The stomach cancer treatment mainly depends on the stage, location of the tumor, performance status of the patient, the presence of certain genetic abnormalities, along with other factors.
Following are the preferred treatment approaches for different stages of stomach cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.
Tis to T1a – Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is considered preferred treatment approach depending on the extent of disease.
T1b – Surgical removal of partial (subtotal gastrectomy) or entire stomach (total gastrectomy) depending on the involvement.
Chemotherapy with/without radiotherapy if surgically unresectable or inoperable.
T2-T4 Any N – Surgical resection in combination with chemotherapy with/without radiotherapy is the preferred treatment.
Chemotherapy with/without radiotherapy if surgically unresectable or inoperable.
Any T Any N M1 (Metastatic disease) – Chemotherapy is the mainstay of treatment.
Radiotherapy, surgery, or other palliative treatment may be employed to relieve the symptoms.
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Treatment of Localised and Locally Advanced Stomach Cancer:
First we will discuss the treatment for localized disease.
Earlier stages of the stomach cancer include the Tis and T1a disease, that is, the disease extending up to muscular mucosa.
Endoscopic mucosal resection is the technique used for the treatment of Tis and T1a disease.
This procedure is performed through an endoscope, in which first a fluid is injected below the lesion, and then the lesion is removed from the sorrounding structures.
As you can see in the figure, only the superficial cancerous portion is removed, while the remaining tissue remains unaffected.
Removal of the stomach is all an option for early stage disease, but is practiced less commonly.
Then comes the T1b disease which infiltrates upto the submucosa.
Gastrectomy is the preferred treatment for T1b disease.
Then comes the T2 disease which extends up to the muscular propria.
And T3, which infiltrates the subserosal tissue. And lastly, T4a which infiltrates the serosa.
Form T2a and T4a, surgery may not be sufficient and may not be possible in many cases, so a combination of chemotherapy, radiation therapy, and surgery may be required.
CancerBro, how is it decided what combination of modalities is to be used?
It is decided by the oncologist on an individual patient basis, depending upon the exact stage of disease, performance status and comorbidities of the patient.
Now lets come to the treatment of the T4b disease, in which the tumor extends through the wall of the stomach to involve adjacent structures.
In this figure, the tumor infiltrates into the large intestine.
And here, it invades the pancreas.
And here it extends into the spleen.
Here it infiltrates into the kidney.
It may also extend into the liver or diaphragm.
Surgery may not be possible in all cases of T4b disease, so in such cases, chemotherapy with or without radiation therapy may be used.
Whereas, if the tumor is surgically resectable, multimodality treatment with surgery, with or without chemotherapy or radiation therapy is used.
In T4b disease also, the decision to move ahead with surgery, or treat the disease with chemotherapy or radiation therapy is taken by the oncologist on an individual patient basis, depending upon the exact stage of the disease, performance status and the comorbidities of the patient. That is the treatment for non-metastatic stomach cancer.
Treatment of Metastatic Stomach Cancer:
Now we come to the treatment of metastatic disease.
It may present as metastasis to the liver or peritoneum or lungs, one or both the ovaries.
It may also present as pelvic deposits in rectovesical pouch or pouch of Douglas.
Or involvement of left supraclavicular lymph node, presenting as swelling in the left side of the neck.
Or as a nodule in the periumbilical region, called as Sister Mary Joesph module.
Very rarely, it may present as metastasis to brain or bones. In all these cases of metastatic disease, chemotherapy is the mainstay of treatment.
But other modalities like surgery, radiation therapy or bone-directed therapy may be used for palliation or relief of symptoms.
Always remember that the treatment for metastatic disease is not generally curative, so the intent of the treatment is prolongation of life, reduction of symptoms and improvement of the quality of life.
So this brings us to the end of stomach cancer treatment.
Following is the brief description of various treatment types employed for stomach cancer:
- Surgery: Surgery is the treatment of choice for some earlier stage cancers that can be completely removed. Surgery can also be employed for some higher stages of cancers that have not spread to distant parts and if the patient is medically fit.
Sometimes, surgery is combined with other treatments such as chemotherapy and/or radiation therapy as per physician discretion and patient’s condition. Surgery for stomach cancer may be partial or total gastrectomy. It may be a D1 resection or D2 resection depending upon number and stations of lymph nodes removed.
- Radiation Therapy: Radiation therapy (or radiotherapy) uses high-energy radiation directed to the affected area to kill cancerous cells. It can be employed either by using an external radiation source (external beam radiation therapy) or by directly placing the source of radiation near the cancer tissue (brachytherapy). Radiotherapy is commonly combined with other treatment options such as surgery and/or chemotherapy for higher stage disease. Sometimes, it is used as palliative therapy to relieve pain, bleeding, and obstructive problems associated with the advanced-stage disease.
- Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. It is considered to be the mainstay of treatment for advanced stage disease that has spread to distant body parts. Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options to accelerate the benefit achievement. It may be associated with side effects due to its effect on normal body cells apart from cancerous cells.
- Targeted Therapy Targeted drugs are designed to target a specific gene or protein characteristic of the stomach cancer cells. With the advancement in diagnostic techniques, genetic abnormalities for gastric cancer have been identified that can be targeted with the help of targeted drugs.
Molecular testing to confirm the genetic abnormality is the pre-requisite for starting a targeted therapy. For example, trastuzumab targets the HER2 protein and Ramucirumab targets receptor for VEGF. They are generally used alone or in combination with chemotherapy for the treatment of higher stage disease.
- Endoscopic Treatments: Several types of endoscopic treatment can be employed for very early stage stomach cancers. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) is alternative to surgery with similar efficacy and safety for early-stage gastric cancer confined to gastric mucosa.
Other treatments like endoscopic tumor ablation and endoscopic stent placement aim mainly to relieve symptoms of more advanced staged gastric cancers.
- Palliative Treatment: These may help in improving the overall quality of life by providing relief from the symptoms caused by stomach cancer. However, they do not directly treat gastric cancer.
They are generally given as supportive care for advanced stage cancer. These include but are not limited to placing stent or feeding tube in the gastric, using drugs to reduce pain and other symptoms such as vomiting, external-beam radiation therapy for bleeding or pain, etc.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes a patient’s choice and health condition are also important to make a treatment choice.
Following are ultimate goals of treating stomach cancer:
- Prolongation of life.
- Reduction of symptoms.
- Improvement of overall quality of life.