Treatment for stomach cancer

Very early-stage tumours in the inner layers of the stomach (mucosa) may be removed with an endoscope through endoscopic resection (ER). Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are two types of endoscopic resection.

For some people, an endoscopic resection may be the only treatment they need. This procedure usually means staying overnight in hospital. Preparation and recovery are similar to an endoscopy, but there is a slightly higher risk of bleeding or getting a small tear or hole in the stomach (perforation).

Surgery aims to remove all of the stomach cancer while keeping as much of the stomach as possible. This may involve having several procedures during the operation. The surgeon will also remove some healthy tissue around the cancer to reduce the risk of the cancer returning. Different types of surgery can be used. The type you have will depend on where the cancer is in the stomach.

How the surgery is done

The surgery will be done under a general anaesthetic. There are two ways to perform surgery for stomach cancer:

• in a laparotomy (open surgery), the surgeon makes a long cut in the upper part of the abdomen from the breastbone to the bellybutton
• in a laparoscopic surgery (minimally invasive or keyhole surgery), the surgeon will make some small cuts in the abdomen, then insert a thin instrument with a light and camera (laparoscope) into one of the cuts. The surgeon puts tools into the other cuts and performs the surgery using the images from the camera for guidance.

Laparoscopic surgery usually means a smaller scar, which means the hospital stay is shorter and the recovery faster, but it’s not always possible to have this type of surgery. Open surgery may be considered a better option in many situations.

Types of surgery

Subtotal or partial gastrectomy – Only part of the stomach is removed when the cancer is in the lower part of the stomach. Nearby fatty tissue (omentum) and lymph nodes are also removed. The upper stomach and oesophagus are usually left in place.

Total gastrectomy – The whole stomach is removed when the cancer is in the upper or middle part of the stomach. Nearby fatty tissue (omentum), lymph nodes and parts of nearby organs, if necessary, are also removed. The surgeon rejoins the oesophagus to the small bowel.

Lymphadenectomy (lymph node dissection) – As the cancer might have spread to nearby lymph nodes, your doctor will also remove some lymph nodes from around your stomach. This reduces the risk of the cancer coming back and helps a specialist doctor called a pathologist more accurately work out the stage of the cancer.

Risks of stomach surgery

As with any major operation, surgery for stomach cancer has risks. Your surgeon will talk to you about the risks and complications of stomach surgery. These may include infection, bleeding, damage to nearby organs, or leaking from the joins between the small bowel and either the oesophagus or stomach. Some people’s heartbeat can become irregular, but this usually settles in a few days. You will be carefully monitored for any side effects.

Having a feeding tube

Before or after surgery, you may need a feeding tube to help you manage issues with eating and drinking, and get the nutrition you need.

You may receive all of your nutrition through this tube, or it may be used to supplement the food you eat.

When feeding tubes are used – Some people with stomach or oesophageal cancer will have a feeding tube before treatment to help them maintain their weight and build up their strength.

Other people will have a feeding tube after surgery until they are able to eat and drink normally. You can be given specially prepared feeding formula through this tube. If you go home with the feeding tube in place, a dietitian will let you know the type and amount of feeding formula you need to take.

How feeding tubes help – Many people find that having a feeding tube makes eating easier and less uncomfortable. Medicines can also be given through some feeding tubes, although you cannot do this with very small feeding tubes because they may become blocked.

How feeding tubes are placed – A feeding tube can be placed into your small bowel either through a nostril (nasojejunal tube) or with an operation that places a tube through the skin of your abdomen (jejunostomy or J-tube).

How to care for a feeding tube – Your treatment team will show you how to care for the tube to keep it clean and prevent leaking and blockages, and when to replace the tube. You can avoid getting infections by washing your hands before using the tube, and keeping the tube and your skin dry.

Your doctor will remove the feeding tube when it is no longer required.

How to cope with a feeding tube – Having a feeding tube is a major change and it’s common to have a lot of questions. Getting used to having a feeding tube takes time. For information, talk to a dietitian or nurse. A counsellor or psychologist can provide emotional support and coping strategies. You can also call Cancer Council 13 11 20 for information and support.

What to expect after surgery

This is a general overview of what to expect. The process varies from hospital to hospital, and everyone will respond to surgery differently.

Recovery time

• When you wake up after the operation, you will be in a recovery room near the operating theatre or in the intensive care unit.
• Most people will need a high level of care. You can expect to spend time in the high dependency unit or intensive care unit before moving to a standard ward.
• How long you stay in hospital will depend on the type of stomach surgery you had, your age and your general health.
• You will probably be in hospital for 3–10 days, but it can take 3–6 months to fully recover from a gastrectomy.
• Talk to your treatment team if you have any concerns about caring for yourself at home. If you think you will need home nursing care, ask about services in your area.

Help with recovery

• You will have some pain and discomfort for several days after surgery, which will be managed with pain medicines. You may be given tablets or injections, or you may have patient-controlled analgesia (PCA), which delivers a measured dose of pain medicine through a drip when you press a button.
• Let your doctor or nurse know if you’re in pain so they can adjust your medicines to make you as comfortable as possible. Do not wait until the pain is severe.
• You may have a dressing over the wound. The doctor or nurse will talk to you about how to keep the wound clean and free from infection when you go home.
• After surgery you will have several tubes in your body, which will be removed as you recover. You may have a drip in your arm to give you pain relief and to replace your body’s fluids until you are able to drink and eat again. You may have a tube from your bladder (catheter) to collect urine in a bag. You may also have a feeding tube.

Eating and drinking

• You will be unable to eat or drink straight after surgery.
• When you can eat again, you will usually start with milk, soup, yoghurt and ice-cream. Then you will move to pureed foods and then to soft foods. This process happens over a number of weeks. Your treatment team will let you know when you are ready for more solid food.
• Eating 6–8 small meals or snacks throughout the day is easier to manage than a few large meals. Ask the hospital dietitian for advice about meal and snack ideas and whether you need to take any nutritional supplements.
• A feeding tube may be put into the small bowel through a cut in the abdomen. Special feeding formula is given through this tube while the join between the oesophagus and small bowel heals. The tube is usually removed after 3–4 weeks.

Activity and exercise

• Your treatment team will probably encourage you to walk the day after surgery. Gentle exercise has been shown to help people manage some treatment side effects, speed up a return to usual activities and improve quality of life. Ask your doctor or nurse for guidance on the right activity levels for you and if there are any suitable exercise programs available in your area.
• You will have to wear compression stockings for a couple of weeks to help the blood in your legs circulate and reduce the risk of developing blood clots.
• Check whether you need to avoid driving and heavy lifting for a few weeks after the surgery.
• A physiotherapist will teach you breathing or coughing exercises to help keep your lungs clear and reduce the risk of a chest infection.

Download our booklet ‘Understanding Surgery’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. For stomach cancer, it is used:

• before surgery (neoadjuvant chemotherapy) – to shrink large tumours and destroy any cancer cells that may have spread
• after surgery (adjuvant chemotherapy) – to reduce the chance of the cancer coming back
• as palliative treatment – to help control the cancer and improve quality of life and prolong overall survival.

Chemotherapy is usually given by injecting the drug into a vein in the arm. It may also be given through a tube that is implanted and stays in your vein throughout treatment (called a port-a-cath or PICC line), or as tablets you swallow. You will usually receive treatment as an outpatient.

Most people have a combination of chemotherapy drugs over several treatment sessions, with rest periods of 2–3 weeks in-between. Together, the session and rest period are called a cycle. Your doctor will talk to you about how long your treatment will last.

Side effects of chemotherapy

The side effects of chemotherapy vary and depend on the drugs you receive. Your medical oncologist or nurse will discuss the likely side effects with you. Most side effects are temporary, and steps can be taken to prevent or reduce their severity.

Side effects may include feeling sick (nausea), vomiting, sore mouth or mouth ulcers, appetite changes and difficulty swallowing, skin and nail changes, numbness in the hands or feet, ringing in the ears or hearing loss, constipation or diarrhoea, and hair loss or thinning. You may also be more likely to catch infections.

Download our booklet ‘Understanding Chemotherapy’

This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading.

HER2 (human epidermal growth factor receptor 2) is a protein that causes cancer cells to grow. If you have HER2 positive advanced stomach or gastro-oesophageal junction cancer, you may be given a targeted therapy drug called trastuzumab. This drug destroys the HER2 positive cancer cells or slows their growth. Trastuzumab is given with chemotherapy every three weeks through a drip into a vein.

Another targeted therapy drug called ramucirumab aims to reduce the blood supply to a tumour to slow or stop its growth. It has been approved to treat advanced stomach or gastro-oesophageal junction cancer that has not responded to chemotherapy.

Side effects of targeted therapy

Ask your doctor what side effects you may experience. Possible side effects of trastuzumab include fever and nausea. In some people, trastuzumab can affect the way the heart works. Possible side effects of ramucirumab include stomach cramps, diarrhoea and high blood pressure. Let your doctor know of any side effects immediately.

Download our fact sheet ‘Understanding Targeted Therapy’

There have been some advances in treating advanced stomach cancer with immunotherapy drugs known as checkpoint inhibitors. These use the body’s own immune system to fight cancer.

Checkpoint inhibitors have been approved for use with chemotherapy as the first treatment for people with advanced stomach cancer that has high levels of the protein PD-L1. Checkpoint inhibitors may also be used when chemotherapy hasn’t worked or when the tumour has a high level of the marker MSI.

Side effects of immunotherapy

The side effects of immunotherapy can vary – not everyone will experience the same effects. Immunotherapy can cause redness, swelling (inflammation) or pain in any of the organs of the body, leading to common side effects such as fatigue, skin rash and diarrhoea. The inflammation can lead to more serious side effects in some people, but this will be monitored closely and managed quickly.

Download our fact sheet ‘Understanding Immunotherapy’

Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. Radiation therapy for stomach cancer is commonly used to control symptoms of pain, difficulty swallowing or bleeding. It is usually given as a short course (between one day and two weeks). Occasionally radiation will be given over a longer period (5–6 weeks), either before or after surgery, or if  surgery is not possible.

Each treatment takes about 15 minutes and is not painful. You will lie on a table under a machine that delivers radiation to the affected parts of your body. Your doctor will let you know your treatment schedule. Possible side effects include fatigue, nausea, vomiting, diarrhoea and loss of appetite.

Download our booklet ‘Understanding Radiation Therapy’

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care. Many people think that palliative treatment is for people at the end of life, but it may help at any stage of advanced stomach cancer. It is about helping you live for as long as possible in the most satisfying way you can.

The treatment you are offered will be tailored to your individual needs, and may include surgery, stenting, radiation therapy, chemotherapy or other medicines. These treatments can help manage symptoms such as pain, bleeding, difficulty swallowing and nausea. They can also slow the spread of the cancer.

Palliative treatment is one aspect of palliative care, in which a team of health professionals help meet your physical, emotional, cultural, spiritual and social needs. The team also supports families and carers.

Download our booklet ‘Understanding Palliative Care’