At Memorial Sloan-Kettering, medical oncologists such as Yelena Janjigian take a team approach to shaping an individualized treatment plan for our patients with stomach cancer.
After a diagnosis of stomach cancer, our team of physicians helps each patient to select the treatment plan that best fits his or her individual needs. The choice of treatment for stomach cancer largely depends on the stage of the disease — that is, how much the tumor has grown, how deeply it has invaded the layers of the stomach, and whether it has spread to nearby organs, lymph nodes, or other parts of the body. The treatment plan may include surgery, chemotherapy, or radiation therapy.(1)
Recent studies suggest that, for patients at high risk of recurrence for stomach cancer, surgery along with chemotherapy or radiation therapy, or a combination of the two, may improve survival compared to surgery alone. One approach is using chemotherapy both before and after surgery,(2) and another is a combination treatment of radiation and chemotherapy after surgery. These are two standards of care for patients with this disease.(3) When the tumor cannot be removed, we may employ laser techniques or stenting to relieve areas of obstruction that can cause pain and disability.
Communicating with patients and caregivers is an important priority at Memorial Sloan-Kettering. We believe that treating the whole person, not just the disease, is the best approach for patients and family members. At Memorial Sloan-Kettering, we offer a broad range of emotional support programs designed to help patients and family members cope with the range of issues related to life during and after cancer treatment. For more information about the services we offer, please visit Survivorship & Support.
Surgery
Surgery is the most common form of treatment for stomach cancer. In the standard “open” surgical approach to treating stomach cancer, surgeons make an incision through the abdominal muscles. For selected patients, Memorial Sloan-Kettering Cancer Center offers minimally invasive laparoscopic surgery. About 100 gastrectomies, both open and laparoscopic, are performed each year at Memorial Sloan-Kettering — one of the highest volumes of surgery for this relatively rare cancer of any center in the country.
For individuals who have already had surgery for stomach cancer, researchers at Memorial Sloan-Kettering have developed a tool called a nomogram to help predict which patients are more likely to have a recurrence following surgery.(4),(5)
Depending on the extent to which the cancer has spread, the doctor may perform one of the following operations:
- Partial, or Subtotal, Gastrectomy
This involves removing part of the stomach, as well as parts of other tissues or organs near the tumor (such as the small intestine or esophagus, depending on the location of the tumor). - Total Gastrectomy
This involves removing the entire stomach and parts of the esophagus, small intestine, and other tissue near the tumor. Following total gastrectomy, the esophagus is directly connected to the small intestine, to allow the patient to continue to eat and swallow normally. During the procedure, the surgeon will also remove nearby lymph nodes to examine them for cancer cells (called lymphadenectomy). Sometimes the spleen (an organ in the upper abdomen that filters blood and eliminates old blood cells) and part of the pancreas are also removed.
Minimally Invasive Surgery
The first minimally invasive, laparoscopic gastrectomy performed at Memorial Sloan-Kettering was in 2001, and since 2005 more than 75 patients have had their stomach cancers treated using a laparoscopic approach. Memorial Sloan-Kettering researchers have demonstrated that laparoscopic surgery results in similar success rates as traditional “open” surgery, with fewer complications, less blood loss and postoperative pain, and shorter hospital stays.
During laparoscopy, a thin, lighted tube with a video camera at its tip (called a laparoscope) is inserted through a tiny incision in the abdominal wall, and the image is projected onto a large viewing screen. Guided by this highly magnified image, the surgeon can operate using specially designed surgical instruments that are inserted through additional small incisions.
In selected patients, minimally invasive surgery can be used to remove stomach tumors or even the entire stomach. A recent study led by researchers at Memorial Sloan-Kettering Cancer Center demonstrated that while laparoscopic surgeries generally took longer to perform than open procedures, the minimally invasive approach yielded shorter hospital stays, decreased need for postoperative pain relief, fewer complications after surgery, and similar rates of recurrence-free survival after 36 months of follow-up.(6)
Chemotherapy
Chemotherapy (drugs that kill cancer cells) is also used to treat stomach cancer, either by itself or in combination with surgery and/or radiation therapy. It may be given to patients whose cancers have invaded the layers of the stomach wall, lymph nodes, and nearby organs. Chemotherapy may be given before surgery (neoadjuvant therapy) to shrink the tumor, or it may be given after surgery (adjuvant therapy) to kill any remaining cancer cells.
When given alone or in combination with radiation therapy, chemotherapy may help alleviate symptoms related to stomach cancer. In patients with more advanced stomach cancer in whom surgery is not possible, chemotherapy may also improve both the length and quality of life.(7),(8)
The drugs most commonly used to treat stomach cancer are 5-fluorouracil, irinotecan, cisplatin, and docetaxel. Our investigators continue to identify novel therapeutic drugs to improve the care of patients with stomach cancer. For example, the newer targeted therapy agents, including bevacizumab11 and cetuximab, as well as new combinations of conventional drugs are currently under investigation at Memorial Sloan-Kettering.
These drugs are given either intravenously or orally. This therapy is known as a systemic therapy, meaning that chemotherapy drugs travel through the blood to cells all over the body. Although used very rarely, another method used to treat stomach cancer is intraperitoneal (IP) chemotherapy. In IP therapy, chemotherapy drugs are placed directly into the internal lining of the abdominal area (called the peritoneal cavity) and are released through a surgically implanted catheter. This allows a high concentration of chemotherapy agents to reach the cancerous tissue, thereby increasing the effectiveness of treatment.
Radiation Therapy
Radiation therapy uses high-energy rays or particles to kill cancer cells. One standard of care for treating stomach cancer is surgery followed by a combination of radiation therapy and chemotherapy to destroy any remaining stomach cancer cells.
We are involved in trials with the Radiation Therapy Oncology Group (RTOG), investigating new combinations of chemotherapy and radiation therapy in esophageal and gastroesophageal cancer. In addition, our researchers are also actively studying the effects of neoadjuvant chemotherapy (chemotherapy given before surgery to help shrink the tumor) followed by surgery and, in some cases, postoperative radiation and/or chemotherapy.
Memorial Sloan-Kettering doctors are involved in ongoing efforts to decrease the toxicity, or damage, to healthy tissues that may occur during radiation therapy for stomach cancer. Intensity-modulated radiation therapy (IMRT) and respiratory gating are two approaches that have potential for decreasing the harmful effects of radiation on normal tissue.
IMRT is a type of 3-D radiation therapy that targets tumors with greater precision than conventional radiation therapy. Using highly sophisticated computer software and 3-D images from CT scans, the radiation oncologist can develop an individualized treatment plan that delivers high doses of radiation to cancerous tissue while sparing surrounding organs and reducing the risk of injury to healthy tissues.
Respiratory gating is another type of radiation therapy used at Memorial Sloan-Kettering to treat stomach cancer with minimal damage to healthy tissue. Because tumors and organs in the abdomen shift during breathing, precise delivery of radiation therapy to cancerous tissue can be difficult. Respiratory gating entails the delivery of radiation treatment only at certain points during a patient's breathing cycle, when the “mobile” tumors and/or regions of the abdomen are in a specific position. This approach decreases the radiation dose to the surrounding healthy tissues.
Investigational Approaches
Our doctors continue to evaluate new chemotherapeutic agents and drug combinations to treat patients with stomach cancer. We also are investigating other treatment modalities and developing programs to improve the care of patients with stomach cancer. For example, to help guide therapeutic decisions, our investigators are also tracking molecular tumor markers (substances that may be found in tumor tissue or released from a tumor into the blood or other body fluids — a high level of a tumor marker may mean that a certain type of cancer is in the body) and using functional imaging such as PET scanning and CT scanning to potentially guide therapy more specifically for the individual patient.
- Power DG, Kelsen DP, Shah MA. Advanced gastric cancer - slow but steady progress. Cancer Treat Rev. 2010 Aug;36(5):384-92.
- Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE, Verma M, Weeden S, Chua YJ, for the MAGIC Trial Participants. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 July 6;355(1):11-20.
- Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, Haller DG, Ajani JA, Gunderson LL, Jessup JM, J. A. Martenson JA. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001 Sep 6;345(10): 725-30.
- Novotny AR, Schuhmacher C, Busch R, Kattan MW, Brennan MF, Siewert JR. Predicting individual survival after gastric cancer resection: validation of a US-derived nomogram at a single high-volume center in Europe. Ann Surg. 2006 Jan;243(1):74-81
- Kattan MW, Karpeh MS, Mazumdar M, Brennan MF. Postoperative nomogram for disease-specific survival after an R0 resection for gastric carcinoma, J Clin Oncol. 2003 Oct;21(19):3647-50.
- Strong VE, Devaud N, Allen PJ, Gonen M, Brennan MF, Coit D. Laparoscopic versus open subtotal gastrectomy for adenocarcinoma: a case-control study. Ann Surg Oncol. 2009 Jun;16(6):1507-13.
- Shah MA and Kelsen DP. Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease. J Natl Compr Canc Netw. 2010 Apr;8(4):437-47.
- Brenner B, Shah MA, Karpeh MS, Gonen M, Brennan MF, Coit DG, Klimstra DS, Tang LH, Kelsen DP. A phase II trial of neoadjuvant cisplatin-fluorouracil followed by postoperative intraperitoneal floxuridine-leucovorin in patients with locally advanced gastric cancer. Ann Oncol. 2006 Sep;17(9):1404-11.
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