Gastric Cancer Treatment Protocols 

Updated: Aug 05, 2014
  • Author: Terence D Rhodes, MD, PhD; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
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General Treatment Recommendations

Treatment decisions should be made with a multidisciplinary team [1] and based on the following:

  • Stage of disease
  • Surgical fitness of the patient
  • The patient’s preference
  • Patient comorbidities

Stage 0 to IA

Endoscopic mucosal resection or surgery is primary treatment for early-stage gastric cancer. Complete surgical resection offers potential for long-term survival.

Stage IB to IIIC, potentially resectable, medically fit

Perioperative, neoadjuvant chemotherapy or chemoradiotherapy followed by surgery is appropriate. Perioperative therapy is common practice, with chemoradiotherapy after surgery showing a clear survival benefit. [2]

Stage IB to IIIC, potentially resectable, medically unfit

See the list below:

  • Chemoradiotherapy or chemotherapy

Stage IV

See the list below:

  • Chemotherapy for metastatic disease; local therapy is not indicated
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Neoadjuvant Chemoradiotherapy Regimens

Preferred regimens

A higher level of evidence supports use of the following regimens; clinical trials have shown strong benefit and there is consensus among experts [1] :

  • Paclitaxel 50 mg/m 2 IV on day 1 plus  carboplatin AUC 2 IV on day 1; weekly for 5 wk [3, 4] (see the Carboplatin AUC Dose Calculation [Calvert formula] calculator) or
  • Cisplatin 75-100 mg/m 2 IV on day 1 plus  5-fluorouracil (5-FU) 750-1000 mg/m 2/day IV continuous infusion on days 1-4 and 29-32; single 35-day cycle [5] or
  • Cisplatin 30 mg/m 2 IV on day 1 plus  capecitabine 800 mg/m 2 PO BID on days 1-5; weekly for 5wk [6] or
  • Cisplatin 15 mg/m 2 IV daily on days 1-5 and days 22-26 plus  5-FU 800 mg/m 2/day IV continuous infusion on days 1-5 and days 22-26; single 35-day cycle [7] or
  • Oxaliplatin 85 mg/m 2 IV on days 1, 15, and 29 plus  capecitabine 625 mg/m 2 PO BID on days 1-5, 8-12, 15-19, 22-26, and 29-33; single 35-day cycle [8] or
  • Oxaliplatin 85 mg/m 2 on days 1, 15, and 29 plus  5-FU 180 mg/m 2 continuous IV infusion daily on days 1-33 [9] or
  • Oxaliplatin 85 mg/m 2 IV on day 1 plus  leucovorin 400 mg/m 2 IV on day 1 plus  5-FU 400 mg/m 2 IVP on day 1 and 5-FU 800 mg/m 2 continuous IV infusion daily on days 1 and 2; every 14 d for three cycles with radiation and three cycles after radiation [10]

Other regimens

A lower level of evidence supports use of the following regimens; smaller studies show benefit of the therapy, and therapy may need to be used on the basis of the clinical situation (eg, limiting toxicities, patient comorbidity) [1] :

  • Oxaliplatin 45-50 mg/m 2 IV on day 1 weekly for 5 wk plus  5-FU 225 mg/m 2 IV daily on days 1-33; single 35-day cycle [11] or
  • Carboplatin AUC 6 IV on days 1 and 22 plus  5-FU 200 mg/m 2 IV daily on days 1-42 [12] or
  • Irinotecan 65 mg/m 2 IV on days 1, 8, 22, and 29 plus  cisplatin 30 mg/m 2 IV on days 1, 8, 22, and 29 [13] or
  • Paclitaxel 45-50 mg/m 2 IV on day 1 plus  5-FU 300 mg/m 2 continuous IV infusion daily on days 1-5; weekly for 5 wk [14] or
  • Paclitaxel 45-50 mg/m 2 IV on day 1 plus  capecitabine 625-825 mg/m 2 PO BID daily on days 1-5; weekly for 5 wk [14, 15]
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Perioperative Chemotherapy Regimens

Treatment consists of three cycles before surgery and three cycles after surgery; the following regimens are used only for adenocarcinoma of the distal esophagus or gastroesophageal junction [1] :

  • Epirubicin 50 mg/m 2 IV on day 1 plus cisplatin 60 mg/m 2 IV on day 1 plus 5-FU 200 mg/m 2/day IV continuous infusion daily for days 1-21; every 21 d for cycles 1-3 preoperatively and cycles 4-6 postoperatively [2] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  oxaliplatin 130 mg/m 2 IV on day 1 plus  5-FU 200 mg/m 2/day IV continuous infusion daily for days 1-21; every 21 d for cycles 1-3 preoperatively and cycles 4-6 postoperatively [18] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  cisplatin 60 mg/m 2 IV on day 1 plus  capecitabine 625 mg/m 2 PO BID daily for days 1-21; every 21 d for cycles 1-3 preoperatively and cycles 4-6 postoperatively [18] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  oxaliplatin 130 mg/m 2 IV on day 1 plus  capecitabine 625 mg/m 2 PO BID daily for days 1-21; every 21 d for three cycles preoperatively and three cycles postoperatively [18] or
  • Cisplatin 75-80 mg/m 2 IV on day 1 plus 5-FU 800 mg/m 2 continuous IV infusion on days 1-5; every 28 d for 2-3 cycles preoperatively and 3-4 cycles postoperatively for a total of six cycles [19]
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Postoperative Chemoradiotherapy Regimens

Uses of the following postoperative chemoradiotherapy regimens include cancers of the gastroesophageal junction:

  • Leucovorin 20 mg/m 2 IVP on days 1-5 plus  5-FU 425 mg/m 2 IVP daily on days 1-5, every 28 d (cycles 1, 3, and 4 given before and after radiation); for cycle 2, give leucovorin 20 mg/m 2 IVP on days 1-4 and 31-33 plus  5-FU 400 mg/m 2 IVP daily on days 1-4, every 35 d (cycle 2 given with radiation) [20]

NOTE: The National Comprehensive Cancer Network (NCCN) panel does not recommend the above specified doses or schedule, because of concerns regarding toxicity; instead, the panel recommends using one of the following modified regimens.

One cycle before and two cycles after chemoradiation:

  • Capecitabine 750-1000 mg/m 2 PO BID on days 1-14; every 28 d (one cycle before and two cycles after chemoradiation)
  • Leucovorin 400 mg/m 2 IV on days 1 and 15 or days 1, 2, 15, and 16 plus  5-FU 400 mg/m 2 IVP on days 1 and 15 or days 1, 2, 15, and 16 and  5-FU 1200 mg/m 2 continuous IV infusion over 24 h daily on days 1, 2, 15 and 16, every 14 d (one cycle before radiation and two cycles after radiation) [21]

With radiation:

  • 5-FU 200-250 mg/m 2/day continuous IV infusion on days 1-5 or 1-7; weekly for 5 wk [22] or
  • Capecitabine 625-825 mg/m 2 PO BID daily for days 1-5 or 1-7; weekly for 5 wk [23]
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Postoperative Chemotherapy Regimens

See the list below:

  • Oxaliplatin 130 mg/m 2 IV on day 1 plus capecitabine 1000 mg/m 2 PO BID on days 1-14; every 21 d for 8 cycles [24] or
  • Cisplatin 60 mg/m 2 IV on day 1 plus capecitabine 1000 mg/m 2 PO BID on days 1-14; every 21 d for 6 cycles [25]

First-Line Chemotherapy for Metastatic or Locally Advanced Cancer (where local therapy not indicated)

Stage IV

For HER2-NEU overexpressing adenocarcinomas, trastuzumab can be added to cisplatin plus fluoropyrimidine (eg, 5-FU, capecitabine) regimens (except regimens containing an anthracycline) [1] :

  • Trastuzumab 8 mg/kg IV loading dose on day 1 of cycle 1, then 6 mg/kg IV; every 21 d with chemotherapy [26] or
  • Trastuzumab 6 mg/kg IV loading dose on day 1 of cycle 1, then 4 mg/kg IV every 14 d with chemotherapy

Preferred regimens [1]

Two-drug regimens are preferred because of lower toxicity; reserve three-drug regimens for patients who are medically fit and have access to frequent follow-up

  • Docetaxel 75 mg/m 2 IV on day 1 plus  cisplatin 75 mg/m 2 IV on day 1 plus  5-FU 1000 mg/m 2/day continuous IV infusion on days 1-5; every 28 d [27]
  • NOTE: NCCN panel does not recommend the above specified doses or schedule because of concerns regarding toxicity; instead, use one of the following modified regimens:
  • Docetaxel 40 mg/m 2 IV on day 1 plus  leucovorin 400 mg/m 2 IV on day 1 plus  5-FU 400 mg/m 2 IV on day 1 plus  5-FU 1000 mg/m 2/day continuous IV infusion on days 1 and 2 plus  cisplatin 40 mg/m 2 IV on day 3; every 14 d [28] or
  • Docetaxel 50 mg/m 2 IV on day 1 plus  oxaliplatin 85 mg/m 2 IV on day 1 plus  5-FU 1200 mg/m 2/day continuous IV infusion on days 1 and 2; every 14 d [32] or
  • Docetaxel 75 mg/m 2 IV on day 1 plus  carboplatin AUC 6 IV on day 2 plus  5-FU 1200 mg/m 2/day continuous IV infusion on days 1-3; every 21 d [33] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  cisplatin 60 mg/m 2 IV on day 1 plus  5-FU 200 mg/m 2/day continuous IV infusion on days 1-21; every 21 d [34, 35] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  oxaliplatin 130 mg/m 2 on day 1 plus  5-FU 200 mg/m 2/day continuous IV infusion on days 1-21; every 21 d [35] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  cisplatin 60 mg/m 2 IV on day 1 plus  capecitabine 625 mg/m 2 PO BID daily on days 1-21; every 21 d [35] or
  • Epirubicin 50 mg/m 2 IV on day 1 plus  oxaliplatin 130 mg/m 2 IV on day 1 plus  capecitabine 625 mg/m 2 PO BID daily on days 1-21; every 21 d [35] or
  • Cisplatin 75-100 mg/m 2 IV on day 1 plus  5-FU 750-1000 mg/m 2/day continuous IV infusion over 24 h on days 1-4; every 28 d [36] or
  • Cisplatin 50 mg/m 2 IV on day 1 plus  leucovorin 200 mg/m 2 IV on day 1 plus  5-FU 2000 mg/m 2/day continuous IV infusion on day 1; every 14 d [37, 38] or
  • Cisplatin 80 mg/m 2 IV on day 1 plus  capecitabine 1000 mg/m 2 PO BID daily on days 1-14; every 21 d [26, 39]
  • Oxaliplatin 85 mg/m 2 IV on day 1 plus  leucovorin 400 mg/m 2 IV on day 1 plus  5-FU 400 mg/m 2 IVP on day 1 plus  5-FU 1200 mg/m 2/day continuous IV infusion on days 1 and 2; every 14 d [40] or
  • Oxaliplatin 85 mg/m 2 IV on day 1 plus  leucovorin 200 mg/m 2 IV on day 1 plus  5-FU 2600 mg/m 2/day continuous IV infusion on day 1; every 14 d [37] or
  • Oxaliplatin 130 mg/m 2 IV on day 1 plus  capecitabine 1000 mg/m 2 PO BID on days 1-14; every 21 d [41]
  • Irinotecan 80 mg/m 2 IV on day 1 plus  leucovorin 500 mg/m 2 IV on day 1 plus  5-FU 2000 mg/m 2/day continuous IV infusion on day 1; weekly for 6 wk followed by 1 wk off treatment [42] or 2 wk off treatment [43, 92] or
  • Irinotecan 150 mg/m 2 IV on day 1 plus  leucovorin 20 mg/m 2 IV on day 1 plus  5-FU 1000 mg/m 2 /day continuous IV infusion on days 1 and 2; every 14 d [91]

Other regimens [1] :

  • Paclitaxel 135-200 mg/m 2 IV on day 1 plus  cisplatin 75 mg/m 2 IV on day 2; every 21 d [45] or
  • Paclitaxel 90 mg/m 2 IV on day 1 plus  cisplatin 50 mg/m 2 IV on day 1; every 14 d [46] or
  • Paclitaxel 200 mg/m 2 IV on day 1 plus  carboplatin AUC 5 IV on day 1; every 21 d [47] or
  • Docetaxel 70-85 mg/m 2 IV on day 1 plus  cisplatin 70-75 mg/m 2 IV on day 1; every 21 d [30, 48, 49] or
  • Docetaxel 35 mg/m 2 IV on days 1 and 8 plus  irinotecan 50 mg/m 2 IV on days 1 and 8; every 21 d [50] or
  • Leucovorin 400 mg/m 2 IV on day 1 plus  5-FU 400 mg/m 2 IVP on day 1 plus  5-FU 1200 mg/m 2/day continuous IV infusion on days 1 and 2; every 14 d [38] or
  • 5-FU 800 mg/m 2/day continuous IV infusion on days 1-5; every 28 d [51] or
  • Capecitabine 1000-1250 mg/m 2 PO BID daily on days 1-14; every 21 d [52] or
  • Docetaxel 75-100 mg/m 2 IV on day 1; every 21 d [53] or
  • Paclitaxel 135-250 mg/m 2 IV on day 1; every 21 d [54] or
  • Paclitaxel 80 mg/m 2 IV on day 1 weekly; every 28 d [55]
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Next:

Second-Line Chemotherapy for Metastatic or Locally Advanced Cancer (Where Local Therapy Not Indicated)

Stage IV

For HER2-NEU overexpressing adenocarcinomas, trastuzumab can be added to other chemotherapy regimens (except regimens containing an anthracycline) [1] ;

  • Trastuzumab 8 mg/m 2 IV loading dose on day 1 of cycle 1, then 6 mg/m 2 IV; every 21 d with chemotherapy [26] or
  • Trastuzumab 6 mg/kg IV loading dose on day 1 of cycle 1, then 4 mg/kg IV every 14 d with chemotherapy

Preferred regimens [1] :

  • Ramucirumab 8 mg/kg IV on day 1; every 14 d [64] or
  • Ramucirumab 8 mg/kg IV on days 1 and 15 plus paclitaxel IV 80 mg/m2 on days 1, 8, and 15; every 28 d [93]
  • Docetaxel 75-100 mg/m 2 IV on day 1; every 21 d [53] or
  • Paclitaxel 135-250 mg/m 2 IV on day 1; every 21 d [54] or
  • Paclitaxel 80 mg/m 2 IV on day 1 weekly; every 28 d [55] or
  • Paclitaxel 80 mg/m 2 IV on days 1, 8, and 15; every 28 d [56] or
  • Irinotecan 250-350 mg/m 2 IV on day 1; every 21 d [57] or
  • Irinotecan 150-180 mg/m 2 IV on day 1; every 14 d [58, 59, 56] or
  • Irinotecan 125 mg/m 2 IV on days 1 and 8; every 21 d [58, 59]

Other regimens [1] :

  • Irinotecan 65 mg/m 2 IV on days 1 and 8 plus cisplatin 25-30 mg/m 2 IV on days 1 and 8; every 21 d [40, 60] or
  • Irinotecan 250 mg/m 2 IV on day 1 plus capecitabine 1000 mg/m 2 PO BID daily on days 1-14; every 21 d [61] or
  • Irinotecan 180 mg/m 2 IV on day 1 plus leucovorin 400 mg/m 2 IV on day 1 plus 5-FU 400 mg/m 2 IVP on day 1 plus 5-FU 600-1200 mg/m 2/day continuous IV infusion on days 1 and 2; every 14 d [62, 63] or
  • Docetaxel 35 mg/m 2 IV on days 1 and 8 plus irinotecan 50 mg/m 2 IV on days 1 and 8; every 21 d [50]

Alternative regimens to consider:

  • Mitomycin 6 mg/m 2 IV on day 1 plus  irinotecan 125 mg/m 2 on days 2 and 9; every 28 d [65] or
  • Irinotecan 150 mg/m 2 IV on days 1 and 15 plus  mitomycin 8 mg/m 2 IV on day 1; every 28 d [66] or
  • Irinotecan 125 mg/m 2 IV on day 1 plus  mitomycin 5 mg/m 2 IV on day 1; every 14 d [67] or
  • Mitomycin 10 mg/m 2 IV on days 1 and 22 plus  leucovorin 500 mg/m 2 IV on day 1 plus  5-FU 2600 mg/m 2/day continuous IV infusion on day 1; weekly for 6 wk, followed by 2 wk off treatment [68]
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