Dr. Raghav Sundar, an associate professor of internal medicine in medical oncology and hematology at Yale School of Medicine, says rapid advances in precision oncology are reshaping care for patients with gastric cancer, expanding options from early-stage treatment through advanced disease.
Gastric cancer is treated differently depending on stage. Very early-stage tumors can sometimes be removed endoscopically without surgery. Locally advanced disease remains surgical, but perioperative chemotherapy—given before and after surgery—has long reduced relapse risk and improved survival. Recently, the FDA approved adding the immunotherapy drug durvalumab (Imfinzi) to chemotherapy in this setting, a change shown to improve relapse-free and overall survival.
In metastatic disease, immunotherapy added to chemotherapy has become a standard approach for many patients. New targeted therapies are also emerging: claudin 18.2, a protein exposed on some tumor cells, can be targeted with zolbetuximab (Vyloy), which received FDA approval last year for tumors that express this marker. HER2 remains an important biomarker; trastuzumab (Herceptin) combined with chemotherapy, and often with immunotherapy, is used for HER2-positive gastric cancers.
Sundar emphasizes the importance of comprehensive biomarker testing to guide these precision treatments so patients receive the therapies most likely to benefit them rather than chemotherapy alone.
Treatment brings specific challenges. Tumors and therapies can reduce appetite, impair stomach motility and cause nausea, vomiting, abdominal pain and fatigue, making weight maintenance a major concern. Nutrition support is essential; most patients at Yale are referred to nutritionists. Sundar cautions against calorie restriction based on the misconception that high-calorie diets “feed” tumors, noting that unintended weight loss from restrictive diets can be harmful.
Peritoneal metastases are a particular challenge because chemotherapy penetrates the peritoneal lining poorly. These metastases can cause bowel obstruction, vomiting and, rarely, intestinal perforation. Yale offers a specialized program for peritoneal disease that combines medical and surgical expertise and access to clinical trials. Treating peritoneal spread differently from liver or lung metastases is an area of active investigation.
Clinical trials remain critical to progress. Despite recent advances, median survival for advanced gastric cancer is roughly 18 to 24 months, varying by biomarkers and available treatments. Trials test therapies specifically for gastric cancer and can provide earlier access to promising agents. Sundar notes the importance of trials in the United States, since many studies are conducted in regions where gastric cancer is more common, such as Asia.
Sundar urges awareness and advocacy to help patients and caregivers understand available options and to highlight the difficult journey patients face. He also clarifies that adenocarcinomas of the lower esophagus, gastroesophageal junction and stomach are often managed similarly to gastric cancer, while squamous cell carcinomas primarily affect the esophagus and follow different treatment paradigms.
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