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Incidence and Mortality
Estimated new cases and deaths from gastric cancer in the United States in 2018:
Management of adenocarcinoma histology, which accounts for 90% to 95% of all gastric malignancies, is discussed in this summary. There are changing epidemiologic patterns in the United States regarding the anatomic location of esophagogastric cancers, with a trend of decreased occurrence of distal or noncardia gastric cancers. However, in persons aged 25 to 39 years, there has been an increase in the incidence of noncardia gastric cancers from 0.27 cases per 100,000 individuals (1977–1981) to 0.45 cases per 100,000 individuals (2002–2006). Additional studies are needed to confirm the observed increases in noncardia gastric cancers in this specific age group.
In contrast to the overall stable trend for noncardia gastric cancers, earlier studies demonstrated an increased incidence of adenocarcinomas of the gastric cardia of 4% to 10% per year from the mid-1970s to the late 1980s. Similarly, the incidence of gastroesophageal junction adenocarcinomas increased sharply, from 1.22 cases per 100,000 individuals (1973–1978) to 2.00 cases per 100,000 individuals (1985–1990). Since that time, the incidence has remained steady at 1.94 cases per 100,000 individuals (2003–2008). More recent data demonstrate that the incidence of gastric cardia cancers has been relatively stable, although an increase has been observed, from 2.4 cases per 100,000 individuals (1977–1981) to 2.9 cases per 100,000 individuals (2001–2006) in the Caucasian population. The reasons for these temporal changes in incidence are unclear.
In the United States, gastric cancer ranks 14th in incidence among the major types of cancer. While the precise etiology is unknown, acknowledged risk factors for gastric cancer include the following:[5,6,7]
Prognosis and Survival
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.[8,9] Tumor grade may also provide some prognostic information.
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 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.
Gastrointestinal stromal tumors occur most commonly in the stomach. (Refer to the PDQ summary on Gastrointestinal Stromal Tumors Treatment for more information.)
Other PDQ summaries containing information related to gastric cancer include the following:
There are two major types of gastric adenocarcinoma including the following:
Intestinal adenocarcinomas are well differentiated, and the cells tend to arrange themselves in tubular or glandular structures. The terms tubular, papillary, and mucinous are assigned to the various types of intestinal adenocarcinomas. Rarely, adenosquamous cancers can occur.
Diffuse adenocarcinomas are undifferentiated or poorly differentiated, and they lack a gland formation. Clinically, diffuse adenocarcinomas can give rise to infiltration of the gastric wall (i.e., linitis plastica).
Some tumors can have mixed features of intestinal and diffuse types.
AJCC Prognostic Stage Groups and TNM Definitions
The AJCC has designated staging by TNM (tumor, node, metastasis) classification to define gastric cancer.
Radical surgery represents the standard form of therapy that has curative intent. However, the incidences of local failure in the tumor bed and regional lymph nodes, and distant failures via hematogenous or peritoneal routes, remain high. As such, adjuvant external-beam radiation therapy with combined chemotherapy has been evaluated in the United States.
In a phase III Intergroup trial (SWOG-9008), 556 patients with completely resected stage IB to stage IV (M0) adenocarcinoma of the stomach and gastroesophageal junction were randomly assigned to receive surgery alone or surgery plus postoperative chemotherapy (5-fluorouracil [5-FU] and leucovorin) and concurrent radiation therapy (45 Gy). With 5 years' median follow-up, a significant survival benefit was reported for patients who received adjuvant combined modality therapy.[Level of evidence: 1iiA] Median survival was 36 months for the adjuvant chemoradiation therapy group and 27 months for the surgery-alone arm (P = .005). Three-year overall survival (OS) rates were 50%, and relapse-free survival rates were 48% with adjuvant chemoradiation therapy versus 3-year OS rates of 41% and relapse-free survival rates of 31% for surgery alone (P = .005). The rate of distant metastases was 18% for the surgery-alone arm and 33% for the chemoradiation-therapy arm. Because distant disease remains a significant concern, the aim of the Cancer and Leukemia Group B study (CALGB-80101 [NCT00052910]) was to augment the postoperative chemoradiation therapy regimen used in INT-0116. Neoadjuvant chemoradiation therapy such as in the RTOG-9904 (NCT00003862) trial, which is completed, and the SWOG-S0425 (NCT00335959) trial, which is closed, was clinically evaluated.
Investigators in Europe evaluated the role of preoperative and postoperative chemotherapy without radiation therapy. In the randomized phase III trial (MRC-ST02 [NCT00002615]), patients with stage II or higher adenocarcinoma of the stomach or of the lower third of the esophagus were assigned 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 (HRdeath, 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.[Level of evidence: 1iiA]
Standard Treatment Options for Stage 0 Gastric Cancer
Standard treatment options for stage 0 gastric cancer include the following:
Stage 0 is gastric cancer confined to mucosa. Experience in Japan, where stage 0 is diagnosed frequently, indicates that more than 90% of patients treated by gastrectomy with lymphadenectomy will survive beyond 5 years. An American series has confirmed these results.
Current Clinical Trials
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
Standard Treatment Options for Stage I Gastric Cancer
Standard treatment options for stage I gastric cancer include the following:
Regional lymphadenectomy is recommended with all of the above procedures. Splenectomy is not routinely performed.
Surgical resection including regional lymphadenectomy is the treatment of choice for patients with stage I gastric cancer. If the lesion is not in the cardioesophageal junction and does not diffusely involve the stomach, subtotal gastrectomy is the procedure of choice, because it has been demonstrated to provide equivalent survival when compared with total gastrectomy and is associated with decreased morbidity.[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 includes greater and lesser curvature perigastric regional lymph nodes. Note that in patients with stage I gastric cancer, perigastric lymph nodes may contain cancer.
Postoperative chemoradiation therapy
In patients with node-positive (T1 N1) and muscle-invasive (T2 N0) disease, postoperative chemoradiation therapy may be considered.
Evidence (postoperative chemoradiation therapy):
Because 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.
Treatment Options Under Clinical Evaluation for Stage I Gastric Cancer
Treatment options under clinical evaluation for stage I gastric cancer include the following:
Standard Treatment Options for Stage II Gastric Cancer
Standard treatment options for stage II gastric cancer include the following:
Surgical resection with regional lymphadenectomy is the treatment of choice for patients with stage II gastric cancer. 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  and in some series is associated with increased morbidity.[5,6]
Postoperative chemoradiation therapy may be considered for patients with stage II gastric cancer.
Neoadjuvant chemoradiation therapy remains under clinical evaluation, which was in the SWOG-S0425 (NCT00335959) trial, and the RTOG-9904 (NCT00003862) trial.
Perioperative chemotherapy and postoperative chemotherapy
Investigators in Europe evaluated the role of perioperative and postoperative chemotherapy without radiation therapy.
Evidence (perioperative chemotherapy and postoperative chemotherapy):
Treatment Options Under Clinical Evaluation for Stage II Gastric Cancer
Treatment options under clinical evaluation for stage II gastric cancer include the following:
All newly diagnosed patients with stage II gastric cancer should be considered candidates for clinical trials.
Standard Treatment Options for Stage III Gastric Cancer
Standard treatment options for stage III gastric cancer include the following:
Surgery is the treatment of choice for all patients who have tumors that can be resected. 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.
Perioperative and postoperative chemotherapy
Investigators in Europe evaluated the role of perioperative and postoperative chemotherapy without radiation therapy.
Treatment Options Under Clinical Evaluation for Stage III Gastric Cancer
Treatment options under clinical evaluation for stage III gastric cancer include the following:
All newly diagnosed patients with stage III gastric cancer should be considered candidates for clinical trials.
Standard Treatment Options for Stage IV and Recurrent Gastric Cancer
Standard treatment options for stage IV and recurrent gastric cancer include the following:
Standard chemotherapy versus best supportive care for patients with metastatic gastric cancer has been tested in several clinical trials, and there is general agreement that patients who receive chemotherapy live for several months longer on average than patients who receive supportive care.[11,12,13][Level of evidence: 1iiA] During the last 20 years, multiple randomized studies evaluating different treatment regimens (monotherapy vs. combination chemotherapy) have been performed in patients with metastatic gastric cancer with no clear consensus emerging as to the best management approach. A meta-analysis of these studies demonstrated a hazard ratio (HR) of 0.83 for overall survival (OS) (95% confidence interval [CI], 0.74–0.93) in favor of combination chemotherapy.
Evidence (palliative chemotherapy):
When patients develop progression of disease after first-line chemotherapy, there is no standard treatment option.
Evidence (second-line chemotherapy):
Ramucirumab is a fully humanized monoclonal antibody directed against the vascular endothelial growth factor receptor-2.
Ramucirumab is an acceptable treatment in cisplatin or 5-FU refractory, stage IV, gastric cancer.
The combination of paclitaxel and ramucirumab is an acceptable second-line-chemotherapy regimen in patients with stage IV gastric or GE junction cancer.
Checkpoint inhibitors, particularly programmed death 1 (PD-1) inhibitors, are actively being investigated in the management of gastric and GE cancers.
On the basis of these data, the U.S. Food and Drug Administration has granted pembrolizumab accelerated approval for PD-L1–positive tumors.
On the basis of these data, the Japanese Ministry of Health, Labor, and Welfare approved nivolumab for treatment of advanced gastric cancer that has progressed on previously received chemotherapy.
Treatment Options Under Clinical Evaluation for Stage IV and Recurrent Gastric Cancer
Treatment options under clinical evaluation for stage IV and recurrent gastric cancer include the following:
Phase II studies evaluating irinotecan-based or oxaliplatin-based regimens demonstrate similar response rates and TTP to those found with ECF or CF, but the former may be less toxic.[24,25,26,27,28,29] There are conflicting data regarding relative efficacy of any one regimen. Ongoing studies are evaluating these newer regimens.
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.
Stage Information for Gastric Cancer
Updated staging information for 2017 (cited American Joint Committee on Cancer as reference 1).
Treatment Option Overview
Editorial changes were made to this section.
Stage 0 Gastric Cancer
Stage I Gastric Cancer
Stage II Gastric Cancer
Stage III Gastric Cancer
Stage IV and Recurrent Gastric Cancer
Added Immunotherapy as a new subsection.
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of gastric cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Gastric Cancer Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
PDQ® Adult Treatment Editorial Board. PDQ Gastric Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/stomach/hp/stomach-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389209]
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.
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Last Revised: 2018-08-17
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