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  • Treatment for stomach and oesophageal cancers

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    Treatment for stomach cancer

    The most important factor in planning treatment for stomach cancer is the stage of the disease, particularly whether the tumour has spread from its original location. Treatment will also depend on your age, medical history, nutritional needs and general health.

    Surgery to remove the tumour is the main treatment for stomach cancer that has not spread. If the cancer has spread, treatment may also include chemotherapy, targeted therapy or radiation therapy.

    Preparing for treatment

    Improve diet and nutrition – People with stomach or oesophageal cancer often lose a lot of weight and can become malnourished. Your doctor will usually refer you to a dietitian for advice on ways to reduce the weight loss through changes to your diet, liquid supplements or a feeding tube. This will help improve your strength, lessen side effects, and lead to better treatment outcomes.

    Stop smoking – If you are a smoker, you will be encouraged to stop smoking before surgery. If you continue to smoke, you may not respond as well to treatment and smoking may make any side effects you experience worse. For support, see your doctor or call the Quitline on 13 7848.

    Surgery 

    Surgery aims to remove all of the stomach cancer while keeping as much normal tissue as possible. The surgeon will remove some healthy tissue around the cancer to reduce the risk of the cancer returning. You may have an endoscopic resection or a gastrectomy depending on where the tumour is growing and how advanced the cancer is.

    Endoscopic resection (ER)

    Very early-stage tumours that have not spread from the stomach walls may be removed with an endoscope. For some people, an endoscopic resection may be the only treatment needed. This is usually an overnight-stay procedure. Preparation and recovery are similar to endoscopy, but there is a higher risk of bleeding or getting a small tear or hole in the stomach (perforation).

    Gastrectomy

    This procedure removes part or all of the stomach, leaving as much healthy tissue as possible. The goal is to completely cut out the cancer, including any nearby affected lymph nodes.

    Subtotal or partial gastrectomy – The cancerous part of the stomach is removed, along with nearby fatty tissue (omentum) and lymph nodes. The upper stomach and oesophagus are usually left in place.

    Total gastrectomy – The whole stomach is removed, along with nearby fatty tissue (omentum), lymph nodes and parts of nearby organs, if necessary. The surgeon reconnects the oesophagus to the small bowel. The top part of this connection (which is a tube of intestine) takes over some of the stomach’s function.

    Lymphadenectomy (lymph node dissection)

    As the cancer might have spread to nearby lymph nodes, your doctor will usually remove some lymph nodes from around your stomach. This reduces the risk of leaving any cancer behind.

    How the surgery is done

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

    • in a laparotomy (open surgery), the procedure is done through a long cut in the upper part of the stomach
    • in a laparoscopy (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 inserts tools into the other cuts and performs the surgery using the images from the camera for guidance.

    The hospital stay and recovery time are fairly similar for both types of surgery. Laparoscopic surgery usually means a smaller scar, however, open surgery may be considered a better option in many situations.

    Risks of stomach surgery

    As with any major surgery, stomach surgery has risks. These may include infection, bleeding, increased strain on the heart and lungs, damage to nearby organs, or leaking from the connections between the small bowel and either the oesophagus or stomach. Some people experience an irregular heartbeat, but this usually settles in a few days. You will be carefully monitored for any side effects. For more information about ongoing effects after surgery.


    Chemotherapy

    Chemotherapy uses drugs to kill or slow the growth of cancer cells. For stomach cancer, chemotherapy is commonly given before surgery to shrink large tumours and destroy any cancer cells that may have spread. It may also be used after surgery to reduce the chance of the disease coming back. Chemotherapy is also used palliatively.

    Chemotherapy is usually given as a liquid through a drip inserted into a vein in the arm. It may also be given through a tube implanted into a vein (called a port, catheter or vascular access device), or as tablets you swallow. You will usually receive treatment as an outpatient.

    Most people receive a combination of drugs in repeating cycles spread over several months. There may be a rest period of 2–3 weeks between each cycle of chemotherapy. Your doctor will talk to you about how long your treatment will last.

    Side effects of chemotherapy

    The side effects of chemotherapy vary greatly for each person. Some people have few side effects, while others have many. Most side effects are temporary, but some may last longer or be ongoing. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine.

    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.

    For more information on chemotherapy, call Cancer Council 13 11 20 or you can download our booklet Understanding Chemotherapy.

    Targeted therapy

    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 uncontrollably. 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. Ramucirumab is not subsidised on the PBS so it is expensive (as at October 2019).

    You may be able to access other new drugs to treat stomach cancer through clinical trials. Talk to your doctor about the latest developments and whether there are any suitable clinical trials for you.

    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.

    For more information on targeted therapy, call Cancer Council 13 11 20 or you can download our factsheet Understanding Targeted Therapy.

    Radiation therapy

    Also known as radiotherapy, this treatment uses a controlled dose of radiation to kill or damage cancer cells. Radiation therapy for stomach cancer is commonly used to control symptoms. It is usually given externally as a short course (between one day and two weeks). Occasionally radiation will be given over a longer period (5–6 weeks), particularly if surgery is not possible, or there are concerns about cancer cells being left behind after surgery.

    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 advise you about your treatment schedule. Potential side effects include fatigue, nausea, vomiting, skin redness and loss of appetite (anorexia).

    For more information about radiation therapy, call
    Cancer Council 13 11 20 or you can download our booklet
    Understanding Radiation Therapy.

    Palliative treatment

    Palliative treatment aims to help maintain a person’s quality of life by managing the symptoms of cancer without trying to cure the disease. Many people think that palliative treatment is for people at the end of life, but it can help at any stage of advanced stomach cancer.

    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.

    For more information on palliative treatment, call
    Cancer Council 13 11 20 or you can download our booklet
    Understanding Palliative Care.

    Treatment for oesophageal cancer

    The most important factor in planning treatment for oesophageal cancer is the stage of the disease. Your treatment will also depend on your age, nutritional needs, medical history and general health.

    The main treatments for oesophageal cancer are surgery, radiation therapy and chemotherapy, either alone or in combination. Treatment will be tailored to your specific situation.

    Surgery

    Oesophageal cancer that has not spread outside the oesophageal wall can generally be treated with surgery. Your doctor will tell you how to prepare for surgery. For example, you may need to treat any nutritional issues before surgery or, if you are a smoker, stop smoking.

    Surgery aims to remove all of the cancer while keeping as much normal tissue as possible. The surgeon will remove some healthy tissue around the cancer to reduce the risk of the cancer coming back. You may have an endoscopic resection or an oesophagectomy depending on where the tumour is growing and how advanced the cancer is.

    Endoscopic resection (ER)

    Very early-stage tumours that have not spread from the oesophageal wall may be removed with an endoscope. For some people, an endoscopic resection may be the only treatment needed. This is usually a day or overnight-stay procedure. Preparation and recovery are similar to endoscopy.

    Oesophagectomy (surgical resection)

    This procedure removes the cancerous tissue and part or all of the oesophagus, leaving as much healthy tissue as possible. The goal is to completely remove the cancer, including nearby affected lymph nodes. It is common to have chemotherapy and/or radiation therapy before an oesophagectomy, as this has been shown to lead to better outcomes.

    Depending on where in the oesophagus the cancer is located, the surgeon may also remove a part of the upper stomach. This is the preferred option for tumours that have spread deeper into the wall of the oesophagus or to nearby lymph nodes.

    Once the cancerous sections have been removed, the stomach is pulled up and reconnected to the healthy part of the oesophagus. This will allow you to swallow and, in time, eat relatively normally. Occasionally, if the oesophagus cannot be reconnected to the stomach, the oesophagus will be connected to the small bowel or a piece of large bowel will be used to help you swallow.

    How the surgery is done

    To remove the cancerous tissue, the surgeon will need to access the upper abdomen and chest. This may be done in two ways:

    • in an open oesophagectomy, the surgeon will open the chest and the abdomen with large surgical cuts
    • in a minimally invasive oesophagectomy (keyhole or laparoscopic surgery), the surgeon will make some small cuts in the abdomen and/or between the ribs, then insert tools into the cuts. One of the tools will have a light and camera so the surgeon can see inside the body.

    The hospital stay and recovery time are fairly similar for both types of surgery. Although laparoscopic surgery usually means a smaller scar, open surgery may be considered a better option in many situations.

    Risks of oesophageal surgery

    As with any major surgery, oesophageal surgery has risks. These may include infection, bleeding, blood clots, damage to nearby organs, leaking from the connections between the oesophagus and stomach or small bowel, pneumonia and paralysis of the vocal cords. Some people may experience an irregular heartbeat, but this usually settles within a few days. Narrowing of the oesophagus from surgical scars (known as oesophageal stricture) can make it difficult to swallow. Your doctor may perform a procedure to stretch the walls of the oesophagus (dilatation). Some people need to have only one dilatation, others need many. Your surgeon will discuss these risks with you before surgery, and you will be carefully monitored for any side effects.

    What to expect after oesophageal surgery

    Recovery after oesophageal surgery is similar to the overview for stomach surgery, but there are some differences:

    Recovery time – You will probably be in hospital for 7–10 days, but it can be significantly longer if any complications occur. It generally takes 6–12 months to recover from an oesophagectomy.

    Drips and drains – You will have a tube down your nose into your stomach (nasogastric tube) to drain fluids from the stomach.

    Dietary changes – As with stomach surgery, you will not be able to eat or drink straight after surgery. It is common for a temporary feeding tube to be inserted at the time of your surgery. You can be given specially prepared feeding formula through this tube while the join between the oesophagus and stomach heals. Once you begin eating, it is common to start with fluids such as soup, and then move onto soft foods for a few weeks. You may be advised to eat 5–6 small meals or snacks throughout the day.

    Breathing problems – It is important that your pain is controlled to help avoid problems with breathing that can lead to pneumonia. To reduce the risk of pneumonia, a physiotherapist will teach you breathing or coughing exercises that help keep your lungs clear. You may also be taught how to use an incentive spirometer, a device you breathe into to help your lungs expand and prevent a chest infection.

    Radiation therapy

    Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. The radiation is targeted at the cancer and treatment is carefully planned to do as little harm as possible to healthy body tissue near the cancer.

    Radiation therapy may be given alone or combined with chemotherapy (chemoradiation). It is commonly used before surgery to shrink large tumours and destroy any cancer cells that may have spread. In this case, there will be a break of one to two months between radiation therapy and surgery to allow the treatment to have its full effect. Radiation therapy, with or without chemotherapy, is also used as the main treatment for oesophageal cancer that has not spread to other parts of the body and cannot be removed surgically.

    Before starting treatment, you will have a planning appointment that will include a CT scan. The radiation therapy team will use the images from the scan to plan your treatments. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.

    You will usually have treatment as an outpatient once a day, Monday to Friday, for 4–5 weeks. If radiation therapy is used palliatively, you may have a short course of 1–10 sessions. Each treatment takes about 20 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 advise you about your treatment schedule.

    Side effects of radiation therapy

    Many people will develop temporary side effects during or shortly after treatment. The lining of the oesophagus can become very sore and inflamed (oesophagitis). This can lead to painful swallowing and difficulty eating. In rare cases, you may need a feeding tube to ensure you receive enough nutrition. Other common side effects include fatigue, skin redness, loss of appetite and weight loss. Most side effects settle within four weeks of treatment finishing.

    More rarely, some people will develop long-term side effects. Radiation therapy can cause scar tissue and narrowing of the oesophagus (known as oesophageal stricture). This can make it difficult to swallow, and your doctor may perform a procedure to stretch the walls of the oesophagus (dilatation). Radiation therapy can also create inflammation in the lungs, causing shortness of breath.

    For more information about radiation therapy, call
    Cancer Council 13 11 20 or you can download our booklet
    Understanding Radiation Therapy.

    Chemotherapy

    Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells, while causing the least possible damage to healthy cells. Chemotherapy for oesophageal cancer may be given alone or combined with radiation therapy.

    For oesophageal cancer, chemotherapy is commonly given before surgery to shrink large tumours and destroy any cancer cells that may have spread. It may be used after surgery to reduce the chance of the disease coming back. Chemotherapy is also used on its own for people unable to have surgery.

    Chemotherapy is usually given as a liquid through a drip inserted into a vein in the arm. It may also be given through a tube implanted into a vein (called a port, catheter or vascular access device), or as tablets you swallow. You will usually receive treatment as an outpatient.

    Most people receive a combination of drugs in repeating rounds of treatment for several months. These may be given on one day, or continuously using a small pump that is linked to the implanted tube. There may be a rest period of a few weeks between each round. Your doctor will talk to you about how long your treatment will last.

    Side effects of chemotherapy

    The side effects of chemotherapy vary greatly, depending on the drugs you receive, how often you have treatment, and your general fitness and health. Most side effects are temporary. Your treatment team can help you prevent or manage any side effects.

    Side effects may include nausea and/or vomiting, sore mouth or mouth ulcers, appetite changes and difficulty swallowing, skin and nail changes, numbness or tingling in the hands or feet, ringing in the ears or hearing loss, changed bowel habits (e.g. constipation, diarrhoea), and hair loss or thinning. You may also be more likely to catch infections. If you feel unwell or have a temperature higher than 38°C, seek urgent medical attention.

    For more information on chemotherapy, call Cancer Council 13 11 20 or you can download our booklet Understanding Chemotherapy.

    Chemoradiation 

    When radiation therapy is combined with chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

    Oesophageal cancer may be treated with chemoradiation before surgery. Chemoradiation may also be used as the main treatment for oesophageal cancer when the tumour can’t be removed safely with surgery.

    If you have chemoradiation, you will usually receive chemotherapy a few hours before some radiation therapy appointments. Your doctor will talk to you about the treatment schedule and how to manage any side effects.

    Palliative treatment

    Palliative treatment aims to help maintain a person’s quality of life by managing the symptoms of cancer without trying to cure the disease. It can help at any stage of advanced oesophageal cancer. Treatments will be tailored to your individual needs. For example, radiation therapy can help to relieve pain and make swallowing easier by helping to shrink a tumour blocking the oesophagus. Palliative treatments can also slow the spread of the cancer.

    People with advanced oesophageal cancer who are having trouble swallowing and do not have any other treatment options may have a flexible tube (stent) inserted into the oesophagus. The stent expands the oesophagus to allow fluid and soft food to pass into the stomach more easily. This stent also prevents food and saliva going into the lungs and causing infection. The stent does not treat the cancer but will allow you to eat and drink more normally. Stents can cause indigestion (heartburn) and discomfort. Occasionally, the stents will move down the oesophagus into the stomach and may need to be removed. 

    For more information on palliative treatment, call
    Cancer Council 13 11 20 or you can download our booklet
    Understanding Palliative Care.

    This website page was last reviewed and updated March 2020.

    Information reviewed by: Prof David Watson, Senior Consultant Surgeon, Oesophago-gastric Surgery Unit, Flinders Medical Centre, and Matthew Flinders Distinguished Professor of Surgery, Flinders University, SA; Kate Barber, 13 11 20 Consultant, Cancer Council Victoria; Katie Benton, Advanced Dietitian, Cancer Care, Sunshine Coast Hospital and Health Service, QLD; Alana Fitzgibbon, Clinical Nurse Consultant, Gastrointestinal Cancers, Royal Hobart Hospital, TAS; Christine Froude, Consumer; Dr Andrew Oar, Radiation Oncologist, Icon Cancer Centre, Gold Coast University Hospital, QLD; Dr Spiro Raftopoulos, Interventional Endoscopist and Consultant Gastroenterologist, Sir Charles Gairdner Hospital, WA; Grant Wilson, Consumer; Prof Desmond Yip, Clinical Director, Department of Medical Oncology, The Canberra Hospital, ACT.

     

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