Stomach and esophagus cancer: Full guide

What is stomach and esophagus cancer?

The esophagus is the food pipe. It carries food from your throat to your stomach. The stomach holds food and starts to break it down.

Cancer starts when cells in the lining of these organs grow out of control. Over time, the cancer can grow deeper into the wall. It can also spread to lymph nodes, the liver, the lining of the belly, or other places.

Cancers of the lower esophagus, the place where the esophagus meets the stomach, and the stomach are often treated in similar ways. That is why they are grouped together here.

Common risk factors include long-term acid reflux, smoking, heavy alcohol use, obesity, and a stomach infection called H. pylori. Diets high in salty, smoked, or cured foods also raise the risk. A small number of cases run in families.

Swallowing and eating are often affected. Good nutrition is a big part of care. Your care team will help with both the cancer and with eating well.

Types

Squamous cell carcinoma of the esophagus

Starts in the flat cells that line the upper and middle esophagus. It is linked to smoking and alcohol. It often responds well to radiation.

Adenocarcinoma of the esophagus

Starts in gland cells, usually in the lower esophagus. It is linked to long-term acid reflux and Barrett esophagus (a change in the lining caused by reflux).

Gastroesophageal junction (GEJ) cancer

Cancer right where the esophagus meets the stomach. It is an adenocarcinoma. It is becoming more common in the US.

Stomach (gastric) adenocarcinoma

The most common stomach cancer. Doctors may call it intestinal type or diffuse type, based on how the cells look. The two types can act differently.

Diffuse type and signet ring cell cancer

A type of stomach cancer that spreads through the wall instead of forming a clear lump. It can be harder to see on scans and scopes.

Hereditary diffuse gastric cancer

A rare form caused by an inherited change in a gene called CDH1. It can run in families and may show up at a young age. Families may be offered genetic testing.

Other rare types

Some stomach tumors, such as GIST (gastrointestinal stromal tumor), lymphoma, and neuroendocrine tumors, are different diseases. They are treated in different ways.

Tests you may have

Upper endoscopy (EGD)

A thin tube with a camera goes through your mouth into the esophagus and stomach. You are sedated. The doctor looks for the tumor and takes small samples (biopsies).

Biopsy

Taking small pieces of tissue to look at under a microscope. It confirms the cancer and its type. The same tissue is used for biomarker tests.

Endoscopic ultrasound (EUS)

An endoscope with a small ultrasound probe. It shows how deep the tumor goes into the wall and checks nearby lymph nodes.

CT scan

Detailed X-ray pictures of the chest, belly, and pelvis. It looks for spread to lymph nodes, the liver, and other organs.

PET-CT scan

A scan that uses a small amount of a sugar tracer. Cancer cells often take up more of it. It can find spread that a CT may miss. Some stomach cancers do not show up well on PET.

Staging laparoscopy

A short surgery with a small camera put into the belly through tiny cuts. It checks for cancer on the lining of the belly that scans can miss. The doctor may also rinse the belly and test the fluid.

Biomarker tests

Lab tests on the tumor for HER2, PD-L1, MSI, CLDN18.2, and other gene changes. The results help choose medicines, especially for advanced cancer.

Blood tests

These check blood counts, liver and kidney function, and nutrition levels. Many people have low iron from slow bleeding.

Nutrition check

A dietitian looks at your weight, eating, and swallowing. This helps plan support before and during treatment.

What the stage means

The stage tells how deep the tumor has grown into the wall of the esophagus or stomach. It also tells if it has spread to lymph nodes or other organs.

Stages go from 0 to 4. The stage helps your care team decide if surgery is possible and which treatments to use first.

Your care team may use the words resectable (can be removed with surgery) or unresectable (cannot be safely removed).

Stage 0 and very early cancer

Abnormal cells or a very small cancer only in the inner lining. It can often be removed through an endoscope, without major surgery.

Stage 1

The cancer has grown a little deeper into the wall, but it has not spread far. Some people need only surgery. Others need more treatment.

Stages 2 and 3

The cancer has grown deeper into the wall or has reached nearby lymph nodes. Treatment usually combines chemotherapy, sometimes radiation, and surgery. Immunotherapy may be added.

Stage 4

The cancer has spread to distant places. These include the liver, lungs, far lymph nodes, or the lining of the belly. Treatment uses medicines that travel through the whole body. The goal is to control the cancer, ease symptoms, and help you live longer and better.

Positive washings

Sometimes cancer cells are found in fluid rinsed from the belly during laparoscopy. Then the cancer is treated as stage 4, even if scans look clear.

Tumor markers and gene tests

Biomarkers are features of the tumor that help choose treatment. Some open the door to targeted medicines or immunotherapy.

Everyone with advanced stomach or esophagus cancer should have biomarker testing. HER2 and CLDN18.2 are tested in adenocarcinoma, not squamous cell cancer.

Ask your care team which tests were done and what the results mean for you.

HER2

A protein that helps some cancer cells grow. When there is a lot of it (HER2-positive), medicines that target HER2 can be added to treatment.

PD-L1 (CPS score)

A protein that helps cancer hide from the immune system. It is often reported as a CPS number. A higher score means immunotherapy is more likely to help.

MSI-H or dMMR

A sign that the tumor cannot fix certain DNA mistakes. These tumors often respond very well to immunotherapy. It can also point to an inherited condition called Lynch syndrome.

CLDN18.2 (claudin 18.2)

A protein on the surface of many stomach cancer cells. If your HER2-negative tumor has a lot of it, a medicine called zolbetuximab can be added to chemotherapy.

Broad gene testing (NGS)

Next-generation sequencing looks at many genes at once. It can find rare changes, such as NTRK, BRAF, or RET, that have their own targeted medicines.

Inherited gene testing

A blood or saliva test for gene changes you were born with, such as CDH1. It may be offered if you are young or have family members with stomach or other cancers.

Main treatments

Endoscopic resection

Removing a very early cancer through an endoscope. No cuts are needed on the outside. It is only for cancers that have not grown deep.

Esophagectomy

Surgery to remove part of the esophagus and nearby lymph nodes. The stomach is then pulled up and connected to what is left. It is a major surgery done at experienced centers.

Gastrectomy

Surgery to remove part or all of the stomach, plus nearby lymph nodes. The surgeon connects the remaining stomach or the esophagus to the small intestine.

Chemotherapy before and after surgery

Called perioperative chemotherapy. A combination called FLOT is common for stomach, GEJ, and many esophageal adenocarcinomas. It shrinks the cancer and treats tiny spread that scans cannot see.

Chemoradiation

Chemotherapy and radiation given together. It is often used before surgery for squamous cell cancer of the esophagus. It may be used instead of surgery for some people, such as cancers high in the esophagus.

Immunotherapy

Medicines that help your immune system attack cancer. They may be given with chemotherapy around surgery, or after surgery if some cancer was left. They are also used with chemotherapy for advanced cancer.

HER2-targeted therapy

Medicines such as trastuzumab are added to chemotherapy for HER2-positive advanced adenocarcinoma. An antibody-drug conjugate called trastuzumab deruxtecan may be used later.

Zolbetuximab

A medicine that targets CLDN18.2. It is added to chemotherapy for some advanced HER2-negative stomach and GEJ cancers.

Later treatments

If cancer grows, ramucirumab (a medicine that blocks blood vessel growth) may be added to chemotherapy. Other chemotherapy, or targeted pills for rare gene changes, are also options.

Help with swallowing and eating

Stents (small tubes that hold the food pipe open), stretching, radiation, or feeding tubes can help. They help you eat and keep up your strength. Palliative care helps with symptoms at any stage.

Common side effects and what helps

Trouble swallowing

Can come from the tumor or from radiation. Choose soft, moist foods and take small bites. Tell your team if it gets worse. A dietitian or speech therapist can help.

Weight loss and low appetite

Very common. Eat small meals 5 to 6 times a day with extra protein and calories. Nutrition drinks help. Some people need a feeding tube for a while.

Nausea and vomiting

Anti-nausea medicines work well when taken as directed. Zolbetuximab can cause strong nausea, so you will get medicines before each dose. Call if you cannot keep fluids down.

Numbness, tingling, and cold sensitivity

Oxaliplatin, a common chemotherapy, can cause this in the hands, feet, and throat. Avoid cold drinks and cold air for a few days after each dose. Tell your team if it affects buttons, writing, or walking.

Diarrhea

Can happen with chemotherapy, targeted medicines, or immunotherapy. Drink plenty of fluids. Call if it is severe, has blood, or does not stop.

Low blood counts and infection

Chemotherapy lowers white blood cells for a time. Wash your hands often. Call right away for a fever.

Mouth sores

Rinse with a mild salt and baking soda mix. Use a soft toothbrush. Ask about medicines if eating hurts.

Immune side effects

Immunotherapy can cause swelling in healthy organs like the bowels, lungs, liver, skin, or hormone glands. Report new cough, diarrhea, rash, or feeling very tired. Early treatment helps.

Dumping syndrome after stomach surgery

Food moves too fast into the bowel. It can cause cramps, sweating, a fast heartbeat, or diarrhea after meals. Eat small meals, limit sweets, and drink liquids between meals instead of with them.

Low vitamin B12, iron, and calcium

After stomach surgery your body may absorb these less well. You may need B12 shots, iron, or other supplements for life. Your team will check your levels.

Living with and after stomach and esophagus cancer

Eating changes are common after surgery. Most people learn to eat smaller meals more often. A dietitian can help you find what works. Weight usually settles over time.

After esophagectomy, reflux can be a problem. Raise the head of your bed, and avoid lying down for a few hours after eating.

If most or all of your stomach was removed, you will likely need vitamin B12 shots and other supplements for life. Do not skip them.

You will have regular visits, blood tests, and scans or scopes for some years. Ask your team what your follow-up plan looks like.

Stopping smoking and limiting alcohol helps your healing and your overall health. Ask for help with quitting.

If you have H. pylori or an inherited gene change, ask whether family members should be tested. It is normal to feel worried or down. Support groups, counselors, and social workers can help you and your family.