with surgery.
  • A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy.
  • A radiation oncologist: a doctor who treats cancer with radiation therapy.

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, nutrition specialists, social workers, and other health professionals.

It is important that you understand the goal of your treatment — whether it is to try to cure your cancer or to keep the cancer under control or relieve symptoms — before starting treatment. If the goal of your treatment is a cure, you will also receive treatment to relieve symptoms and side effects. If a cure is not possible, treatment is aimed at keeping the cancer under control for as long as possible and relieving symptoms, such as trouble eating, pain, or bleeding.

If time permits, you may want to get a second opinion about your treatment options. A second opinion can provide you with more information and help you feel more confident about the treatment plan that you choose.

Thinking about taking part in a clinical trial

Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases, they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service at 1-800-303-5691 for a list of studies that meet your medical needs, or see the Clinical Trials section on our website to learn more.

Considering complementary and alternative methods

You may hear about alternative or complementary methods that your doctor hasn’t mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be dangerous.

Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known (or not known) about the method, which can help you make an informed decision. See theComplementary and Alternative Medicine section of our website to learn more.

Help getting through cancer treatment

Your cancer care team will be your first source of information and support, but there are other resources for help when you need it. Hospital- or clinic-based support services are an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help.

The American Cancer Society also has programs and services – including rides to treatment, lodging, support groups, and more – to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists on call 24 hours a day, every day.

The next few sections describe the different types of treatment for stomach cancer. This is followed by a discussion of the most common treatment options based on the extent of the cancer

The treatment information given here is not official policy of the American Cancer Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor. Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

Surgery for stomach cancer

Surgery is part of the treatment for many different stages of stomach cancer if it can be done. If a patient has a stage 0, I, II, or III cancer and is healthy enough, surgery (often along with other treatments) offers the only realistic chance for cure at this time.

Surgery may be done to remove the cancer and part or all of the stomach and some nearby lymph nodes, depending on the type and stage of stomach cancer. The surgeon will try to leave behind as much normal stomach as possible. Sometimes other organs will need to be removed as well.

Even when the cancer is too widespread to be removed completely, patients may be helped by surgery because it may help prevent bleeding from the tumor or prevent the stomach from being blocked by tumor growth. This type of surgery is called palliative surgery, meaning that it relieves or prevents symptoms but it is not expected to cure the cancer.

The type of operation usually depends on what part of the stomach the cancer is in and how much cancer is in the surrounding tissue. Different kinds of surgery can be used to treat stomach cancer:

Endoscopic resection

Endoscopic mucosal resection and endoscopic submucosal resection can be used only to treat some very early-stage cancers, where the chance of spread to the lymph nodes is very low.

These procedures do not require a cut (incision) in the skin. Instead, the surgeon passes an endoscope (a long, flexible tube with a small video camera on the end) down the throat and into the stomach. Surgical tools can be passed through the endoscope to remove the tumor and part of the normal stomach wall around it.

These are not done as much in the United States as they are in countries (like Japan) where stomach cancer is more common and more often found at an early stage due to screening. If you are going to have this kind of surgery, it should be at a center that has experience with this technique.

Subtotal (partial) gastrectomy

This operation is often recommended if the cancer is only in the lower part of the stomach. It is also sometimes used for cancers that are only in the upper part of the stomach.

Only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine (the duodenum). The remaining section of stomach is then reattached. Some of the omentum (an apron-like layer of fatty tissue that covers the stomach and intestines) is removed as well, along with nearby lymph nodes, and possibly the spleen and parts of other nearby organs.

Eating is much easier after surgery if only part of the stomach is removed instead of the entire stomach.

Total gastrectomy

This operation is done if the cancer has spread throughout the stomach. It is also often advised if the cancer is in the upper part of the stomach, near the esophagus.

The surgeon removes the entire stomach, nearby lymph nodes, and omentum, and may remove the spleen and parts of the esophagus, intestines, pancreas, or other nearby organs. The end of the esophagus is then attached to part of the small intestine. This allows food to move down the intestinal tract. But people who have had their stomach removed can only eat a small amount of food at a time. Because of this, they must eat more often.

Most subtotal and total gastrectomies are done through a large incision (cut) in the skin of the abdomen. In some centers, they can be done using laparoscopy, which allows the stomach to be removed through several smaller cuts in the abdomen. Although this approach shows promise, many doctors feel that this needs to be studied further before it can be considered a standard treatment for stomach cancer.

Placement of a feeding tube

Some patients have trouble taking in enough nutrition after surgery for stomach cancer. Further treatment like chemotherapy with radiation can make this problem worse. To help with this, a tube can be placed into the intestine at the time of gastrectomy. The end of this tube, called a jejunostomy tube or J tube, remains outside of the skin on the abdomen. Through this, liquid nutrition can be put directly into the intestine to help prevent and treat malnutrition.

Lymph node removal

In either a subtotal or total gastrectomy, the nearby lymph nodes are removed. This is a very important part of the operation. Many doctors feel that the success of the surgery is directly related to how many lymph nodes the surgeon removes.

In the United States, it is recommended that at least 15 lymph nodes are removed (called a D1 lymphadenectomy) when a gastrectomy is done. Surgeons in Japan have had very high success rates by removing even more lymph nodes near the cancer (called a D2 lymphadenectomy).

Surgeons in Europe and the United States have not been able to equal the results of the Japanese surgeons. It is not clear if this is because Japanese surgeons are more experienced (stomach cancer is much more common in their country), because Japanese patients tend to have earlier stage disease (because they screen for stomach cancer) and are healthier, or if other factors play a role.

In any event, it takes a skilled surgeon who is experienced in stomach cancer surgery to remove all the lymph nodes successfully. Ask your surgeon about his or her experience in operating on stomach cancer. Studies have shown that the results are better when both the surgeon and the hospital have had extensive experience in treating patients with stomach cancer.

Palliative surgery for unresectable cancer

For people with unresectable stomach cancer, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.

Subtotal gastrectomy: For some people who are healthy enough for surgery, removing the part of the stomach with the tumor can help treat problems such as bleeding, pain, or blockage in the stomach, even if it does not cure the cancer. Because the goal of this surgery is not to cure the cancer, nearby lymph nodes and parts of other organs usually do not need to be removed.

Gastric bypass (gastrojejunostomy): Tumors in the lower part of the stomach may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (called the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

Endoscopic tumor ablation: In some cases, such as in people who are not healthy enough for surgery, an endoscope (a long, flexible tube passed down the throat) can be used to guide a laser beam to vaporize parts of the tumor. This can be done to stop bleeding or help relieve a blockage without surgery.

Stent placement: Another option to keep a tumor from blocking the opening at the beginning or end of the stomach is to use an endoscope to place a stent (a hollow metal tube) in the opening. This helps keep it open and allows food to pass through it. For tumors in the upper (proximal) stomach, the stent is placed where the esophagus and stomach meet. For tumors in the lower (distal) part of the stomach, the stent is placed at the junction of the stomach and the small intestine.

Feeding tube placement: Some people with stomach cancer are not able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the distal part of the stomach (known as agastrostomy tube or G tube) or into the small intestine (known as a jejunostomy tube or J tube). Liquid nutrition can then be put directly into the tube.

Possible complications and side effects of surgery

Surgery for stomach cancer is difficult and can have complications. These can include bleeding from the surgery, blood clots, and damage to nearby organs during the operation. Rarely, the new connections made between the ends of the stomach or esophagus and small intestine may leak.

Surgical techniques have improved in recent years, so only about 1% to 2% of people die from surgery for stomach cancer. This number is higher when the operation is more extensive, such as when all the lymph nodes are removed, but it is lower in the hands of highly skilled surgeons.

You will not be allowed to eat or drink anything for at least a few days after a total or subtotal gastrectomy. This is to give the digestive tract time to heal and to make sure there are no leaks in parts that have been sewn together during the operation.

You may develop side effects after you recover from surgery. These can include nausea, heartburn, abdominal pain, and diarrhea, particularly after eating. These side effects result from the fact that once part or all of the stomach is removed, food enters the intestines too quickly after eating. The side effects often get better over time, but in some people they can last for a long time. Your doctor might prescribe medicines to help with this.

Changes in your diet will be needed after a partial or total gastrectomy. The biggest change is that you will need to eat smaller, more frequent meals. The amount of stomach removed will affect how much you need to change the way you eat.

The stomach helps the body absorb some vitamins, so people who have had a subtotal or total gastrectomy may develop vitamin deficiencies. If certain parts of the stomach are removed, doctors routinely prescribe vitamin supplements, some of which can only be injected.

Before your surgery, ask your surgeon how much of the stomach he or she intends to remove. Some surgeons try to leave behind as much of the stomach as they can to allow patients to eat more normally afterward. The tradeoff is that the cancer might be more likely to come back. The extent of the surgery should be discussed with your doctor before it is done.

It cannot be stressed enough that you should make sure your surgeon is experienced in treating stomach cancer and able to perform the most up-to-date operations to reduce your risk of complications. To learn more about surgery for cancer, see A Guide to Cancer Surgery .

Chemotherapy for stomach cancer

Chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein 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.

Chemo can be used in different ways to help treat stomach cancer:

  • Chemo can be given before surgery for stomach cancer. This, known as neoadjuvanttreatment, can 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 to remove the cancer. This is called adjuvanttreatment. The goal of adjuvant chemo is to kill any cancer cells 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 combination is called chemoradiation. This may be especially helpful for cancers that could not be removed completely by surgery.
  • Chemo may be given as the primary (main) treatment for stomach cancer that has spread (metastasized) to distant organs. It may help shrink the cancer or slow its growth, which can relieve symptoms for some patients and help them 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.

A number of chemo drugs can be used to treat stomach cancer, including:

  • 5-FU (fluorouracil), often given along with leucovorin (folinic acid)
  • Capecitabine (Xeloda®)
  • Carboplatin
  • Cisplatin
  • Docetaxel (Taxotere®)
  • Epirubicin (Ellence®)
  • Irinotecan (Camptosar®)
  • Oxaliplatin (Eloxatin®)
  • Paclitaxel (Taxol®)

Depending on the situation (including the stage of the cancer, the person’s overall health, and whether chemo is combined with radiation therapy), these drugs may be used alone or combined with other chemotherapy or targeted drugs.

Some common drug combinations used when surgery is planned include:

  • ECF (epirubicin, cisplatin, and 5-FU),which may be given before and after surgery
  • Docetaxel or paclitaxel plus either 5-FU or capecitabine, combined with radiation as treatment before surgery
  • Cisplatin plus either 5-FU or capecitabine, combined with radiation as treatment before surgery
  • Paclitaxel and carboplatin, combined with radiation as treatment before surgery

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

To treat advanced stomach cancer, ECF may also be used, but other combinations may also be helpful. Some of these include:

  • DCF (docetaxel, cisplatin and 5-FU)
  • Irinotecan plus cisplatin
  • Irinotecan plus 5-FU or capecitabine
  • Oxaliplatin plus 5-FU or capecitabine

Many doctors prefer to use combinations of 2 chemo drugs to treat advanced stomach cancer. 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.

Side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects. The type of side effect depends on the type of drugs, the amount taken, and the length of treatment. Short-term side effects common to most chemotherapy drugs can include:

  • Nausea and vomiting
  • Loss of appetite
  • Hair loss
  • Diarrhea
  • Mouth sores
  • Increased chance of infection (from a shortage of white blood cells)
  • Bleeding or bruising after minor cuts or injuries (from a shortage of platelets)
  • Fatigue and shortness of breath (from a shortage of red blood cells)

These side effects are usually short-term and 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 lessen them. For example, you can be given drugs to prevent or reduce nausea and vomiting.

Some chemotherapy drugs have specific side effects. You should be given specific information about each drug you are receiving and you should review it before you start treatment.

Neuropathy: Cisplatin, oxaliplatin, docetaxel, and paclitaxel can damage nerves outside the brain and spinal cord. 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 patients. Oxaliplatin can also affect nerves in the throat, causing throat pain that is worse when trying to eat or drink cold liquids or foods. This pain can lead to trouble swallowing or even breathing, and can last a few days after treatment.

Heart damage: Doxorubicin, epirubicin, and some other drugs may cause permanent heart damage 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 or skin peeling can occur, sometimes leading to open, painful sores. There is no specific treatment, although some creams may help. These symptoms gradually get better when the drug is stopped or the dose is decreased. The best way to prevent severe hand-foot syndrome is to tell your doctor when early symptoms come up, so that the drug dose can be changed.

Targeted therapies for stomach cancer

Chemotherapy (chemo) drugs target cells that divide rapidly, which is why they often work against cancer cells. But there are other aspects of cancer cells that make them different from normal cells. In recent years, researchers have developed new drugs to try to target these differences. Targeted drugs may work in some cases when standard chemo drugs don’t. They also tend to have fewer severe side effects than standard chemo drugs.

Trastuzumab

About 1 out of 5 of stomach cancers has too much of a growth-promoting protein called HER2/neu (or just HER2) on the surface of the cancer cells. Tumors with increased levels of HER2 are called HER2-positive.

Trastuzumab (Herceptin) is a monoclonal antibody, a man-made version of a very specific immune system protein, which targets the HER2 protein. Giving trastuzumab with chemo can help some patients with advanced, HER2-positive stomach cancer live longer than giving chemo alone.

This drug only works if the cancer cells have too much HER2, so samples of your tumor must be tested to look for HER2 before starting treatment (see “How is stomach cancer diagnosed?”). It is not used in people whose cancer is HER2-negative.

Trastuzumab is injected into a vein (IV). For stomach cancer it is given once every 2 or 3 weeks along with chemo. The best length of time to give it is not yet known.

The side effects of trastuzumab tend to be relatively mild. They can include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. These side effects occur less often after the first dose. This drug can also rarely lead to heart damage. The risk of heart damage is increased if trastuzumab is given with certain chemo drugs calledanthracyclines, such as epirubicin (Ellence) or doxorubicin (Adriamycin).

Ramucirumab

In order for cancers to grow and spread, they need to create new blood vessels so that the tumors get blood and nutrients. One of the proteins that tells the body to make new blood vessels is called VEGF. VEGF binds to cell surface proteins called receptors to act. Ramucirumab (Cyramza®) is a monoclonal antibody that binds to a receptor for VEGF. This keeps VEGF from binding to the receptor and signaling the body to make more blood vessels. This can help slow or stop the growth and spread of cancer.

Ramucirumab is used to treat advanced stomach cancer, most often after another drug stops working.

This drug is given as infusion into a vein (IV) every 2 weeks.

The most common side effects of this drug are high blood pressure, headache, and diarrhea. Rare but possibly serious side effects include blood clots, severe bleeding, holes forming in the stomach or intestines (called perforations), and problems with wound healing. If a hole forms in the stomach or intestine it can lead to severe infection and may require surgery to correct.

Other targeted drugs

Other targeted therapy drugs are being tested against stomach cancer. Some of these also focus on the HER2 protein, while others have different targets. Some of these drugs are discussed in more detail in the section “What’s new in stomach cancer research and treatment?

Radiation therapy for stomach cancer

Radiation therapy uses high-energy rays or particles to kill cancer cells in a specific area of the body. Radiation can be used in different ways to help treat stomach cancer:

  • Before surgery for some cancers, radiation can be used along with chemotherapy(chemo) to try to shrink the tumor to make surgery easier.
  • After surgery, radiation therapy can be used to kill very small remnants of the cancer that cannot be seen and removed during surgery. Radiation therapy — especially when combined with chemo drugs such as 5-FU — may delay or prevent cancer recurrence after surgery and may help patients live longer.
  • Radiation therapy can be used to slow the growth and ease the symptoms of advanced stomach cancer, such as pain, bleeding, and eating problems.

External beam radiation therapy is the type of radiation therapy often used to treat stomach cancer. This treatment focuses radiation on the cancer from a machine outside the body. Often, special types of external beam radiation, such three-dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) are used. These use computers and special techniques to focus the radiation on the cancer and limit the damage to nearby normal tissues.

Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is much stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — usually takes longer. Treatments are usually given 5 days a week over several weeks or months. Side effects from radiation therapy for stomach cancer can include:

  • Skin problems, ranging from redness to blistering and peeling, in the area where the radiation passed through
  • Nausea and vomiting
  • Diarrhea
  • Fatigue
  • Low blood cell counts

These usually go away within several weeks after the treatment is finished.

When radiation is given with chemotherapy, side effects are often worse. Patients may have problems eating and getting enough fluids. Some need to have fluids given into a vein (IV) or have a feeding tube placed to get nutrition during treatment.

Please be sure to tell your doctor about any side effects you have, because there are often ways to relieve them.

Radiation might also damage nearby organs that are exposed to the beams. This could lead to problems such as heart or lung damage, or even an increased risk of another cancer later on. Doctors do everything they can to prevent this by using only the needed dose of radiation, carefully controlling where the beams are aimed, and shielding certain parts of the body from the radiation during treatment.

It is very important that you get treated at a center that has extensive experience in treating stomach cancer.

More information on radiation therapy can be found in the “Radiation” section of our website, or in Understanding Radiation Therapy: A Guide for Patients and Families.

Treatment choices by type and stage of stomach cancer

Treatment of stomach cancer depends to a large degree on where the cancer started in the stomach and how far it has spread.

Stage 0

Because stage 0 cancers are limited to the inner lining layer of the stomach and have not grown into deeper layers, they can be treated by surgery alone. No chemotherapy or radiation therapy is needed.

Surgery with either subtotal gastrectomy (removal of part of the stomach) or total gastrectomy (removal of the entire stomach) is often the main treatment for these cancers. Nearby lymph nodes are removed as well.

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

Stage I

Stage IA: People with stage IA stomach cancer typically have their cancer removed by total or subtotal gastrectomy. The nearby lymph nodes are also removed. Endoscopic resection may rarely be an option for some small T1a cancers. No further treatment is usually needed after surgery.

Stage IB: The main treatment for this stage of stomach cancer is surgery (total or subtotal gastrectomy). Chemotherapy (chemo) or chemoradiation (chemo plus radiation therapy) may be given before surgery to try to shrink the cancer and make it easier to remove.

After surgery, patients whose lymph nodes (removed at surgery) show no signs of cancer spread are sometimes observed without further treatment, but often doctors will recommend treatment with either chemoradiation or chemo alone after surgery (especially if the patient didn’t get one of these before surgery). Patients who were treated with chemo before surgery may get the same chemo (without radiation) after surgery.

If cancer is found in the lymph nodes, treatment with either chemoradiation, chemo alone, or a combination of the two is often recommended.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage II

The main treatment for stage II stomach cancer is surgery to remove all or part of the stomach, the omentum, and nearby lymph nodes. Many patients are treated with chemo or chemoradiation before surgery to try to shrink the cancer and make it easier to remove. Treatment after surgery may include chemo alone or chemoradiation.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage III

Surgery is the main treatment for patients with this stage disease (unless they have other medical conditions that make them too ill for it). Some patients may be cured by surgery (along with other treatments), while for others the surgery may be able to help control the cancer or help relieve symptoms.

Some people may get chemo or chemoradiation before surgery to try to shrink the cancer and make it easier to remove. Patients who get chemo before surgery will probably get chemo after, as well. For patients who don’t get chemo before surgery and for those who have surgery but have some cancer left behind, treatment after surgery is usually chemoradiation.

If a person is too sick (from other illnesses) to have surgery, they may be treated with chemoradiation if they can tolerate it. Other options include radiation therapy or chemo alone.

Stage IV

Because stage IV stomach cancer has spread to distant organs, a cure is usually not possible. But treatment can often help keep the cancer under control and help relieve symptoms. This might include surgery, such as a gastric bypass or even a subtotal gastrectomy in some cases, to keep the stomach and/or intestines from becoming blocked (obstructed) or to control bleeding.

In some cases, a laser beam directed through an endoscope (a long, flexible tube passed down the throat) can destroy most of the tumor and relieve obstruction without surgery. If needed, a stent (a hollow metal tube) may be placed where the esophagus and stomach meet to help keep it open and allow food to pass through it. This can also be done at the junction of the stomach and the small intestine.

Chemo and/or radiation therapy can often help shrink the cancer and relieve some symptoms as well as help patients live longer, but is usually not expected to cure the cancer. Combinations of chemo drugs are most commonly used, but which combination is best is not clear.

Targeted therapy can also be helpful in treating advanced cancers. Trastuzumab (Herceptin) can be added to chemotherapy for patients whose tumors are HER2-positive. Ramucirumab (Cyramza) may also be an option at some point. It can be given by itself or added to chemo.

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 ways to relieve pain and symptoms from the disease. Patients should tell their cancer care team about any symptoms or pain they have right way, so they can be managed effectively.

Nutrition is another concern for many patients with stomach cancer. Help is available ranging from nutritional counseling to placement of a tube into the small intestine to help provide nutrition for those who have trouble eating, if needed.

Recurrent cancer

Cancer that comes back after initial treatment is known as recurrent cancer. Treatment options for recurrent disease are generally the same as they are for stage IV cancers. But they also depend on where the cancer recurs, what treatments a person has already had, and the person’s general health.

 

 

 

 

 

 

 

 

 

 

 

 

 

 



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