gastrointestinal disorders
Stomach Cancer
Treatment of Stomach Cancer
Surgical resection, sometimes combined with chemotherapy, radiation, or both (chemoradiation) Stomach cancer treatment decisions depend on tumor staging and the patient’s wishes (some may choose to forgo aggressive treatment—see Advance Directives ). 50% of patients). Depending on the initial stage of the tumor, some patients receive chemotherapy before surgery and after surgery. This strategy, termed perioperative chemotherapy, was the standard of care ( Treatment references ) but has been refined to the current standard of care termed perioperative FLOT (5- For patients with inadequate lymphadenectomy or with node-positive or incompletely resected disease, adjuvant chemotherapy or chemoradiation is sometimes used. Metastasis or extensive nodal involvement precludes curative surgery, and, at most, palliative procedures should be undertaken. However, the true extent of tumor spread often is not recognized until curative surgery is attempted. Palliative surgery typically consists of a gastroenterostomy to bypass a pyloric obstruction and should be done only if the patient’s quality of life can be improved. In patients not undergoing surgery, various combination chemotherapy regimens (5-fluorouracil,capecitabine,doxorubicin,mitomycin,cisplatin,oxaliplatin,irinotecan,paclitaxel,docetaxel, orleucovorin) may produce a temporary response and only a minor improvement in survival. In recent years, targeted therapies usingtrastuzumabfor tumors that overexpress human epidermal growth factor receptor 2 (HER2+) tumors andramucirumab(a vascular endothelial growth factor [VEGF] inhibitor) in conjunction with chemotherapy have been used in advanced cancer. Immunotherapy such as withpembrolizumabis available for use in patients with programmed cell death ligand 1 (PD-L1)–positive advanced or metastatic gastric cancer. Programmed cell death receptor 1 inhibitors (eg,nivolumab) are available for use outside the United States for patients with advanced gastric cancer. Radiation therapy is of limited benefit for patients with metastases. 1.Cunningham D, Allum WH, Stenning SP, et al: Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer.N Engl J Med355(1):11-20, 2006. doi: 10.1056/NEJMoa055531 2.Al-Batran SE, Homann N, Pauligk C, et al: Perioperative chemotherapy withfluorouracilplusleucovorin,oxaliplatin, anddocetaxelversusfluorouracilorcapecitabinepluscisplatinandepirubicinfor locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): A randomised, phase 2/3 trial.Lancet393(10184):1948-1957, 2019. doi: 10.1016/S0140-6736(18)32557-1 