Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Opinion
  • Published:

Does surgery have a role in managing incurable gastric cancer?

Nature Reviews Clinical Oncology volume 12, pages 676–682 (2015)Cite this article

Subjects

Abstract

Although the incidence of gastric cancer is decreasing, the outcomes of this disease are among the poorest of all solid-organ tumours, predominantly due to the frequent presence of stage IV metastatic disease at primary presentation. Stage IV gastric cancer is incurable and carries a very poor prognosis (5-year survival rate of ∼4%); palliative chemotherapy remains the standard of care, but increasing evidence indicates that palliative surgery can provide a prognostic and symptomatic benefit, particularly in combination with chemotherapy and/or radiotherapy. Ongoing prospective trials should further clarify the efficacy of palliative surgery in comparison with other treatment modalities. Until such data are available, surgery should not be offered as a standard first-line treatment, but can be considered in selected cases after thorough multidisciplinary discussions involving the patient. Patient selection for both gastrectomy and nonresectional surgery must include consideration of various factors that predict quality of life after surgery. This Perspectives summarizes the available evidence and discusses the utility of palliative surgery in relation to other therapeutic modalities in the management of incurable gastric cancer.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Survival of patients with metastatic gastric cancer after palliative tumour resection versus no resection in the Dutch Gastric Cancer Trial.26
Figure 2: a | Median overall survival and b | progression-free survival in the primary analysis population of the ToGA trial.49

Similar content being viewed by others

References

  1. Ferlay, J. et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int. J. Cancer 136, E359–E386 (2015).

    CAS  Google Scholar 

  2. Guggenheim, D. E. & Shah, M. A. Gastric cancer epidemiology and risk factors. J. Surg. Oncol. 107, 230–236 (2013).

    Article  Google Scholar 

  3. Cunningham, D. et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N. Engl. J. Med. 355, 11–20 (2006).

    Article  CAS  Google Scholar 

  4. Macdonald, J. S. et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N. Engl. J. Med. 345, 725–730 (2001).

    Article  CAS  Google Scholar 

  5. Sakuramoto, S. et al. Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine. N. Engl. J. Med. 357, 1810–1820 (2007).

    Article  CAS  Google Scholar 

  6. Jemal, A. et al. Global cancer statistics. CA Cancer J. Clin. 61, 69–90 (2011).

    Article  Google Scholar 

  7. Leung, W. K. et al. Screening for gastric cancer in Asia: current evidence and practice. Lancet Oncol. 9, 279–287 (2008).

    Article  Google Scholar 

  8. Hamashima, C. et al. The Japanese guidelines for gastric cancer screening. Jpn J. Clin. Oncol. 38, 259–267 (2008).

    Article  Google Scholar 

  9. Ohata, H. et al. Gastric cancer screening of a high-risk population in Japan using serum pepsinogen and barium digital radiography. Cancer Sci. 96, 713–720 (2005).

    Article  CAS  Google Scholar 

  10. Shin, A., Kim, J. & Park, S. Gastric cancer epidemiology in Korea. J. Gastric Cancer 11, 135–140 (2011).

    Article  Google Scholar 

  11. Schlansky, B. & Sonnenberg, A. Epidemiology of noncardia gastric adenocarcinoma in the United States. Am. J. Gastroenterol. 106, 1978–1985 (2011).

    Article  Google Scholar 

  12. Cancer Research UK. Statistics and outlook for stomach cancer [online], (2014).

  13. Wagner, A. D. et al. Chemotherapy for advanced gastric cancer. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD004064 http://dx.doi.org/10.1002/14651858.CD004064.pub3 (2010).

  14. Marrelli, D. et al. Prediction of recurrence after radical surgery for gastric cancer: a scoring system obtained from a prospective multicenter study. Ann. Surg. 241, 247–255 (2005).

    Article  Google Scholar 

  15. Sun, J. et al. Clinical significance of palliative gastrectomy on the survival of patients with incurable advanced gastric cancer: a systematic review and meta-analysis. BMC Cancer 13, 577 (2013).

    Article  CAS  Google Scholar 

  16. Power, D. G., Kelsen, D. P. & Shah, M. A. Advanced gastric cancer—slow but steady progress. Cancer Treat. Rev. 36, 384–392 (2010).

    Article  Google Scholar 

  17. Lasithiotakis, K., Antoniou, S. A., Antoniou, G. A., Kaklamanos, I. & Zoras, O. Gastrectomy for stage IV gastric cancer. a systematic review and meta-analysis. Anticancer Res. 34, 2079–2085 (2014).

    PubMed  Google Scholar 

  18. Chang, Y. R. et al. The value of palliative gastrectomy in gastric cancer with distant metastasis. Ann. Surg. Oncol. 19, 1231–1239 (2012).

    Article  Google Scholar 

  19. Dittmar, Y. et al. Non-curative gastric resection for patients with stage 4 gastric cancer—a single center experience and current review of literature. Langenbecks Arch. Surg. 397, 745–753 (2012).

    Article  Google Scholar 

  20. Macdonald, J. S. Gastric cancer: Nagoya is not New York. J. Clin. Oncol. 29, 4348–4350 (2011).

    Article  Google Scholar 

  21. Crew, K. D. & Neugut, A. I. Epidemiology of gastric cancer. World J. Gastroenterol. 12, 354–362 (2006).

    Article  Google Scholar 

  22. Kang, Y. K. et al. Capecitabine/cisplatin versus 5-fluorouracil/cisplatin as first-line therapy in patients with advanced gastric cancer: a randomised phase III noninferiority trial. Ann. Oncol. 20, 666–673 (2009).

    Article  Google Scholar 

  23. Ross, P. et al. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. J. Clin. Oncol. 20, 1996–2004 (2002).

    Article  CAS  Google Scholar 

  24. Hallissey, M. T., Allum, W. H., Roginski, C. & Fielding, J. W. Palliative surgery for gastric cancer. Cancer 62, 440–444 (1988).

    Article  CAS  Google Scholar 

  25. Kulig, P., Sierzega, M., Kowalczyk, T., Kolodziejczyk, P. & Kulig, J. Non-curative gastrectomy for metastatic gastric cancer: rationale and long-term outcome in multicenter settings. Eur. J. Surg. Oncol. 38, 490–496 (2012).

    Article  CAS  Google Scholar 

  26. Hartgrink, H. H., Putter, H., Klein Kranenbarg, E., Bonenkamp, J. J. & van de Velde, C. J. Value of palliative resection in gastric cancer. Br. J. Surg. 89, 1438–1443 (2002).

    Article  CAS  Google Scholar 

  27. Mahar, A. L., Coburn, N. G., Singh, S., Law, C. & Helyer, L. K. A systematic review of surgery for non-curative gastric cancer. Gastric Cancer 15 (Suppl. 1), S125–S137 (2012).

    Article  Google Scholar 

  28. Ajani, J. A. et al. NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer (Version 2.2013). National Comprehensive Cancer Network [online], (2015).

    Google Scholar 

  29. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 14, 113–123 (2011).

  30. Rudloff, U. et al. Impact of maximal cytoreductive surgery plus regional heated intraperitoneal chemotherapy (HIPEC) on outcome of patients with peritoneal carcinomatosis of gastric origin: results of the GYMSSA trial. J. Surg. Oncol. 110, 275–284 (2014).

    Article  Google Scholar 

  31. Fujitani, K. et al. Randomized controlled trial comparing gastrectomy plus chemotherapy with chemotherapy alone in advanced gastric cancer with a single non-curable factor: Japan Clinical Oncology Group Study JCOG 0705 and Korea Gastric Cancer Association Study KGCA01. Jpn J. Clin. Oncol. 38, 504–506 (2008).

    Article  Google Scholar 

  32. He, M. M. et al. The role of non-curative surgery in incurable, asymptomatic advanced gastric cancer. PLoS ONE 8, e83921 (2013).

    Article  Google Scholar 

  33. Mariette, C. et al. Palliative resection for advanced gastric and junctional adenocarcinoma: which patients will benefit from surgery? Ann. Surg. Oncol. 20, 1240–1249 (2013).

    Article  Google Scholar 

  34. Jeurnink, S. M. et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest. Endosc. 71, 490–499 (2010).

    Article  Google Scholar 

  35. Samarasam, I. et al. Palliative gastrectomy in advanced gastric cancer: is it worthwhile? ANZ J. Surg. 76, 60–63 (2006).

    Article  Google Scholar 

  36. Kahlke, V. et al. Palliation of metastatic gastric cancer: impact of preoperative symptoms and the type of operation on survival and quality of life. World J. Surg. 28, 369–375 (2004).

    Article  Google Scholar 

  37. Murad, A. M. et al. Modified therapy with 5-fluorouracil, doxorubicin, and methotrexate in advanced gastric cancer. Cancer 72, 37–41 (1993).

    Article  CAS  Google Scholar 

  38. Pyrhonen, S., Kuitunen, T., Nyandoto, P. & Kouri, M. Randomised comparison of fluorouracil, epidoxorubicin and methotrexate (FEMTX) plus supportive care with supportive care alone in patients with non-resectable gastric cancer. Br. J. Cancer 71, 587–591 (1995).

    Article  CAS  Google Scholar 

  39. Glimelius, B. et al. Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer. Ann. Oncol. 8, 163–168 (1997).

    Article  CAS  Google Scholar 

  40. Koizumi, W. et al. S-1 plus cisplatin versus S-1 alone for first-line treatment of advanced gastric cancer (SPIRITS trial): a phase III trial. Lancet Oncol. 9, 215–221 (2008).

    Article  CAS  Google Scholar 

  41. Cunningham, D. et al. Capecitabine and oxaliplatin for advanced esophagogastric cancer. N. Engl. J. Med. 358, 36–46 (2008).

    Article  CAS  Google Scholar 

  42. Webb, A. et al. Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer. J. Clin. Oncol. 15, 261–267 (1997).

    Article  CAS  Google Scholar 

  43. Yun, J. et al. A randomised phase II study of combination chemotherapy with epirubicin, cisplatin and capecitabine (ECX) or cisplatin and capecitabine (CX) in advanced gastric cancer. Eur. J. Cancer 46, 885–891 (2010).

    Article  CAS  Google Scholar 

  44. Oba, K. et al. Role of chemotherapy for advanced/recurrent gastric cancer: an individual-patient-data meta-analysis. Eur. J. Cancer 49, 1565–1577 (2013).

    Article  Google Scholar 

  45. Lamont, E. B. & Schilsky, R. L. The oral fluoropyrimidines in cancer chemotherapy. Clin. Cancer Res. 5, 2289–2296 (1999).

    CAS  PubMed  Google Scholar 

  46. Lee, J. et al. Phase III trial comparing capecitabine plus cisplatin versus capecitabine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial. J. Clin. Oncol. 30, 268–273 (2012).

    Article  CAS  Google Scholar 

  47. Kochi, M. et al. Effect of gastrectomy on the pharmacokinetics of S-1, an oral fluoropyrimidine, in resectable gastric cancer patients. Cancer Chemother. Pharmacol. 60, 693–701 (2007).

    Article  CAS  Google Scholar 

  48. Bang, Y. et al. Pathological features of advanced gastric cancer (GC): relationship to human epidermal growth factor receptor 2 (HER2) positivity in the global screening programme of the ToGA trial [abstract]. J. Clin. Oncol. 27 (15s Suppl.), a4556 (2009).

    Google Scholar 

  49. Bang, Y. J. et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet 376, 687–697 (2010).

    Article  CAS  Google Scholar 

  50. Asakura, H. et al. Palliative radiotherapy for bleeding from advanced gastric cancer: is a schedule of 30 Gy in 10 fractions adequate? J. Cancer Res. Clin. Oncol. 137, 125–130 (2011).

    Article  CAS  Google Scholar 

  51. Sun, J. et al. Consideration of the role of radiotherapy for abdominal lymph node metastases in patients with recurrent gastric cancer. Int. J. Radiat. Oncol. Biol. Phys. 77, 384–391 (2010).

    Article  Google Scholar 

  52. Temel, J. S. et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N. Engl. J. Med. 363, 733–742 (2010).

    Article  CAS  Google Scholar 

  53. Kokkola, A., Louhimo, J. & Puolakkainen, P. Does non-curative gastrectomy improve survival in patients with metastatic gastric cancer? J. Surg. Oncol. 106, 193–196 (2012).

    Article  Google Scholar 

  54. Al-Amawi, T., Swider-Al-Amawi, M., Halczak, M., Wojtasik, P. & Kladny, J. Advisability of palliative resections in incurable advanced gastric cancer. Pol. Przegl. Chir. 83, 449–456 (2011).

    Article  Google Scholar 

  55. Li, C. et al. Survival benefit of non-curative gastrectomy for gastric cancer patients with synchronous distant metastasis. J. Gastrointest. Surg. 14, 282–288 (2010).

    Article  Google Scholar 

  56. Turanli, S. The value of resection of primary tumor in gastric cancer patients with liver metastasis. Indian J. Surg. 72, 200–205 (2010).

    Article  Google Scholar 

  57. Lin, S. Z. et al. Palliative gastrectomy and chemotherapy for stage IV gastric cancer. J. Cancer Res. Clin. Oncol. 134, 187–192 (2008).

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Royal Marsden NHS Foundation Trust London and Surrey, Fulham Road, London, SW3 6JJ, UK

    Sri G. Thrumurthy, M. Asif Chaudry & William Allum

  2. Department of Medicine, Royal Marsden NHS Foundation Trust London and Surrey, Fulham Road, London, SW3 6JJ, UK

    Ian Chau

Authors
  1. Sri G. Thrumurthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Asif Chaudry
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ian Chau
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William Allum
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

S.G.T. and M.A.C. contributed equally to the preparation of the manuscript for publication. S.G.T., M.A.C., I.C., and W.A. contributed to researching data, wrote the manuscript, and reviewed/edited the article before submission. S.G.T. and W.A. contributed substantially to discussion of content.

Corresponding author

Correspondence to M. Asif Chaudry.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Thrumurthy, S., Chaudry, M., Chau, I. et al. Does surgery have a role in managing incurable gastric cancer?. Nat Rev Clin Oncol 12, 676–682 (2015). https://doi.org/10.1038/nrclinonc.2015.132

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrclinonc.2015.132

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer