Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
surgery
Multidisciplinary evaluation is strongly encouraged before therapy is started.[39][40]
Surgery is the primary treatment option for patients with localised (T1b or higher) gastric cancer or actively bleeding cancer or when post-operative chemotherapy is preferred.[39][40] Patients with carcinoma in situ (Tis) or T1a tumours may be candidates for endoscopic therapies.[39]
The aim is complete resection of the primary tumour with negative margins.[39] Subtotal gastrectomy is the preferred approach for distal gastric cancer.[39] Patients undergoing total gastrectomy for distal gastric cancers have no survival benefit compared with those undergoing subtotal gastrectomy.[47][48] Proximal gastrectomy or total gastrectomy is usually recommended for patients with proximal tumours.[39]
The American Society for Gastrointestinal Endoscopy (ASGE) suggests surgery over endoscopic approaches for lesions that are poorly differentiated and of any size; however, surgery is not recommended in early-stage lesions that are well- or moderately differentiated, intestinal type, and measure ≤3 cm.[49]
Patients with superficial early-stage gastric cancer (T1a) can be treated with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).[39] Patients who are medically fit with early-stage gastric adenocarcinoma confined to the mucosa, <2 cm in diameter, low or moderate degree of differentiation, without evidence of ulcer, and with no lymphovascular involvement can be effectively treated with either EMR or ESD.[50][51][52]
The factors to consider while choosing between ESD and EMR as per ASGE include differentiation (well or moderate vs. poor), morphology (ulcerated vs. non-ulcerated), type of cancer (intestinal vs. diffuse), and size.[49] Either ESD or EMR can be used in early-stage, well- or moderately differentiated, non-ulcerated, intestinal type gastric cancers measuring <20 mm, while ESD is preferred over EMR in well- or moderately differentiated lesions measuring 20-30 mm, with or without ulceration.[49]
Extent of lymph node dissection is controversial. Studies have failed to show survival benefit between D1 dissection (dissection of the perigastric nodes) and D2 dissection (dissection of perigastric nodes and nodes along the left gastric, hepatic, coeliac, and splenic arteries). D2 dissection may be associated with lower rates of locoregional recurrence and gastric cancer-related death, but may also be associated with higher rates of morbidity and mortality. A modified (spleen-preserving) D2 dissection is considered a standard at many institutions. The addition of para-aortic dissection to D2 dissection does not improve survival.[53][54][55]
[ 
]
Short-term outcomes from randomised controlled trials suggest that laparoscopic gastrectomy for clinical stage 1 gastric cancer is safe and has the benefit of lower occurrence of wound complication compared with conventional open gastrectomy, although evidence is low quality.[56][57][58]
[ ]
Other studies show no difference in short-term mortality between laparoscopic and open gastrectomy and no evidence for any differences in short-term or long-term outcomes between laparoscopic and open gastrectomy, based on low-quality evidence.[59]
chemotherapy + trastuzumab
Chemotherapy improves quality of life and survival when compared with best supportive care in patients with metastatic gastric cancer.[70][71][72]
[ ]
Chemotherapy regimens should be chosen in the context of the patient's performance status (PS), medical comorbidities, toxicity profile, and tumour biomarker expression.[39]
Studies have demonstrated that fluorouracil can be replaced by capecitabine, and cisplatin by oxaliplatin (except in regimens including irinotecan).[39][85][86] Oxaliplatin is preferred over cisplatin owing to its lower toxicity.[39][85][87]
Folinic acid is indicated with certain fluorouracil-based regimens. Depending on availability, the regimens may be used with or without folinic acid.[39]
In tumours with HER2 overexpression, trastuzumab (a humanised monoclonal antibody that acts on the HER2 receptor) should be added to chemotherapy.[39] This combination has been shown to improve overall survival in patients with advanced gastric cancer.
See local specialist protocols for dosing guidelines.
Primary options
fluorouracil
or
capecitabine
-- AND --
oxaliplatin
or
cisplatin
-- AND --
trastuzumab
chemotherapy
Chemotherapy improves quality of life and survival when compared with best supportive care in patients with metastatic gastric cancer.[70][71][72]
[ ]
Chemotherapy regimens should be chosen in the context of the patient's performance status (PS), medical comorbidities, toxicity profile, and tumour biomarker expression.[39]
Studies have demonstrated that fluorouracil can be replaced by capecitabine, and cisplatin by oxaliplatin (except in regimens including irinotecan).[39][85][86] Oxaliplatin is preferred over cisplatin owing to its lower toxicity.[39][85][87]
Folinic acid is indicated with certain fluorouracil-based regimens. Depending on availability, the regimens may be used with or without folinic acid.[39]
See local specialist protocols for dosing guidelines.
Primary options
fluorouracil
or
capecitabine
-- AND --
oxaliplatin
or
cisplatin
chemotherapy and/or immunotherapy
Chemotherapy improves quality of life and survival when compared with best supportive care in patients with metastatic gastric cancer.[70][71][72]
[ ]
Immunotherapy plus chemotherapy is associated with improved survival, compared with chemotherapy alone, in patients with metastatic gastric cancer.[73][74][75][76][77][78] Chemotherapy regimens should be chosen in the context of the patient's performance status (PS), medical comorbidities, toxicity profile, and tumour biomarker expression.[39]
Targeted therapies may be indicated for patients with high microsatellite instability/mismatch repair deficiency (MSI-H/dMMR) tumours. Pembrolizumab and dostarlimab are anti-PD-1 monoclonal antibodies that may be considered for patients with high MSI-H/dMMR tumours.[39]
NICE in the UK recommends pembrolizumab as an option for treating tumours with MSI-H/dMMR in adults with unresectable or metastatic stomach cancer that has progressed during or after one therapy.[89] Other options for MSI-H/dMMR tumours include nivolumab plus ipilimumab, or a fluoropyrimidine (fluorouracil or capecitabine) plus oxaliplatin plus nivolumab or pembrolizumab.
See local specialist protocols for dosing guidelines.
Primary options
pembrolizumab
OR
dostarlimab
OR
nivolumab
and
ipilimumab
OR
fluorouracil
or
capecitabine
-- AND --
oxaliplatin
-- AND --
nivolumab
or
pembrolizumab
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer