Stomach Cancer

Stomach Cancer

In the United States, about 21,000 people are diagnosed with stomach cancer annually, and 10,000 die of the disease. Worldwide, stomach cancer is much more common, in part because of high rates of infection with the bacterium H. Pylori, which was found in the 1990s to increase the risk of stomach cancer, ulcers, and other stomach problems.

Since the late 1980s, major research findings have improved options for patients with early stage disease. While full surgical removal of the stomach (gastrectomy) was previously the only option to potentially cure early stage stomach cancer, studies showed that a partial removal of the stomach was just as effective for many patients. Other research found significant improvement in long-term survival with the addition of adjuvant radiation and chemotherapy.

For patients with advanced disease, survival remains relatively low and effective new treatments are urgently needed. Through clinical trials, doctors continue to refine chemotherapy regimens in ways that extend patients' lives and significantly delay problems like loss of appetite and weight loss.

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2014

New targeted treatment helps people with advanced stomach cancer live longer

New targeted treatment helps people with advanced stomach cancer live longer

The FDA approves ramucirumab (Cyramza), for treatment of advanced cancers of the stomach and gastroesophageal junction. This marked the first FDA-approved treatment for patients with advanced stomach cancer that worsened during or after chemotherapy. The approval follows results from a clinical trial showing that ramucirumab both alone and combined with the chemotherapy paclitaxel (Abraxane) modestly extends patient survival. Anti-angiogenic drugs like ramucirumab block the growth of blood vessels to the tumors.

Chemotherapy extends survival after stomach cancer surgery

Chemotherapy extends survival after stomach cancer surgery

A large trial shows that patients with early stomach cancer who receive chemotherapy with capecitabine (Xeloda) and oxaliplatin (Eloxatin) after surgery live longer than those who have surgery alone. These results affirm that adjuvant (post-surgery) chemotherapy can make a vital difference for patients with stomach cancer, as it does for breast, colon, and several other cancers.   

2012

Adding radiation to chemotherapy after surgery still benefits some patients

Adding radiation to chemotherapy after surgery still benefits some patients

Building on the results of a 2011 Korean trial, a study suggests that for patients with stomach cancer that has spread to the lymph nodes, there is a small but significant improvement in survival from adding radiation to adjuvant (post-surgical) chemotherapy, in this case using the drugs capecitabine (Xeloda) and cisplatin. A larger trial is currently underway to confirm these results.

Because radiation only slightly improved outcomes, adjuvant chemotherapy alone after aggressive surgery also remains a viable treatment option for certain patients.

2011

Korean study affirms value of chemotherapy, alone, following surgery

2010

Common targeted breast cancer drug also improves survival for certain gastric cancers

2008

New chemotherapy regimen extends survival for metastatic gastric cancers

New chemotherapy regimen extends survival for metastatic gastric cancers

Chemotherapy with the drugs cisplatin or fluorouracil was used to shrink or stall the growth of tumors in patients with advanced gastric cancers, but results were inconsistent and treatment often caused significant side effects. In 2008, a large trial finds that adding oxaliplatin to fluorouracil and leucovorin chemotherapy shrinks tumors in many patients and generally causes fewer side effects than a regimen of cisplatin, fluorouracil and leucovorin. The newer regimen is particularly effective in older patients.

A later trial finds that replacing one part of this regimen – fluorouracil – with an oral version of the same drug, called capecitabine (Xeloda) is comparably effective. This alternative allows patients the freedom to receive more of their treatment outside of their doctor's office.

Adjuvant chemotherapy alone, without radiation, may be sufficient for early gastric cancer

Adjuvant chemotherapy alone, without radiation, may be sufficient for early gastric cancer

A large Japanese trial suggests that surgery plus adjuvant (post-surgical) chemotherapy with the drug S-1 – without radiation – is an effective treatment option. Patients in the trial had outcomes comparable to those in past trials who were treated with another standard chemotherapy regimen, plus radiation, following surgery. Further research has shown that S1 tends to be safer and more effective in Asian patients, whose cancers tend to grow and respond to treatment differently than those of Western patients. While debate continues about the best adjuvant approach, in particular for patients who undergo more extensive surgery, this study suggests that patients may be able to forgo the added side effects of radiation without reducing their chances of long-term survival.

2006

New addition to chemotherapy improves survival for select patients
Chemotherapy before and after surgery improves survival for many patients

Chemotherapy before and after surgery improves survival for many patients

Results of the "MAGIC" trial provide one of the most significant advances against stomach cancer in many years, showing that chemotherapy both before and after surgery improves survival. This regimen soon becomes standard for patients with operable gastric cancer. The substantial benefit of chemotherapy leads investigators to question for the first time whether post-surgery radiation therapy is needed for patients with this form of gastric cancer.

2005

Removal of additional lymph nodes shown to help improve survival

Removal of additional lymph nodes shown to help improve survival

While gastric cancer surgery had long involved removal of both the tumor and surrounding lymph nodes to prevent further spread, an open question was whether removing lymph nodes further away from the tumor – to find additional signs of cancer's spread and guide treatment decisions – could help improve survival.

In 1999, Dutch researchers initially report no survival benefit with more extensive lymph node surgery, a procedure known as D2 surgery, compared to removal of just the nearby lymph nodes (known as D1). However, longer follow-up from the same study ultimately reveals that the more extensive D2 dissection is in fact associated with fewer recurrences and gastric cancer-related deaths. Today, D2 resection is the global standard for gastric cancer surgery.

2001

Gene identified in inherited gastric cancer

Gene identified in inherited gastric cancer

Researchers first link a specific gene – the E-cadherin gene (CHD1) – to a type of hereditary gastric cancer. Three in four carriers of the gene will develop the disease. Such cases make up a small share of all stomach cancers, but given the extremely high cancer risk, people with the gene are typically advised to undergo a prophylactic gastrectomy (preventive surgical removal of the stomach).

Adjuvant therapy improves long-term survival for patients with early-stage stomach cancer

Adjuvant therapy improves long-term survival for patients with early-stage stomach cancer

In 2001, a major trial shows that giving patients chemotherapy and radiation after surgery – an approach known as adjuvant therapy – significantly improves survival. The study compared surgery alone with surgery followed by the chemotherapy drugs fluorouracil and leucovorin, together with radiation.

These findings quickly establish adjuvant chemotherapy and radiation as a standard of care, and make stomach cancer one of several cancers in which adjuvant therapy can increase patients' chances of cure.

1997

Laparoscopy provides less invasive way to assess and treat stomach tumors

Laparoscopy provides less invasive way to assess and treat stomach tumors

Researchers begin to utilize this minimally invasive surgical procedure for "staging" of gastric cancer patients. Laparoscopy is found to be roughly as effective as more invasive approaches, but requires a much smaller incision and allows an easier and shorter recovery time for patients. With laparoscopy, a surgeon inserts a thin, lighted tube through a small incision to examine the abdominal organs.

As surgeons become more adept with the technique, many patients with gastric cancer are able to be surgically treated using laparoscopy, which is far less invasive than traditional open surgery on the stomach.

New chemotherapy regimen becomes standard for advanced stomach cancer

New chemotherapy regimen becomes standard for advanced stomach cancer

A major trial shows that a new combination chemotherapy regimen involving the drugs epirubicin, cisplatin and fluorouracil (together called ECF) helps extend survival and reduces serious side effects for patients with advanced stomach cancer, compared with an earlier three-drug regimen. The study establishes ECF as a new standard for advanced stomach cancer, helping patients live longer with a better quality of life.

1993

Bacterial infection linked to gastric cancer risk

Bacterial infection linked to gastric cancer risk

Researchers show a strong correlation between the incidence of stomach cancer and infection with a bacterium called H. pylori. Further studies estimate a 3- to 6-fold increased risk of stomach cancer for people infected with the bacteria.

H. pylori is spread through contaminated food, water and direct mouth-to-mouth contact. The U.S. Centers for Disease Control and Prevention estimates that approximately two-thirds of the world's population carries the bacterium, with infection rates being highest in developing countries. However, the bacterium does not cause illness in the majority of carriers.

In Western Europe and the United States, declining rates of H. pylori infection are thought to partly account for declines in stomach cancer cases in recent decades.

1990

Genetic risk factors for gastric cancer are identified

Genetic risk factors for gastric cancer are identified

Researchers find that patients with a family history of a condition called Lynch syndrome are at increased risk for gastric cancer, in addition to colorectal cancer. Later studies indicate that first-degree relatives (e.g., a parent or sibling) of patients with gastric cancer have a two- to three-fold increased risk of developing the disease, compared to the general population. These findings help doctors identify patients at high risk for developing the disease, potentially improving the chances of finding the cancer early when treatment is likely to be more effective.

1989

Less extensive stomach surgery offers same chance of cure

Less extensive stomach surgery offers same chance of cure

While surgery had long been established as the only chance of cure for gastric cancer, physicians had debated whether the full stomach needed to be removed (gastrectomy) or if removing only the part of the stomach containing the tumor (partial gastrectomy) would be sufficient.

In 1989, research shows that for patients with tumors in the lower (distal) part of the stomach, partial gastrectomy combined with removal of the surrounding lymph nodes is as effective and results in fewer complications than total gastrectomy.

1988

New ultrasound device offers minimally invasive cancer evaluation and treatment tool

New ultrasound device offers minimally invasive cancer evaluation and treatment tool

Doctors begin using advanced ultrasound techniques to assess the size, depth and spread of gastric cancers. In a procedure call endoscopic ultrasound, a thin, lighted tube is passed through the patient's mouth and into the stomach. The device then uses sound waves to create an image of the inside of the stomach.

Subsequent refinements to the procedure enable doctors to obtain small tumor biopsies or even to remove early-stage gastric tumors and precancerous lesions, a process known as endoscopic mucosal resection.

1985

New imaging tools help detect and evaluate stomach cancer

1980

Combination chemotherapy improves outcomes for advanced stomach cancer

Combination chemotherapy improves outcomes for advanced stomach cancer

Throughout the 1970's, many chemotherapy drugs are tested in combinations of two to four drugs in the hope of improving survival for patients with inoperable stomach cancer. While most combinations have no significant impact, a three-drug regimen called FAM (5-fluorouracil, mitomycin C and Adriamycin, also known as doxorubicin) provides some benefit and is widely used throughout the 1980s. In 1989, doctors find that adding methotrexate to fluorouracil and Adriamycin, a three-drug regimen called FAMTX, further improves survival for some patients.

1881

First successful surgery performed for stomach cancer

First successful surgery performed for stomach cancer

In 1881, the Austrian physician Theodore Billroth partially removes the stomach of a 43-year old woman suffering from a gastric obstruction. Sixteen years later, Carl Schlatter takes the surgery further and completes the first total gastrectomy, or complete removal of the stomach.

For nearly a century afterward, gastrectomy remains the only treatment available for gastric cancer. While it offers a chance of cure for patients whose tumors have not spread, patients are limited to eating only small amounts of food at a time and are at risk for vitamin B deficiency, chronic low blood sugar and anemia.