Gastric cancer Medical Services in China

Gastric cancer, also known as stomach cancer, is a malignant neoplasm arising from the epithelial lining of the gastric mucosa—most commonly adenocarcinoma (accounting for over 90% of cases). It typically develops through a multistep carcinogenic cascade: chronic gastritis → atrophic gastritis → intestinal metaplasia → dysplasia → invasive adenocarcinoma. This progression is strongly associated with persistent Helicobacter pylori infection, which induces chronic inflammation, oxidative DNA damage, and aberrant cell proliferation. Other pathogenic mechanisms include Epstein-Barr virus (EBV) integration in ~10% of cases, microsatellite instability (MSI-H), and CDH1 germline mutations in hereditary diffuse gastric cancer (HDGC). Globally, gastric cancer ranks fifth in incidence and fourth in cancer-related mortality, with an estimated 969,000 new cases and 738,000 deaths annually (GLOBOCAN 2022). Incidence is markedly higher in East Asia (especially Korea, Japan, and China), Eastern Europe, and parts of Central and South America—regions where high-salt diets, smoked/preserved foods, smoking, and widespread H. pylori prevalence converge. In China alone, gastric cancer accounts for approximately 40% of global cases, with age-standardized incidence rates exceeding 25 per 100,000 in high-risk provinces. Key modifiable risk factors include long-standing H. pylori infection (relative risk ~3–6), tobacco use (2-fold increased risk), excessive salt intake, low fruit/vegetable consumption, and heavy alcohol consumption. Non-modifiable risks include male sex (2:1 male-to-female ratio), advanced age (median diagnosis at 68 years), family history, blood type A, and genetic syndromes such as Lynch syndrome or HDGC. Early-stage disease is often asymptomatic; later symptoms—including persistent epigastric pain, early satiety, unintentional weight loss, nausea, vomiting (sometimes with hematemesis), and iron-deficiency anemia—frequently indicate locally advanced or metastatic disease. Diagnosis relies on upper gastrointestinal endoscopy with systematic biopsy, enhanced by chromoendoscopy or magnification techniques in high-prevalence regions. Staging integrates EUS, contrast-enhanced CT, and sometimes PET-CT or diagnostic laparoscopy. Quality of life is profoundly impacted: patients experience significant nutritional compromise due to impaired gastric digestion and motility, fatigue from chronic inflammation and anemia, anxiety related to prognosis (5-year survival drops from >70% in Stage I to <10% in Stage IV), and psychosocial burden affecting work capacity, social engagement, and caregiver dynamics. Palliative care integration—addressing pain, nausea, depression, and nutritional support—is essential across all stages to preserve dignity and functional independence.

Gastric cancer—also known as stomach cancer—is a malignant neoplasm arising from the gastric mucosa, most commonly adenocarcinoma. Its management requires a multidisciplinary approach integrating endoscopic evaluation, histopathological staging, molecular profiling, and individualized therapeutic planning. Treatment strategies are stratified by tumor stage (per AJCC/UICC TNM 8th edition), patient performance status, comorbidities, and biomarker status (e.g., HER2, PD-L1, MSI-H/dMMR). In the Department of Gastroenterology, initial diagnosis and conservative management—including surveillance, chemoprevention, and symptom control—are central to early-stage and unresectable or metastatic disease.

Conservative treatment is indicated for patients with early gastric cancer (T1a or select T1b lesions) without lymphovascular invasion, those unfit for surgery due to advanced age or severe comorbidities, or those with widespread metastatic disease where palliation supersedes curative intent. Endoscopic resection—specifically endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)—is the cornerstone of minimally invasive curative therapy for intramucosal (T1a) and superficial submucosal (T1b SM1, ≤500 µm invasion) cancers meeting strict criteria (e.g., well-to-moderately differentiated, <2 cm, no ulceration). ESD achieves higher en bloc and R0 resection rates (>90%) compared to EMR and is widely adopted in high-volume centers across China. For unresectable locally advanced or metastatic disease, conservative management focuses on nutritional optimization (including enteral feeding support when gastroparesis or obstruction occurs), antiemetic regimens (e.g., 5-HT3 antagonists + NK1 receptor antagonists), proton pump inhibitors for acid-related symptoms, and opioid-based analgesia for pain control. Psychosocial support and palliative care integration are initiated early to improve quality of life.

Pharmacotherapy plays a pivotal role across disease stages. Adjuvant chemotherapy—typically capecitabine/oxaliplatin (XELOX) or S-1 monotherapy—is standard after D2 gastrectomy for stage II–III disease, improving 5-year overall survival by 10–15% versus surgery alone. Neoadjuvant chemotherapy (e.g., FLOT regimen: 5-FU, leucovorin, oxaliplatin, docetaxel) is increasingly used for locally advanced resectable tumors (cT3–4/N+), enhancing R0 resection rates and downstaging. For HER2-positive advanced gastric or gastroesophageal junction (GEJ) adenocarcinoma, trastuzumab combined with platinum-fluoropyrimidine chemotherapy remains first-line; newer agents such as trastuzumab deruxtecan show promising activity in pretreated patients. Immune checkpoint inhibitors have transformed systemic therapy: nivolumab plus chemotherapy is approved for first-line advanced gastric/GEJ cancer regardless of PD-L1 status, while pembrolizumab is indicated for MSI-H/dMMR or PD-L1–positive (CPS ≥1) tumors. Targeted therapies including ramucirumab (anti-VEGFR2 monoclonal antibody) are used as second-line monotherapy or in combination with paclitaxel. Supportive medications include erythropoiesis-stimulating agents for chemotherapy-induced anemia, granulocyte colony-stimulating factors for neutropenia prophylaxis, and bisphosphonates or denosumab for bone metastases.

Surgical treatment remains the only potentially curative modality for non-metastatic gastric cancer. Radical gastrectomy with D2 lymphadenectomy—removal of perigastric (stations 1–6) and celiac axis–adjacent (stations 7–11) lymph nodes—is the global standard for clinical T2–T4 or node-positive disease. Laparoscopic and robotic-assisted D2 gastrectomy are now routinely performed in tertiary Chinese hospitals, offering reduced postoperative pain, shorter hospital stays (median 6–8 days), faster return of gastrointestinal function, and comparable oncologic outcomes to open surgery at 3–5 years. Total gastrectomy is preferred for proximal or diffuse-type (linitis plastica) tumors, while distal or subtotal gastrectomy suffices for distal antral cancers. Reconstruction options include Roux-en-Y esophagojejunostomy (total gastrectomy) or Billroth I/II or Roux-en-Y gastrojejunostomy (subtotal). Postoperative pathology guides adjuvant therapy decisions, with meticulous reporting of margin status (R0 vs R1/R2), lymph node yield (>16 nodes recommended), and tumor regression grade following neoadjuvant therapy.

China offers distinct advantages in gastric cancer management. First, its high incidence (~40% of global cases) has fostered unparalleled clinical expertise and procedural volume—many top-tier hospitals perform >500 gastrectomies annually, correlating with lower perioperative mortality (<2%) and superior long-term survival. Second, China leads in real-world implementation of ESD, with standardized training programs, national ESD quality benchmarks, and AI-assisted endoscopic imaging (e.g., deep learning algorithms for real-time lesion characterization) enhancing diagnostic accuracy. Third, rapid regulatory approval pathways (e.g., NMPA’s conditional approval program) enable timely access to novel agents like fruquintinib (anti-angiogenic TKI) and zolbetuximab (CLDN18.2-targeted therapy), often months ahead of Western markets. Fourth, integrated traditional Chinese medicine (TCM) is evidence-informed adjunctive care: formulas such as Jianpi Yangzheng Xiaoji decoction demonstrate improved tolerance to chemotherapy, reduced fatigue, and enhanced immune parameters in randomized trials—though used strictly as supportive, not alternative, therapy.

Recovery advice emphasizes structured, stage-specific rehabilitation. Post-endoscopic resection patients should adhere to a clear liquid diet for 24 hours, advance to soft foods over 5–7 days, avoid NSAIDs and anticoagulants for 2 weeks, and undergo surveillance endoscopy at 3, 6, and 12 months. After gastrectomy, patients require lifelong nutritional monitoring: small, frequent meals (6–8/day); avoidance of simple carbohydrates to prevent dumping syndrome; supplementation with vitamin B12 (intramuscular or high-dose oral), iron, calcium, and vitamin D; and referral to a registered dietitian. Physical recovery includes early ambulation (day 1 post-op), progressive resistance training to counteract sarcopenia, and pulmonary hygiene to prevent atelectasis. Psychologically, patients benefit from structured counseling addressing body image concerns, fear of recurrence, and adjustment to altered digestion. All patients should undergo annual upper endoscopy and CT surveillance per guidelines (e.g., JSGC or CSCO), with attention to family history—first-degree relatives warrant screening endoscopy starting at age 40 or 10 years younger than the youngest affected relative. Finally, smoking cessation and alcohol abstinence are non-negotiable, given their synergistic carcinogenic effects with H. pylori infection and dietary nitrosamines.