Management of Gastric Cancer

Geoffrey Y. Ku; David H. Ilson


Curr Opin Gastroenterol. 2014;30(6):596-602. 

In This Article

Abstract and Introduction


Purpose of review Gastric cancer is an uncommon cancer in the United States but is a very common cancer globally and is endemic in East Asia. It is a virulent cancer that presents with metastatic disease in about one half of United States patients.

Recent findings In this review article, we discuss palliative chemotherapy options as well as validated preoperative, perioperative and postoperative strategies for locally advanced disease, which include chemotherapy and/or chemoradiation.

Summary In the metastatic setting, there has been incremental improvement in cytotoxic chemotherapy combinations in the past 2 decades. Two targeted agents – trastuzumab and ramucirumab – are now approved. In the locally advanced setting, perioperative chemotherapy or postoperative chemotherapy or chemoradiation improves outcomes relative to surgery alone.


Gastric cancer, an uncommon but highly virulent malignancy in the United States, will be diagnosed in 22 220 patients in 2014, with 10 990 deaths.[1] In comparison to its relative rarity in the United States, gastric cancer is endemic in parts of East Asia, which account for more than half of the approximately 1 million cases that develop per year globally.[2]

In the United States, the incidence of gastric cancer has decreased significantly in the past 50 years, but the location of the primary tumor has also changed. Distal gastric cancer, which previously predominated, has become uncommon, whereas the incidence of tumors of the gastric cardia and gastroesophageal junction have increased 4–10% per year among United States men since 1976.[3,4]

Changing epidemiologic factors account for the increasing incidence of proximal tumors. Chronic infection with Helicobacter pylori has been implicated in the development of gastric cancer on the basis of epidemiological evidence.[5] A decline in H. pylori infection in the United States has led to an overall decrease in the number of gastric cancer cases. On the other hand, proximal and gastroesophageal junction tumors are now more common because of an increased incidence of gastroesophageal reflux disease[6] and obesity.[7]

In the metastatic setting, chemotherapy is the mainstay of treatment. Although there have been incremental improvements in terms of efficacy and tolerability, outcomes remain poor.

For locally advanced gastric cancer, surgery remains the most important component of curative therapy. Numerous studies have evaluated preoperative and postoperative strategies for locally advanced disease, including chemotherapy or chemoradiation. As a whole, these studies show that some treatment in addition to surgery clearly improves outcomes.

These studies have variously enrolled purely gastric cancers (especially distal tumors, which is the predominant location in Asia) or have also included tumors that involve the gastroesophageal junction or even lower esophagus. Consistent with guidelines from the National Comprehensive Cancer Network, our practice pattern is to apply the conclusions of these studies based on the Siewert classification of gastroesophageal junction adenocarcinomas.[8] Siewert type I tumors arise from the distal esophagus and infiltrate the gastroesophageal junction from above, whereas type III tumors are gastric cardia tumors that infiltrate the gastroesophageal junction from below; type II tumors are true tumors of the gastroesophageal junction. Therefore, this review is applicable only to Siewert type III gastroesophageal junction and gastric adenocarcinomas. Specifically, preoperative chemoradiation is a validated option for lower esophageal and Siewert type I/II gastroesophageal junction adenocarcinomas,[9] but this approach and these diseases are not the focus of this review.