Treatments for Gastric Cancer

How do doctors decide on a treatment plan?

This page includes information about treatment for gastric (stomach) cancer and gastroesophageal junction (GEJ) cancer. GEJ cancers begin where the esophagus (food pipe) joins the stomach.

Doctors base their treatment recommendations on several factors, including:

• the stage of your cancer
• the subtype based on pathology
• additional test results, including biomarkers and genetic tests
• how fast the cancer is growing or how likely it is to spread
• whether the cancer is contained to the stomach or has spread to lymph nodes or other organs (metastasis)
• whether the cancer is newly diagnosed or has recurred after treatments
• your overall health

Make sure that you receive a copy of your records. Ask your doctor to explain your diagnosis, test results, pathology report, stage, prognosis and treatment recommendations in terms that you can understand. This will allow you to work with your doctor to choose a treatment plan that is right for you. 

Most gastric and GEJ cancers are treated with one or more of the following treatments. Every treatment has potential risks and side effects. Before any new treatment or surgery, make sure your healthcare team tells you about what to expect.

Surgery

Treatment for earlier-stage or locally advanced gastric cancer (cancer that has not spread to distant parts of the body) typically involves surgery. This usually includes one of the following approaches:

• Endoscopic mucosal resection allows doctors to remove the cancer and the surrounding tissue using an endoscope.
• Partial gastrectomy is used to remove tumors that cannot be removed during an endoscopy. In some situations this may be done using a laparoscope. During laparoscopic surgery, small incisions are made in the abdominal wall so that the surgeone can insert cameras to help see the stomach and instruments to help remove the cancer and surrounding tissue. When laparoscopic surgery isn't possible, laparotomy using an open incision into the abdomen is used.
• Total gastrectomy removes the entire stomach. The esophagus is attached directly to the small intestine. This surgery may be used for large tumors or to treat or prevent diffuse gastric cancer, the type of cancer most often seen in people with CDH1 and CTNNA1 mutations.  
• Esophagectomy (surgery to move a section of the esophagus) or surgery involving both the esophagus and stomach may be used for some GEJ cancers, especially when the tumor extends into the lower esophagus.
• Nearby lymph nodes may be removed for staging during gastric surgery.

Chemotherapy

Chemotherapy for early-stage gastric or GEJ cancers may be given before surgery to shrink the tumor, and/or given after surgery to lower the risk of the cancer coming back. Chemotherapy may be used as the main treatment if the cancer has spread. 

Chemotherapy is usually a combination of two or three chemotherapy drugs. The most common chemotherapies are:

• 5-flourouracil (5FU)
• Capecitabine (Xeloda) an oral form of 5-fluoruracil
• Oxaliplatin
• Docetaxel (Taxotere)

A commonly-used regimen in people who can tolerate it is FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel). The specific regimen depends on the stage of the cancer, overall health, and whether treatment is being given before surgery, after surgery, or for advanced disease.

How is radiation therapy used in gastric cancer and GEJ cancer?

Radiation therapy may be used to treat some gastric and GEJ cancers. It may be combined with chemotherapy (chemoradiation).  

• It may be used before surgery for some GEJ cancers to shrink the tumor and help make surgery more effective.
• It may be used after surgery if there is a concern that surgery alone did not remove all the cancer.
• It may be used to control symptoms in some advanced cancers.

See our general section on radiation for more information possible side effects. 

How is immunotherapy used in gastric cancer and GEJ cancer?

Immunotherapies are cancer treatments that help the body’s immune system detect and attack cancer cells.

Immune checkpoint inhibitors are a type of immunotherapy used to treat several different cancers, including gastric and GEJ cancers. Some cancers are able to grow because they learn how to evade or “turn off” the body’s immune system, preventing it from being killed. Immune checkpoint inhibitors block this evasion, allowing the immune system to find and destroy cancer cells.

Other names for these drugs are:

• PD-1/PD-L1 inhibitors
• PD-1/PD-L1-directed therapies

See the tables below for a list of immunotherapies used to treat gastric cancer.

See our general section on immunotherapy for more information on different types of immunotherapy, how they work and their possible side effects. 

When is immunotherapy used?

Immunotherapy is used most often for advanced or metastatic gastric cancer, and is typically given:

• Together with chemotherapy as part of first treatment for some people
• On its own or with other drugs after cancer has grown despite earlier treatment
• Occasionally for cancers that cannot be removed with surgery

Testing the tumor for biomarkers is important to determine if immunotherapy is likely to help.

Who is most likely to benefit from immunotherapy?

Immunotherapy works particularly well for gastric cancers with the following biomarkers:

• MSI-H (microsatellite instability-high) or dMMR / MMR-deficient (mismatch repair deficiency)
  • These are more common in people with Lynch syndrome.
• High PD-L1 expression (a marker that may predict benefit when immunotherapy is combined with chemotherapy). 

People with these biomarkers may have better and longer-lasting responses to immunotherapy than those without them. Testing for MSI and PD-L1 is recommended for all people with gastric and GEJ cancers. 

Which immunotherapies are used for gastric cancer and GEJ cancer?  

Immunotherapies are usually given as an injection into the vein, althgouh some have a version that can be given under the skin. The immunotherapies used for gastric and GEJ cancer are:

• Imfinzi (durvalumab) - given as an intravenous injection (injected in the vein)
• Jemperli (dostarlimab) - given as an intravenous injection (injected in the vein)
• Keytruda (pembrolizumab) - given as an intravenous injection (injected in the vein)
• Opdivo (nivolumab) given as an intravenous injection (injected in the vein) or a subcuteous injection (injected under the skin)
• Tevimbra(tislelizumab-jsgr) - given as an intravenous injection (injected in the vein) 
• Yervoy (ipilimumab) - given as an intravenous injection (injected in the vein)

See the table below for more information on the indications for each of these drugs. 

How is targeted therapy used in gastric cancer and GEJ cancer?

Targeted therapy is a type of cancer treatment designed to attack or kill cancer cells, while sparing normal cells as much as possible. The targeted therapies used in gastric cancer are designed to target abnormal proteins, receptors or genes that are found in the cancer cells or the surrounding tissue, but not usually found in normal tissue.. Most FDA-approved targeted therapies for gastric or GEJ cancers are used in the advanced or metastatic setting. 

See below for more information on the different targeted therapies used to treat gastric or GEJ cancer. Tumor biomarker testing can help doctors identify the patients most likely to benefit from certain targeted therapies.

Also see our general section on targeted therapy for more information about the different types of targeted therapy drugs, their uses and side effects. 

Which targeted therapies are used for gastric cancer or GEJ cancer?  

Several targeted therapies are used to treat advanced or metastatic gastric or GEJ cancer. Most require biomarker testing, either from a tumor sample or sometimes from a blood test, before being prescribed to select patients who are most likely to benefit. 

Targeted therapies that do not require biomarker testing

Cyramza (ramucirumab) is a drug that blocks tumors from forming blood vessels. This medication targets a protein called vascular epithelial growth factor, or VEGF. 

Targeted therapies that require biomarker testing

CLDN18.2-positive
Claudin18.2, is a protein normally found only on gastric cells. When these cells become cancerous, they can make too much of this protein, making them a target for treatment. Vyloy (zolbetuximab) is a targeted therapy approved for gastric and GEJ cancers that produce excess amounts of claudin18.2.

HER2-positive
Anti-HER2 therapies are used for people with advanced gastric cancer with a biomarker called HER2-positive. The drugs used to treat advanced gastric and GEJ cancers include:

• Enhertu (trastuzumab deruxtecan)
• Herceptin (trastuzumab)

NTRK gene fusions
NTRK gene fusions are biomarkers that are rarely found in gastric and GEJ cancers. The following drugs may be used for different types of advanced cancers (including gastric and GEJ cancers) with NTRK gene fusions that have gotten worse, stopped responding or came back after other treatments.   

• Entrectinib (Rozlytrek)
• Repotrectinib (Augtyro)
• Vitrakvi (larotrectinib) 

RET gene fusions
RET gene fusions are biomarkers that are rarely found in gastric and GEJ cancers.   

• Retevmo (selpercatinib) is a targeted therapy that is used to treat advanced cancers with a rare mutation known as a RET gene fusion.

Targeted therapies for other biomarkers
Researchers are studying new ways to use targeted therapies to treat gastric cancer. Many of these studies rely on the results of biomarker testing to determine eligibility. See our Research Search and Enroll Tool for more information.

Treatment side effects

Your healthcare team should explain what you should expect from all treatments, including:

• all of the possible risks and side effects of each treatment.
• which side effects may be serious and how to tell. 
• when and who you should call if you experience a side effect.
• what can be done to treat or alleviate each side effect. 

Make sure you let your healthcare team know if you experience any side effects of your treatment. For more information about possible treatment side effects, see our section on Cancer Treatment by Treatment Type.