Gastric Cancer Stage IV
Stage 4 gastric cancer represents the most advanced form of stomach cancer, where the disease has spread beyond the stomach to distant parts of the body or grown through the outer stomach wall into nearby organs.
Table of contents
- What is stage 4 gastric cancer?
- Where gastric cancer spreads
- Understanding staging systems
- Treatment approaches
- Prognosis and survival
- Living with stage 4 gastric cancer
What is stage 4 gastric cancer?
Stage 4 gastric cancer means the cancer has spread to distant areas of your body or has grown through the outer layer of your stomach into nearby organs or tissues[1]. This is also called advanced stomach cancer or metastatic cancer, which means the cancer cells have traveled from where they started to other parts of your body[4].
In some cases, stage 4 is divided into two groups. Stage 4A means your cancer has grown through the stomach wall and into nearby organs or tissues. It might have spread to nearby lymph nodes (small bean-shaped organs that are part of your immune system), but it hasn’t spread to distant body parts. This is sometimes called locally advanced cancer[1].
Stage 4B means your cancer has spread to distant body parts. This spread is called advanced, metastatic, or secondary cancer[1].
Where gastric cancer spreads
When stomach cancer spreads to other parts of the body, it most commonly travels to specific organs. The cancer is more likely to spread to the liver, lungs, or the tissue lining the abdominal cavity, which is called the peritoneum[1]. Cancer may also be found in distant lymph nodes[4].
Understanding staging systems
Doctors use different methods to determine the stage of your cancer. Your doctor might use clinical staging, which happens before treatment and if you don’t have surgery. This means the doctor stages you after examining you and looking at test and scan results[1].
If you do have surgery, doctors use pathological staging. This is also called surgical staging. The doctors examine the tissue that the surgeon removes during an operation. They combine your clinical stage results with the surgical results. Pathological staging is generally a more precise way to find out how far your cancer has spread[1].
Another method is post neoadjuvant staging, which is used if you have had chemotherapy (medicines that kill cancer cells) before surgery and the doctor stages you again after surgery[1].
Treatment approaches
Stage 4 gastric cancer is harder to treat than earlier stage stomach cancer because it’s no longer confined to the stomach and may involve several distant organs. It’s usually not curable, but it’s certainly treatable[4]. The goal of treatment is to ease symptoms and control the cancer’s growth[4].
Treatment for stage 4 aims to control the cancer and maintain a good quality of life[1]. The stage of your cancer helps your doctor to decide what treatment you need. Treatment also depends on your type of cancer, where the cancer is in your stomach, and other health conditions[1].
Chemotherapy
Chemotherapy is usually offered for stage 4 or recurrent gastric cancer to help shrink the tumor and control the growth of the cancer. It may be given as a single drug or a combination of drugs. Common drugs include fluorouracil (also called 5-fluorouracil or 5-FU), capecitabine, or combinations with either of these drugs[7].
There are many chemotherapy drugs used for stage 4 stomach cancer, including capecitabine, cisplatin, docetaxel, epirubicin, fluorouracil (5-FU), leucovorin, and oxaliplatin. These drugs may be given alone or in combination[10].
Targeted therapy
You may be offered targeted therapy for stage 4 gastric cancer. These are medicines that target specific features of cancer cells. Trastuzumab may be used with chemotherapy for stomach cancer that makes too much of the HER2 protein, called HER2-positive stomach cancer[7].
Other targeted therapies include trastuzumab deruxtecan, which may be used for HER2-positive stomach cancer after treatment with trastuzumab. Ramucirumab may be used with paclitaxel or alone if chemotherapy drugs have stopped working[7].
Immunotherapy
Nivolumab may be used with chemotherapy to treat advanced or metastatic stomach cancer. Pembrolizumab may be used with chemotherapy and trastuzumab to treat advanced or metastatic stomach cancer. Zolbetuximab may be used with chemotherapy for stomach cancer that doesn’t make the HER2 protein, called HER2-negative stomach cancer[7].
Surgery
Surgery is sometimes offered for stage 4 or recurrent gastric cancer to relieve the symptoms of advanced cancer such as bleeding, blockage, or pain. This is called palliative surgery[7].
A subtotal gastrectomy may be done to remove the part of the stomach with the tumor. This can help ease bleeding and pain[4]. If tumors are blocking the opening of the stomach, a stent (a hollow metal or plastic tube) may be placed during surgery. It will allow a person with advanced stomach cancer to swallow more easily[7].
If surgery or other methods cannot relieve a blockage caused by a stomach tumor, a person with advanced stomach cancer may have a feeding tube placed during surgery. A feeding tube is used to give a special liquid mixture of nutrients directly into the stomach or small intestine[7].
Radiation therapy
You may be offered external radiation therapy for stage 4 or recurrent gastric cancer. It uses high-energy rays to kill cancer cells. It is used alone or in combination with chemotherapy. It may be used to relieve the symptoms caused by advanced stomach cancer such as bleeding, pain, difficulty swallowing, or a blockage[7].
Laser therapy
Laser therapy can be used to destroy tumors, stop bleeding, or alleviate a blockage in the stomach. This can sometimes be accomplished without surgery. The doctor inserts a long, flexible tube called an endoscope down the throat and into the stomach to deliver the laser beam. This is also called endoscopic tumor ablation[4].
Prognosis and survival
Around 20 out of 100 people (around 20%) with stage 4 stomach cancer will survive their cancer for 1 year or more after their diagnosis[19]. Please remember, this doesn’t mean you will only live 1 year. It relates to the number of people who are still alive 1 year after their diagnosis of cancer. Some of these people might live longer than 1 year.
In patients who have metastatic disease, cure is rarely achieved. Therefore, the treatment goal is to prolong life and improve quality of life[3].
Living with stage 4 gastric cancer
Gastric cancer and its treatment can cause physical and emotional side effects. When you first learn that you have stomach cancer, you may wonder how you’re going to cope with the upcoming changes in your life. Speaking up about any problems you have can give you a greater sense of control[24].
Stomach cancer and its treatments may affect your ability to eat enough food or absorb the nutrients from food. If part or all of your stomach has been removed, you might need to eat smaller amounts of food more often or make changes to what you eat. Your doctor or dietitian may recommend that you stay upright for some time after eating. They can also help you adjust your diet to make sure you get the nutrition you need[24].
It’s important to work with a wide range of providers in different fields of medicine when you’re living with advanced stomach cancer. Palliative medicine specialists, for example, help in a variety of ways. They assist you with pain management and find other strategies for making you comfortable throughout the course of your treatment while prioritizing self-care[20].
If you can’t have or don’t want cancer treatment, you may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition, or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment. Talk to your healthcare team[7].
