Gastroenterology and Hepatology

Current Diagnostic and Treatment Algorithm for Gastric Cancer  

According to information from Robert Koch Institute, about 15,000 patients were diagnosed with gastric cancer in 2014 in Germany alone (1).  The prognosis of gastric cancer is generally poor with an estimated relative 5 years survival rate of 30 % for males and 33% for females (1). According to statistics from 2013, the lethality is reduced one third in comparison to what we used to see 40 years ago (2). This improvement is due to advancements in the prevention, diagnosis and treatment of gastric cancer. Extensive research work is underway to develop better treatment modalities. 

In Gastric cancer care, doctors from different specialty areas often work together to create a patient’s overall treatment plan that combines different types of treatment.The personalized care plan is the cornerstone of the successful treatment of cancers in Germany.  Each patient receives an individualised treatment plan depending on their tumour type and its stage of progression. In this procedure, the identification of tumour histology and staging of the tumour is of fundamental importance for the successful planning of treatment options.  This is a key factor in German Health Advisors’ daily work.  

For each patient with a tumour, we attempt to initially fulfil these two aspects in collaboration with our patients and local colleagues.  We then discuss the case with the specialists, or, at the multidisciplinary tumour boards at our partner clinics in Germany.  If any problems present themselves, we communicate this to our patients and try to move forward to their solutions. This is most common when we get incorrect or incomplete pathology or radiology reports (discussed in details below). 

Initial Staging and Risk Assessment 

Gastric cancer is treated based on the stage of cancer. Staging identifies the severity of the cancer (Stages I-IV). The various stages of a gastric cancer are determined by the depth of invasion through the wall of the stomach; the involvement of the lymph nodes and the spread to other organs (metastases). 

The staging for overseas patients is usually not complete when they contact us for a second opinion and any subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patient is in his homeland. It is not necessary to come to Germany for cancer staging. You will be informed if there are any obstacles in the staging process. For the staging of breast cancer, please bear in mind the following: 

  • Family history, physical examination, blood count and differential, liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter. 
  • Endoscopy of Stomach. Your stomach has probably already been examined with Endoscope by your endoscopist.  Currently, all endoscopic equipment have video recording option. If your endoscopist took a video from the endoscopic procedure, please send it to us. You can send your video data using German Health Advisors’ secure data transfer system.
  • Pathology of Gastric Cancer.  Gastric cancer is usually diagnosed by gastroscopy and your local doctor has already took biopsy and sent it to the pathologist. Please, keep this report to send it to us later on. . In some cases, when our specialists are not satisfied with the quality of a pathology report, we will contact you with a recommendation for further steps. You may have to send us the frozen/paraffin embedded tissue samples for further histology investigation at one of German Health Advisors’ partner laboratories in Germany.    
  • Contrast-enhanced computed tomography (CT) scan of the thorax, abdomen and pelvis. You can send the DICOM files of CTscans using German Health Advisors’ secure data transfer system. Our experience shows that the quality of radiology images might not be good enough to correctly stage the cancer. In such cases, we will contact you in order to work towards a solution. It is of great importance for us to have high quality radiology images from our local colleagues. This greatly assists in defining the diagnostic and treatment plan in timely fashion and helps to avoid unnecessary expenses.   
  • Staging laparoscopy. This procedure can help to diagnose and stage intra-abdominal disease; serving as a complement to other imaging studies; allowing to do biopsies; facilitate intraoperative ultrasound evaluations; allowing sampling of peritoneal fluid for cytological examination.  If you would like to come to Germany, we would advise you to do this staging Laparoscopy here, otherwise, please send us the video data of the procedure along with diagnostic report of the histopathology or/and cytology. 
  • Endoscopic ultrasound (EUS) is helpful in determining the proximal and distal extent of the tumor and provides further assessment of the T and N stage; however, it is less useful in antral tumors. EUS is more consistently accurate than CT for the diagnosis of malignant lymph nodes: patterns associated with malignancy on EUS include hypoechogenicity, round shape, smooth, distinct margin and size >1 cm (3).
  • Positron emission tomography (PET)-CT technology represents an efficient tool for use in gastric cancer patients, since it is useful to integrate other imaging modalities in staging tumors. Moreover, it can be effective in monitoring tumor response to treatments and may have prognostic value with the potential to change therapeutic strategies.  

Treatment of Gastric Cancer 

In our partner clinics in Germany, usually, a multidisciplinary team of gastroenterologists, surgeons, oncologists, radiologists, and pathologists discuss each case to define the best treatment strategy for the patients.Below we list the main current treatment options: 

  • Perioperative chemotherapy.The recent studies demonstrated significant improvement in 5-year survival for patients with resectable Stage II and III gastric cancers treated with pre- and postoperative Chemotherapy compared to patients treated with surgery alone (4,5,6,7). Perioperative chemotherapy has therefore been widely adopted as a standard of care throughout  Europe and Germany. Various effective chemotherapy regimens have been developed for gastric cancer patients. A recent multicenter, randomized (FLOT4) study by Prof. Al-Batran et al (4) showed that Docetaxel, oxaliplatin, and fluorouracil/leucovorin (FLOT) versus epirubicin, cisplatin, and fluorouracil or capecitabine (ECF/ECX) as perioperative treatment of operable (completely removable tumor) gastric or gastro-esophageal junction cancer improve survival.  This therapy approach is now being widely applied in German clinics.  You will be thoroughly explained by our doctors why you should get a curtain chemotherapy regime. 
  • The surgical treatment. Surgical resection with adequate lymphadenectomy remains the only potentially curative treatment of gastric cancer. The extent of resection is usually determined based on staging data and intraoperative findings. Recently, laparoscopic gastrectomy is increasingly applied for gastric cancer.  
  • Targeted therapy. Although chemotherapy has improved survival in patients with advanced gastric cancer, the prognosis of these patients remains poor. In recent years, some therapies targeting biological molecules have been reported to prolong the survival of patients with advanced gastric cancer. Trastuzumab (Herceptin) is one of these drugs which targets the HER2 protein.    
  • Hyperthermic intraperitoneal chemotherapy (HIPEC). Several recent studies have demonstrated a significant survival benefit for HIPEC in high-risk curatively resected gastric cancer patients. Furthermore, for the patients with advanced peritoneal metastases, the use of multivisceralresections (gastrectomy with resection of adjacent organs) plus HIPEC in selected patients can improve survival.   The increased operative risk of multivisceralresections must be weighed against the evidence that only selected patients may benefit from the radical operation. If you consider this therapy, German Health Advisor will help you to get the Second Opinion from certified HIPEC Centers in Germany

Follow-Up After Treatment Gastric Cancer 

Follow-up should be tailored to the individual patient and the stage of the disease. The German Health Advisors’ partner clinics will normally schedule follow-ups in this manner: 

  • 3 months after the initial treatment: physical examination, blood count and differential, liver and renal function tests, vitamin B12 levels, ultrasonography or contrast-enhanced computed tomography (CT) scan of the thorax, abdomen and pelvis. 
  • Every 3-6 months for the first 2 years: physical examination, blood count and differential, liver and renal function tests, vitamin B12 levels, ultrasonography or contrast-enhanced computed tomography (CT) scan of the thorax, abdomen and pelvis. 
  • Every 6-12 months for the next 3 years: physical examination, blood count and differential, liver and renal function tests, vitamin B12 levels, ultrasonography or contrast-enhanced computed tomography (CT) scan of the thorax, abdomen and pelvis. 
  • After 5 years annual control: physical examination, blood count and differential, liver and renal function tests, vitamin B12 levels, ultrasonography or contrast-enhanced computed tomography (CT) scan of the thorax, abdomen and pelvis.

The patients, who got their treatments in Germany, usually do not need to come for the follow-up controls to Germany. German Health Advisors will provide you with follow-up care through its Telemedicine platform.

Keywords: cytoreductive surgery, HIPEC, gastric cancer, targeted therapy, HER2

1. Magenkrebs (Magenkarzinom),  https://www.krebsdaten.de

2. August 2017: Das Risiko für Magenkrebs sinkt - nicht nur in Deutschland, https://www.krebsdaten.de

3. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology 27 (Supplement 5): v38–v49, 2016 

4. Al-Batran SE, Homann N, Schmalemberg H et al.: Perioperative chemotherapy with docetaxel, oxaliplatin, and fluorouracil/leucovorin (FLOT) versus epirubicin, cisplatin, and fluorouracil or capecitabine (ECF/ECX) for resectable gastric or gastroesophageal junction (GEJ) adenocarcinoma (FLOT4-AIO): a multicenter, randomized phase 3 trial. J Clin Oncol. 2017;35(suppl; abstr 4004)

5. Cunningham D, Allum WH, Stenning SP et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 11–20.

6.  Ychou M, Boige V, Pignon JP et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011; 29: 1715–1721.

7.  Schuhmacher C, Gretschel S, Lordick F et al. Neoadjuvant chemotherapy compared with surgery alone for locally advanced cancer of the stomach and cardia: European Organisation for Research and Treatment of Cancer randomized trial 40954. J Clin Oncol 2010; 28: 5210–5218.