Gastric Cancer

Summary Type: Treatment
Summary Audience: Health professionals
Summary Language: English
Summary Description: Expert-reviewed information summary about the treatment of gastric cancer.


Gastric Cancer

General Information

Note: Separate PDQ summaries on Prevention of Gastric Cancer and Screening for Gastric Cancer are also available.

Note: Estimated new cases and deaths from gastric cancer in the United States in 2007:1,

  • New cases: 21,260.
  • Deaths: 11,210.

In the United States, gastric cancer ranks 14th in incidence among the major types of cancer malignancies. While the precise etiology is unknown, acknowledged risk factors for gastric cancer include:2,3,4,

  • Helicobacter pylori gastric infection.
  • Advanced age.
  • Male gender.
  • Diet low in fruits and vegetables.
  • Diet high in salted, smoked, or preserved foods.
  • Chronic atrophic gastritis.
  • Intestinal metaplasia.
  • Pernicious anemia.
  • Gastric adenomatous polyps.
  • Family history of gastric cancer.
  • Cigarette smoking.
  • Menetrier’s disease (giant hypertrophic gastritis).
  • Familial adenomatous polyposis.

Management of adenocarcinoma histology, which accounts for 90% to 95% of all gastric malignancies, is discussed in this summary. The site of cancer origin within the stomach has changed in frequency in the United States over recent decades.5 Cancer of the distal half of the stomach has been decreasing in the United States since the 1930s. However, in the last 2 decades, the incidence of cancer of the cardia and gastroesophageal junction has been rapidly rising. The incidence of this cancer has increased dramatically, especially in patients younger than 40 years.

The prognosis of patients with gastric cancer is related to tumor extent and includes both nodal involvement and direct tumor extension beyond the gastric wall.6,7 Tumor grade may also provide some prognostic information.8,

In localized distal gastric cancer, more than 50% of patients can be cured. However, early-stage disease accounts for only 10% to 20% of all cases diagnosed in the United States. The remaining patients present with metastatic disease in either regional or distant sites. The overall survival (OS) rate in these patients at 5 years ranges from almost no survival for patients with disseminated disease to almost 50% survival for patients with localized distal gastric cancers confined to resectable regional disease. Even with apparent localized disease, the 5-year survival rate of patients with proximal gastric cancer is only 10% to 15%. Although the treatment of patients with disseminated gastric cancer may result in palliation of symptoms and some prolongation of survival, long remissions are uncommon.

Radical surgery represents the standard form of therapy having curative intent. The incidence of local failure in the tumor bed and regional lymph nodes, and distant failure via hematogenous or peritoneal routes, however, remain high.9 Therefore, adjuvant therapy has been evaluated. Chemotherapy or radiation therapy as single adjuvant modalities have not significantly altered OS patterns. Adjuvant postoperative 5-fluorouracil (5-FU)-based chemotherapy following curative resection for localized gastric cancer demonstrated no survival benefit in a meta-analysis of randomized trials published since 1980.3,10 A prospective randomized trial from the British Stomach Cancer Group failed to demonstrate a survival benefit for postoperative adjuvant radiation alone, although locoregional failures were decreased from 27% to 10.6%.4

Adjuvant external-beam radiation therapy with combined chemotherapy has been evaluated in the United States. In a phase III intergroup trial (INT-0166), 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction were randomized to receive surgery alone or surgery plus postoperative chemotherapy (5-FU and leucovorin) and concurrent radiation therapy (45 Gy). With 5 years' median follow-up, a significant survival benefit has been reported for adjuvant combined modality therapy.11 Median survival was 36 months for the adjuvant chemoradiation group as compared to 27 months for the surgery-alone arm (P = .005). Three-year OS and relapse-free survival were 50% and 48% with adjuvant chemoradiation versus 41% and 31% for surgery alone (P = .005). Neoadjuvant chemoradiation therapy is under clinical evaluation.12,

Gastrointestinal stromal tumors occur most commonly in the stomach. (Refer to the PDQ summary on Adult Soft Tissue Sarcoma Treatment for more information.)



1 American Cancer Society.: Cancer Facts and Figures 2007. Atlanta, Ga: American Cancer Society, 2007. Also available online. Last accessed March 5, 2007.

2 Kurtz RC, Sherlock P: The diagnosis of gastric cancer. Semin Oncol 12 (1): 11-8, 1985.

3 Scheiman JM, Cutler AF: Helicobacter pylori and gastric cancer. Am J Med 106 (2): 222-6, 1999.

4 Fenoglio-Preiser CM, Noffsinger AE, Belli J, et al.: Pathologic and phenotypic features of gastric cancer. Semin Oncol 23 (3): 292-306, 1996.

5 Blot WJ, Devesa SS, Kneller RW, et al.: Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 265 (10): 1287-9, 1991.

6 Siewert JR, Böttcher K, Stein HJ, et al.: Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 228 (4): 449-61, 1998.

7 Nakamura K, Ueyama T, Yao T, et al.: Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy. Cancer 70 (5): 1030-7, 1992.

8 Adachi Y, Yasuda K, Inomata M, et al.: Pathology and prognosis of gastric carcinoma: well versus poorly differentiated type. Cancer 89 (7): 1418-24, 2000.

9 Gunderson LL, Sosin H: Adenocarcinoma of the stomach: areas of failure in a re-operation series (second or symptomatic look) clinicopathologic correlation and implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 8 (1): 1-11, 1982.

10 Chang HM, Jung KH, Kim TY, et al.: A phase III randomized trial of 5-fluorouracil, doxorubicin, and mitomycin C versus 5-fluorouracil and mitomycin C versus 5-fluorouracil alone in curatively resected gastric cancer. Ann Oncol 13 (11): 1779-85, 2002.

11 Macdonald JS, Smalley SR, Benedetti J, et al.: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10): 725-30, 2001.

12 Ajani JA, Radiation Therapy Oncology Group: Phase II Study of Preoperative Chemotherapy and Chemoradiotherapy in Patients With Potentially Resectable Adenocarcinoma of the Stomach, RTOG-9904, Clinical trial, Completed.

Cellular Classification

The cellular classification relates only to adenocarcinomas and not to other cell types such as lymphoma and sarcomas.1 Adenocarcinomas can be divided into the following subtypes:

  • Fungating or polypoid.
  • Ulcerating.
  • Superficial spreading.
  • Diffusely spreading (linitis plastica).

Microscopically, four histologic types of adenocarcinoma may prove to have prognostic significance:2,

  • Intestinal.
  • Pylorocardial (or antral).
  • Signet ring cell.3,
  • Anaplastic (undifferentiated).

Other histologies include:

  • Papillary adenocarcinoma.
  • Mucinous adenocarcinoma.
  • Adenosquamous carcinoma.
  • Squamous cell carcinoma.
  • Mixed adenocarcinoma and choriocarcinoma.


1 Fine G, Chan K: Alimentary tract. In: Kissane JM, ed.: Anderson's Pathology. Vol 2. 8th ed. Saint Louis, Mo: CV Mosby, 1985, pp 1055-1095.

2 Stomach. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 99-106.

3 Maehara Y, Sakaguchi Y, Moriguchi S, et al.: Signet ring cell carcinoma of the stomach. Cancer 69 (7): 1645-50, 1992.

Stage Information

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.1,2,3,

TNM Definitions

Primary tumor (T)

  • TX: Primary tumor cannot be assessed
  • T0: No evidence of primary tumor
  • Tis: Carcinoma in situ : intraepithelial tumor without invasion of the lamina propria
  • T1: Tumor invades lamina propria or submucosa
  • T2: Tumor invades the muscularis propria or the subserosa*
    • T2a: Tumor invades muscularis propria
    • T2b: Tumor invades subserosa
  • T3: Tumor penetrates the serosa (visceral peritoneum) without invading adjacent structures**,***
  • T4: Tumor invades adjacent structures**,***

*A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum covering these structures. In this case, the tumor is classified T2. If there is perforation of the visceral peritoneum covering the gastric ligaments or the omentum, the tumor should be classified T3.

**The adjacent structures of the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum.

***Intramural extension to the duodenum or esophagus is classified by the depth of greatest invasion in any of these sites, including stomach.

Regional lymph nodes (N)

The regional lymph nodes are the perigastric nodes, found along the lesser and greater curvatures, and the nodes located along the left gastric, common hepatic, splenic, and celiac arteries. For pN, a regional lymphadenectomy specimen will ordinarily contain at least 15 lymph nodes. Involvement of other intra-abdominal lymph nodes, such as the hepatoduodenal, retropancreatic, mesenteric, and para-aortic, is classified as distant metastasis.

  • NX: Regional lymph node(s) cannot be assessed
  • N0: No regional lymph node metastasis*
  • N1: Metastasis in one to six regional lymph nodes
  • N2: Metastasis in 7 to 15 regional lymph nodes
  • N3: Metastasis in more than 15 regional lymph nodes

*A designation of pN0 should be used if all examined lymph nodes are negative, regardless of the total number removed and examined.

Distant metastasis (M)

  • MX: Distant metastasis cannot be assessed
  • M0: No distant metastasis
  • M1: Distant metastasis

AJCC Stage Groupings

    Stage 0
  • Tis, N0, M0
    Stage IA
  • T1, N0, M0
    Stage IB
  • T1, N1, M0
  • T2a, N0, M0
  • T2b, N0, M0
    Stage II
  • T1, N2, M0
  • T2a, N1, M0
  • T2b, N1, M0
  • T3, N0, M0
    Stage IIIA
  • T2a, N2, M0
  • T2b, N2, M0
  • T3, N1, M0
  • T4, N0, M0
    Stage IIIB
  • T3, N2, M0
    Stage IV
  • T4, N1, M0
  • T4, N2, M0
  • T4, N3, M0
  • T1, N3, M0
  • T2, N3, M0
  • T3, N3, M0
  • Any T, any N, M1


1 Stomach. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 99-106.

2 Roder JD, Böttcher K, Busch R, et al.: Classification of regional lymph node metastasis from gastric carcinoma. German Gastric Cancer Study Group. Cancer 82 (4): 621-31, 1998.

3 Ichikura T, Tomimatsu S, Uefuji K, et al.: Evaluation of the New American Joint Committee on Cancer/International Union against cancer classification of lymph node metastasis from gastric carcinoma in comparison with the Japanese classification. Cancer 86 (4): 553-8, 1999.

Treatment Option Overview

The designations in PDQ that treatments are “standard” or “under clinical evaluation” are not to be used as a basis for reimbursement determinations.

Stage 0 Gastric Cancer

Stage 0 is gastric cancer confined to mucosa. Experience in Japan, where stage 0 is diagnosed frequently, indicates that greater than 90% of patients treated by gastrectomy with lymphadenectomy will survive beyond 5 years. An American series has confirmed these results.1,



1 Green PH, O'Toole KM, Slonim D, et al.: Increasing incidence and excellent survival of patients with early gastric cancer: experience in a United States medical center. Am J Med 85 (5): 658-61, 1988.

Stage I Gastric Cancer

Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)

Surgical resection including regional lymphadenectomy is the treatment of choice for patients with stage I gastric cancer.1 If the lesion is not in the cardioesophageal junction and does not diffusely involve the stomach, subtotal gastrectomy is the procedure of choice, since it has been demonstrated to provide equivalent survival when compared with total gastrectomy and is associated with decreased morbidity.2,[Level of evidence: 1iiA] When the lesion involves the cardia, proximal subtotal gastrectomy or total gastrectomy (including a sufficient length of esophagus) may be performed with curative intent. If the lesion diffusely involves the stomach, total gastrectomy is required. At a minimum, surgical resection should include greater and lesser curvature perigastric regional lymph nodes. Note that in patients with stage I gastric cancer, perigastric lymph nodes may contain cancer.

In patients with node-positive (T1 N1) and muscle-invasive (T2 N0) disease, postoperative chemoradiation therapy may be considered. A prospective multi-institution phase III trial (INT-0116) evaluating postoperative combined chemoradiation therapy versus surgery alone in 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction reported a significant survival benefit with adjuvant combined modality therapy.3,[Level of evidence: 1iiA] With a median follow-up of 5 years, median survival was 36 months for the adjuvant chemoradiation therapy group as compared to 27 months for the surgery-alone arm (P = .005). Three-year overall survival and relapse-free survival rates were 50% and 48% with adjuvant chemoradiation therapy versus 41% and 31% for surgery alone (P = .005). Only 36 patients in the trial, however, had stage IB tumors (18 patients in each arm).4 Since the prognosis is relatively favorable for patients with completely resected stage IB disease, the effectiveness of adjuvant chemoradiation therapy for this group is less clear. Neoadjuvant chemoradiation therapy is under clinical evaluation.5,

Standard treatment options:

  1. One of the following surgical procedures:
    • Distal subtotal gastrectomy (if the lesion is not in the fundus or at the cardioesophageal junction).
    • Proximal subtotal gastrectomy or total gastrectomy, both with distal esophagectomy (if the lesion involves the cardia). These tumors often involve the submucosal lymphatics of the esophagus.
    • Total gastrectomy (if the tumor involves the stomach diffusely or arises in the body of the stomach and extends to within 6 cm of the cardia or distal antrum).

    Regional lymphadenectomy is recommended with all of the above procedures. Splenectomy is not routinely performed.1,

  2. Postoperative chemoradiation therapy for patients with node-positive (T1 N1) and muscle-invasive (T2 N0) disease.3,

Treatment options under clinical evaluation:

  • Neoadjuvant chemoradiation therapy.5,

Information about ongoing clinical trials is available from the NCI Web site.



1 Brennan MF, Karpeh MS Jr: Surgery for gastric cancer: the American view. Semin Oncol 23 (3): 352-9, 1996.

2 Bozzetti F, Marubini E, Bonfanti G, et al.: Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg 230 (2): 170-8, 1999.

3 Macdonald JS, Smalley SR, Benedetti J, et al.: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10): 725-30, 2001.

4 Kelsen DP: Postoperative adjuvant chemoradiation therapy for patients with resected gastric cancer: intergroup 116. J Clin Oncol 18 (21 Suppl): 32S-4S, 2000.

5 Ajani JA, Radiation Therapy Oncology Group: Phase II Study of Preoperative Chemotherapy and Chemoradiotherapy in Patients With Potentially Resectable Adenocarcinoma of the Stomach, RTOG-9904, Clinical trial, Completed.

Stage II Gastric Cancer

Surgical resection with regional lymphadenectomy is the treatment of choice for patients with stage II gastric cancer.1 If the lesion is not in the cardioesophageal junction and does not diffusely involve the stomach, subtotal gastrectomy is the procedure of choice. When the lesion involves the cardia, proximal subtotal gastrectomy or total gastrectomy may be performed with curative intent. If the lesion diffusely involves the stomach, total gastrectomy and appropriate lymph node resection may be required. The role of extended lymph node (D2) dissection is uncertain 2 and in some series is associated with increased morbidity.3,4,

Postoperative chemoradiation therapy may be considered for patients with stage II gastric cancer. A prospective multi-institution phase III trial (INT-0116) evaluating postoperative combined chemoradiation therapy versus surgery alone in 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction reported a significant survival benefit with adjuvant combined modality therapy.5 With a median follow-up of 5 years, median survival was 36 months for the adjuvant chemoradiation therapy group as compared to 27 months for the surgery-alone arm (P = .005). Three-year overall survival (OS) and relapse-free survival rates were 50% and 48% with adjuvant chemoradiation therapy versus 41% and 31% for surgery alone (P = .005).

Investigators in Europe evaluated the role of preoperative and postoperative chemotherapy without radiation therapy.6 In the randomized trial, patients with stage II or higher adenocarcinoma of the stomach or of the lower third of the esophagus were assigned either to receive three cycles of epirubicin, cisplatin, and continuous infusion 5-FU before and after surgery or to receive surgery alone. Compared with the surgery group, the perioperative-chemotherapy group had a significantly higher likelihood of progression-free survival (hazard ratio [HR] for progression, 0.66; 95% confidence interval [CI], 0.53–0.81; P < .001) and of OS (HR for death, 0.75; 95% CI, 0.60–0.93; P = .009). Five-year OS was 36.3%, 95% CI, 29 to 43 for the perioperative chemotherapy group and 23%, 95% CI, 16.6 to 29.4 for the surgery group.6,[Level of evidence: 1iiA]

Standard treatment options:

  1. One of the following surgical procedures:
    • Distal subtotal gastrectomy (if the lesion is not in the fundus or at the cardioesophageal junction).
    • Proximal subtotal gastrectomy or total gastrectomy (if the lesion involves the cardia).
    • Total gastrectomy (if the tumor involves the stomach diffusely or arises in the body of the stomach and extends to within 6 cm of the cardia).

    Regional lymphadenectomy is recommended with all of the above procedures. Splenectomy is not routinely performed.1,

  2. Postoperative chemoradiation therapy.5,
  3. Perioperative chemotherapy.


1 Brennan MF, Karpeh MS Jr: Surgery for gastric cancer: the American view. Semin Oncol 23 (3): 352-9, 1996.

2 Kitamura K, Yamaguchi T, Sawai K, et al.: Chronologic changes in the clinicopathologic findings and survival of gastric cancer patients. J Clin Oncol 15 (12): 3471-80, 1997.

3 Bonenkamp JJ, Songun I, Hermans J, et al.: Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 345 (8952): 745-8, 1995.

4 Cuschieri A, Fayers P, Fielding J, et al.: Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial.The Surgical Cooperative Group. Lancet 347 (9007): 995-9, 1996.

5 Macdonald JS, Smalley SR, Benedetti J, et al.: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10): 725-30, 2001.

6 Cunningham D, Allum WH, Stenning SP, et al.: Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 355 (1): 11-20, 2006.

Stage III Gastric Cancer

All patients with tumors that can be resected should undergo surgery. As many as 15% of selected stage III patients can be cured by surgery alone, particularly if lymph node involvement is minimal (<7 lymph nodes).

Postoperative chemoradiation therapy may be considered for patients with stage III gastric cancer. A prospective multi-institution phase III trial (INT-0116) evaluating postoperative combined chemoradiation therapy versus surgery alone in 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction reported a significant survival benefit with adjuvant combined modality therapy.1 With a median follow-up of 5 years, median survival was 36 months for the adjuvant chemoradiation therapy group as compared to 27 months for the surgery-alone arm (P = .005). Three-year overall survival (OS) and relapse-free survival rates were 50% and 48% with adjuvant chemoradiation therapy versus 41% and 31% for surgery alone (P = .005). Neoadjuvant chemoradiation therapy is under clinical evaluation.2 All newly diagnosed patients with stage III gastric cancer should be considered candidates for clinical trials.3,4,

Investigators in Europe evaluated the role of preoperative and postoperative chemotherapy without radiation therapy.5 In the randomized trial, patients with stage II or higher adenocarcinoma of the stomach or of the lower third of the esophagus were assigned either to receive three cycles of epirubicin, cisplatin, and continuous infusion 5-FU before and after surgery or to receive surgery alone. Compared with the surgery group, the perioperative chemotherapy group had a significantly higher likelihood of progression-free survival (hazard ratio [HR] for progression, 0.66; 95% confidence interval [CI], 0.53–0.81; P < .001) and of OS (HR for death, 0.75; 95% CI, 0.60–0.93; P = .009). Five-year OS was 36.3%, 95% CI, 29 to 43 for the perioperative chemotherapy group and 23%, 95% CI, 16.6 to 29.4 for the surgery group.5,[Level of evidence: 1iiA]

Standard treatment options:

  1. Radical surgery. Curative resection procedures are confined to patients who at the time of surgical exploration do not have extensive nodal involvement.
  2. Postoperative chemoradiation therapy.1,
  3. Perioperative chemotherapy.


1 Macdonald JS, Smalley SR, Benedetti J, et al.: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10): 725-30, 2001.

2 Ajani JA, Radiation Therapy Oncology Group: Phase II Study of Preoperative Chemotherapy and Chemoradiotherapy in Patients With Potentially Resectable Adenocarcinoma of the Stomach, RTOG-9904, Clinical trial, Completed.

3 Douglass HO Jr, Nava HR: Gastric adenocarcinoma--management of the primary disease. Semin Oncol 12 (1): 32-45, 1985.

4 Douglass HO Jr: Gastric cancer: overview of current therapies. Semin Oncol 12 (3 Suppl 4): 57-62, 1985.

5 Cunningham D, Allum WH, Stenning SP, et al.: Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 355 (1): 11-20, 2006.

Stage IV Gastric Cancer

Patients with no distant metastases (M0)

All patients with stage IV (M0) tumors that can be resected should undergo surgery followed by postoperative chemoradiation therapy.1 The majority of patients with stage IV disease with no evidence of distance metastatic disease, however, have tumors that are unresectable for cure at diagnosis (as determined at surgical exploration or as defined preoperatively with computed tomography, endoscopic ultrasonography, laparoscopy, or other studies). These patients should be considered candidates for clinical trials.

Standard treatment options:

  • Radical surgery if possible, followed by postoperative chemoradiation.1,

Treatment options under clinical evaluation:

  • Neoadjuvant chemoradiation therapy.2,

Information about ongoing clinical trials is available from the NCI Web site.

Patients with distant metastases (M1)

All newly diagnosed patients with hematogenous or peritoneal metastases should be considered candidates for clinical trials if possible. In some patients, chemotherapy may provide substantial palliation and occasional durable remission, though it does not prolong life or provide a cure.3,4,5,6,7,8,9,10,11,

Because survival is poor with all available single and multimodal approaches to treatment, no single approach can be considered state of the art.3

Information about ongoing clinical trials is available from the NCI Web site.

Standard treatment options:

  1. Palliative chemotherapy with:
    • Fluorouracil.4,5,12,
    • FAM (fluorouracil, doxorubicin, mitomycin-C).6,7,
    • FAP (fluorouracil, doxorubicin, cisplatin).8,
    • ECF (epirubicin, cisplatin, fluorouracil).9,
    • ELF (etoposide, fluorouracil, leucovorin).10,
    • PELF (cisplatin, epidoxorubicin, leucovorin, fluorouracil with glutathione and filgrastim).11,
    • FAMTX (fluorouracil, doxorubicin, methotrexate).3,
    • FUP (fluorouracil, cisplatin).3,12,
  2. Endoscopic laser therapy or endoluminal stent placement may be helpful to patients whose tumors have occluded the gastric inlet.13,
  3. Palliative radiation therapy may alleviate bleeding, pain, and obstruction.
  4. Palliative resection should be reserved for patients with continued bleeding or obstruction.


1 Macdonald JS, Smalley SR, Benedetti J, et al.: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345 (10): 725-30, 2001.

2 Ajani JA, Radiation Therapy Oncology Group: Phase II Study of Preoperative Chemotherapy and Chemoradiotherapy in Patients With Potentially Resectable Adenocarcinoma of the Stomach, RTOG-9904, Clinical trial, Completed.

3 Vanhoefer U, Rougier P, Wilke H, et al.: Final results of a randomized phase III trial of sequential high-dose methotrexate, fluorouracil, and doxorubicin versus etoposide, leucovorin, and fluorouracil versus infusional fluorouracil and cisplatin in advanced gastric cancer: A trial of the European Organization for Research and Treatment of Cancer Gastrointestinal Tract Cancer Cooperative Group. J Clin Oncol 18 (14): 2648-57, 2000.

4 Comis RL, Carter SK: Integration of chemotherapy into combined modality treatment of solid tumors. III. Gastric cancer. Cancer Treat Rev 1 (3): 221-238, 1974.

5 Cullinan SA, Moertel CG, Fleming TR, et al.: A comparison of three chemotherapeutic regimens in the treatment of advanced pancreatic and gastric carcinoma. Fluorouracil vs fluorouracil and doxorubicin vs fluorouracil, doxorubicin, and mitomycin. JAMA 253 (14): 2061-7, 1985.

6 MacDonald JS, Schein PS, Woolley PV, et al.: 5-Fluorouracil, doxorubicin, and mitomycin (FAM) combination chemotherapy for advanced gastric cancer. Ann Intern Med 93 (4): 533-6, 1980.

7 Douglass HO Jr, Lavin PT, Goudsmit A, et al.: An Eastern Cooperative Oncology Group evaluation of combinations of methyl-CCNU, mitomycin C, Adriamycin, and 5-fluorouracil in advanced measurable gastric cancer (EST 2277). J Clin Oncol 2 (12): 1372-81, 1984.

8 Moertel CG, Rubin J, O'Connell MJ, et al.: A phase II study of combined 5-fluorouracil, doxorubicin, and cisplatin in the treatment of advanced upper gastrointestinal adenocarcinomas. J Clin Oncol 4 (7): 1053-7, 1986.

9 Waters JS, Norman A, Cunningham D, et al.: Long-term survival after epirubicin, cisplatin and fluorouracil for gastric cancer: results of a randomized trial. Br J Cancer 80 (1-2): 269-72, 1999.

10 Ajani JA, Ota DM, Jackson DE: Current strategies in the management of locoregional and metastatic gastric carcinoma. Cancer 67 (1 Suppl): 260-5, 1991.

11 Cascinu S, Labianca R, Alessandroni P, et al.: Intensive weekly chemotherapy for advanced gastric cancer using fluorouracil, cisplatin, epi-doxorubicin, 6S-leucovorin, glutathione, and filgrastim: a report from the Italian Group for the Study of Digestive Tract Cancer. J Clin Oncol 15 (11): 3313-9, 1997.

12 Ohtsu A, Shimada Y, Shirao K, et al.: Randomized phase III trial of fluorouracil alone versus fluorouracil plus cisplatin versus uracil and tegafur plus mitomycin in patients with unresectable, advanced gastric cancer: The Japan Clinical Oncology Group Study (JCOG9205). J Clin Oncol 21 (1): 54-9, 2003.

13 Ell C, Hochberger J, May A, et al.: Coated and uncoated self-expanding metal stents for malignant stenosis in the upper GI tract: preliminary clinical experiences with Wallstents. Am J Gastroenterol 89 (9): 1496-500, 1994.

Recurrent Gastric Cancer

Because survival is poor with all available single and multimodal approaches to treatment, patients should be considered candidates for phase I and phase II clinical trials testing new anticancer drugs or biologicals. Patients with obstructive tumors in the gastric remnant may be relieved of dysphagia by endoscopic Nd:Yag or electrocautery destruction of the obstructing lesion. Radiation therapy may also help control bleeding, pain, and obstruction.

Information about ongoing clinical trials is available from the NCI Web site.

Standard treatment options:

  1. Palliative chemotherapy with:
    • Fluorouracil.1,
    • FAM (fluorouracil, doxorubicin, mitomycin-C).2,
    • FAP (fluorouracil, doxorubicin, cisplatin).3,
    • ECF (epirubicin, cisplatin, fluorouracil).4,5,
    • ELF (etoposide, fluorouracil, leucovorin).6,
    • FLAP (fluorouracil, leucovorin, doxorubicin, cisplatin).7,
    • PELF (cisplatin, epidoxorubicin, leucovorin, fluorouracil with glutathione and filgrastim).8,
    • FAMTX (fluorouracil, doxorubicin, methotrexate).9,
    • FUP (fluorouracil, cisplatin).9,
  2. Endoscopic laser therapy or electrocautery may be helpful for obstructive lesions.
  3. Radiation therapy may alleviate bleeding, pain, and obstruction.


1 Comis RL, Carter SK: Integration of chemotherapy into combined modality treatment of solid tumors. III. Gastric cancer. Cancer Treat Rev 1 (3): 221-238, 1974.

2 MacDonald JS, Schein PS, Woolley PV, et al.: 5-Fluorouracil, doxorubicin, and mitomycin (FAM) combination chemotherapy for advanced gastric cancer. Ann Intern Med 93 (4): 533-6, 1980.

3 Moertel CG, Rubin J, O'Connell MJ, et al.: A phase II study of combined 5-fluorouracil, doxorubicin, and cisplatin in the treatment of advanced upper gastrointestinal adenocarcinomas. J Clin Oncol 4 (7): 1053-7, 1986.

4 Waters JS, Norman A, Cunningham D, et al.: Long-term survival after epirubicin, cisplatin and fluorouracil for gastric cancer: results of a randomized trial. Br J Cancer 80 (1-2): 269-72, 1999.

5 Ross P, Nicolson M, Cunningham D, et al.: Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) With epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. J Clin Oncol 20 (8): 1996-2004, 2002.

6 Ajani JA, Ota DM, Jackson DE: Current strategies in the management of locoregional and metastatic gastric carcinoma. Cancer 67 (1 Suppl): 260-5, 1991.

7 Vaughn DJ, Meropol NJ, Holroyde C, et al.: A phase II study of 5-fluorouracil, leucovorin, adriamycin, and cisplatin (FLAP) for metastatic gastric and gastroesophageal junction adenocarcinoma. A Penn Cancer Clinical Trial Group and Roswell Park Cancer Institute Community Oncology Research Program Trial. Am J Clin Oncol 20 (3): 242-6, 1997.

8 Cascinu S, Labianca R, Alessandroni P, et al.: Intensive weekly chemotherapy for advanced gastric cancer using fluorouracil, cisplatin, epi-doxorubicin, 6S-leucovorin, glutathione, and filgrastim: a report from the Italian Group for the Study of Digestive Tract Cancer. J Clin Oncol 15 (11): 3313-9, 1997.

9 Vanhoefer U, Rougier P, Wilke H, et al.: Final results of a randomized phase III trial of sequential high-dose methotrexate, fluorouracil, and doxorubicin versus etoposide, leucovorin, and fluorouracil versus infusional fluorouracil and cisplatin in advanced gastric cancer: A trial of the European Organization for Research and Treatment of Cancer Gastrointestinal Tract Cancer Cooperative Group. J Clin Oncol 18 (14): 2648-57, 2000.

Changes to This Summary (03/01/2007)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information

Updated statistics with estimated new cases and deaths for 2007 (cited American Cancer Society as reference 1).

More Information

About PDQ

  • PDQ® - NCI's Comprehensive Cancer Database.
    • Full description of the NCI PDQ database.

Additional PDQ Summaries

  • PDQ® Cancer Information Summaries: Adult Treatment
    • Treatment options for adult cancers.
  • PDQ® Cancer Information Summaries: Pediatric Treatment
    • Treatment options for childhood cancers.
  • PDQ® Cancer Information Summaries: Supportive Care
    • Side effects of cancer treatment, management of cancer-related complications and pain, and psychosocial concerns.
  • PDQ® Cancer Information Summaries: Screening/Detection (Testing for Cancer)
    • Tests or procedures that detect specific types of cancer.
  • PDQ® Cancer Information Summaries: Prevention
    • Risk factors and methods to increase chances of preventing specific types of cancer.
  • PDQ® Cancer Information Summaries: Genetics
    • Genetics of specific cancers and inherited cancer syndromes, and ethical, legal, and social concerns.
  • PDQ® Cancer Information Summaries: Complementary and Alternative Medicine
    • Information about complementary and alternative forms of treatment for patients with cancer.

Important:

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) .

2007-03-01