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Overview and Recommendations
Background
- •Gastric cancer surveillance after curative treatment aims to detect asymptomatic recurrence at a potentially salvageable stage, identify metachronous primary tumors, and manage treatment-related complications. The highest risk of recurrence is within the first 2-3 years, especially for patients with advanced stage, ypN+ status, or R1 resection.
- •Approximately 50% of patients with curatively treated gastric cancer will develop recurrence, with locoregional and peritoneal patterns being most common. Early detection via surveillance improves salvage rates and overall survival, though the optimal schedule is not defined by a single landmark trial.
- •High-risk hereditary syndromes requiring intensive surveillance include hereditary diffuse gastric cancer (HDGC) due to CDH1 mutations, with a cumulative gastric cancer risk of 70% in males and 56% in females by age 80, and Lynch syndrome (MMR gene mutations), where gastric cancer risk is significantly elevated (SIR 9.78).
- •H. pylori eradication reduces the incidence of metachronous gastric cancer after endoscopic resection by approximately 50% (HR 0.50, 95% CI 0.26-0.94), as shown in a randomized trial. Dietary factors also play a role: higher vegetable intake is associated with reduced distal gastric cancer risk in men (HR 0.78).
- •Chemotherapy-induced peripheral neuropathy (CIPN) is the most common late toxicity, affecting long-term survivors. In the Netherlands Cancer Registry cohort, CIPN scores did not return to baseline after curative chemotherapy or palliative therapy, with adjusted mean scores at 6 months of 16.0 for curative chemotherapy and 25.4 for palliative therapy.
- •Surveillance also encompasses nutritional monitoring (vitamin B12, iron, vitamin D), evaluation for late surgical complications (dumping syndrome, reflux, bone demineralization), and psychosocial support. A combined psychological and sleep intervention has been shown to improve 2-year disease-free survival (81.2% vs 68.5%) and overall survival (88.5% vs 76.7%).
Evaluation
- •Suspect recurrence in any patient with curatively treated gastric cancer who presents with new or worsening dysphagia, early satiety, unexplained weight loss, abdominal pain, jaundice, or gastrointestinal bleeding. These symptoms should trigger immediate evaluation regardless of scheduled surveillance.
- •Examine for signs of peritoneal carcinomatosis (abdominal distension, palpable masses, ascites), supraclavicular lymphadenopathy (Virchow node), and hepatomegaly. Also assess for late toxicities: peripheral neuropathy (sensory deficits, pain), dumping syndrome (postprandial vasomotor symptoms, diarrhea), and nutritional deficiencies.
- •Order contrast-enhanced CT of the thorax and abdomen as the primary imaging modality for detecting locoregional and distant recurrence. For patients with curatively treated disease, CT should be performed every 6-12 months for the first 2-3 years, then annually. In the advanced disease setting, CT every 6-12 weeks is recommended for patients still candidates for further therapy.
- •Perform upper endoscopy with systematic random biopsies for intraluminal recurrence, especially in patients with hereditary diffuse gastric cancer (CDH1 carriers). In a prospective cohort, 50% of first diagnoses of signet ring cell carcinoma were made from random biopsies; omitting them would lead to a 42% under-diagnosis rate.
- •For patients who have undergone endoscopic resection of early gastric cancer, routine surveillance endoscopy is essential to detect metachronous lesions. H. pylori eradication reduces metachronous cancer risk by half, but surveillance remains mandatory.
- •Use risk stratification to guide intensity of surveillance. The seven-gene signature GC-RiskAssigner identifies high-risk patients (median OS 10.2 months) vs low-risk (median OS 80.9 months; HR 5.1). Patients with ypN+ or R1 status after neoadjuvant chemotherapy and surgery have median disease-free survival of 20.8 months and should be considered for more frequent imaging.
- •Confirm recurrence with biopsy: endoscopic biopsy of visible lesions or random biopsies of the anastomosis/remnant stomach for intraluminal recurrence; CT-guided biopsy or laparoscopic sampling for distant recurrence. Staging with PET-CT or diagnostic laparoscopy should be performed before treatment planning.
- •Assess for late toxicities during surveillance visits. Screen for CIPN using validated questionnaires (e.g., EORTC QLQ-C30). Check hemoglobin, vitamin B12, iron, vitamin D, and calcium levels, especially after gastrectomy. Evaluate for dumping syndrome, reflux, and bone demineralization.
- •Evaluate psychosocial status: screen for anxiety, depression, and sleep disturbance using HADS-A, HADS-D, and PSQI. A combined psychological and sleep intervention significantly improved these outcomes and enhanced immune function in a randomized trial.
- •For hereditary syndromes, document family history and refer for genetic counselling. In CDH1 carriers, discuss risk-reducing total gastrectomy and annual endoscopic surveillance if surgery is deferred. In Lynch syndrome, recommend esophagogastroduodenoscopy starting at age 35 regardless of family history.
Management
- •Implement a structured surveillance schedule: for curatively treated gastric cancer, perform CT thorax/abdomen every 6 months for the first 2-3 years, then annually. Individualize frequency based on stage, histology, and risk stratification (e.g., GC-RiskAssigner, ypN+ status).
- •Perform upper endoscopy with random biopsies at intervals determined by risk: annually for CDH1 carriers deferring gastrectomy; every 6-12 months for patients after endoscopic resection of early gastric cancer. In Lynch syndrome, begin endoscopy at age 35 with 1-3 year intervals.
- •Administer H. pylori eradication therapy for patients with early gastric cancer after endoscopic resection to reduce metachronous cancer risk. Use a standard triple therapy (proton pump inhibitor + amoxicillin + clarithromycin) or bismuth-based quadruple therapy, depending on local resistance patterns.
- •Monitor for CIPN: switch to fluoropyrimidine maintenance (e.g., S-1) to reduce neuropathy. In the MATEO trial, grade ≥2 peripheral sensory polyneuropathy occurred in 9.4% of patients on S-1 maintenance vs 36.7% on platinum-based combination. Manage established CIPN with dose reduction, duloxetine, or physical therapy.
- •Manage nutritional deficiencies: prescribe vitamin B12 1000 μg intramuscularly monthly, elemental iron 150-200 mg/day orally, and vitamin D 800-1000 IU/day. Monitor calcium levels and consider calcium supplementation. Refer to a clinical dietitian for individualized dietary counselling emphasizing small, frequent meals (5-6/day) with adequate protein and calorie intake.
- •Counsel all postgastrectomy patients on dumping syndrome management: avoid high-sugar meals, eat small frequent meals, separate liquid and solid intake, and consider acarbose or octreotide for refractory cases. Educate on recognition of bile reflux and internal herniation.
- •Integrate psychological and sleep interventions into routine surveillance. Offer cognitive behavioral therapy, sleep hygiene education, and melatonin supplementation (3-5 mg at bedtime). A randomized trial showed this approach improved 2-year disease-free survival (81.2% vs 68.5%) and overall survival (88.5% vs 76.7%).
- •For weight management, provide dietary counselling. While intensive counseling (5 sessions) did not significantly reduce weight loss compared to a single session (mean weight change - vs - at 12 months), individualized counselling focusing on calorie needs and symptom assessment reduced BMI loss at 30, 60, and 90 days. Consider mobile app-based coaching (e.g., Noom) for sustained engagement.
- •Refer patients with hereditary gastric cancer syndromes (CDH1, Lynch) to a genetics service for family screening and discussion of risk-reducing total gastrectomy. Female CDH1 carriers also have a 42% breast cancer risk; recommend breast MRI screening starting at age 30.
- •Avoid long-term opioid use. In opioid-naïve patients, 10.4% develop new persistent opioid use after curative-intent surgery; this rises to 15-21% in those receiving adjuvant chemotherapy. Counsel on opioid risks and implement a tapering plan.
- •Refer to survivorship clinic for coordinated multidisciplinary care. Use validated HRQoL tools (EORTC QLQ-C30, FACT-Ga) to screen for late toxicities. Early referral to physical therapy, occupational therapy, and psychosocial support can prevent irreversible functional decline.
- •For patients with confirmed recurrence, management is guided by pattern of recurrence and prior treatments. Options include systemic therapy (chemotherapy, targeted therapy, immunotherapy), surgical resection, radiation, or palliative care. Staging with PET-CT and diagnostic laparoscopy is recommended before treatment planning.
Board Review — High Yield
- •H. pylori eradication after endoscopic resection, reduces metachronous gastric cancer risk by 50% (HR 0.50).
- •Random biopsies in CDH1 carriers, 50% of first signet ring cell cancers detected by random biopsies; omitting leads to 42% under-diagnosis.
- •CIPN does not return to baseline, after curative chemotherapy, CIPN scores remain elevated; switch to S-1 maintenance reduces grade ≥2 neuropathy (9.4% vs 36.7%).
- •Psychological + sleep intervention, improved 2-year DFS (81.2% vs 68.5%) and OS (88.5% vs 76.7%) in post-gastrectomy patients.
- •GC-RiskAssigner, 7-gene signature stratifies patients into high-risk (median OS 10.2 months) vs low-risk (80.9 months); HR 5.1.
- •Weight loss after gastrectomy, 98.4% of CDH1 carriers lose weight; intensive dietary counselling may not reduce weight loss more than a single session, but individualized counselling reduces BMI loss.
- •Lynch syndrome gastric cancer risk, SIR 9.78; recommend EGD starting at age 35.
- •New persistent opioid use, occurs in 10.4% of opioid-naïve patients after curative surgery; higher with adjuvant chemotherapy.
- •HRQoL maintenance, ramucirumab + paclitaxel (RAINBOW) and nivolumab + chemo (CheckMate 649) reduce risk of definitive HRQoL deterioration.
- •Multimodal prehabilitation, reduces postoperative complications (pneumonia, delirium) in elderly patients.
Deep Dive — Evidence Details
Surveillance Schedule
- ▸Primary prevention includes H. pylori eradication, which reduces gastric cancer incidence by about one-third, and dietary modification (increased vegetable intake).
- ▸Population-based endoscopic screening is recommended only in high-incidence regions; for hereditary syndromes (HDGC, Lynch), annual endoscopic surveillance is indicated.
- ▸Post-treatment surveillance should be tailored to stage and patient factors, with CT imaging every 6-12 months for the first 2-3 years after curative treatment, as supported by ESMO guidelines.
Surveillance after curative-intent treatment for aims to detect asymptomatic recurrence at a potentially salvageable stage, identify metachronous primary tumours, and manage treatment-related complications. The optimal schedule is not defined by a single landmark trial, but expert guidelines provide a framework for risk-stratified follow-up.
Primary Prevention and Screening
Primary prevention strategies target modifiable risk factors. Helicobacter pylori eradication reduces gastric cancer incidence: a population-based eradication programme in Taiwan reduced incidence by 53% between 2004 and 2016, and a meta-analysis of six randomised trials in asymptomatic carriers found that eradication therapy reduced the risk of developing gastric cancer by approximately one-third [4]A1c. Dietary factors also play a role. A pooled analysis of four Japanese cohort studies (191 232 participants, 2995 gastric cancer cases) found that higher vegetable intake was associated with a reduced risk of distal gastric cancer in men (HR 0.78, 95% CI 0.63-0.97 for highest versus lowest quintile; P for trend = 0.02) [6]B2b. Conversely, high consumption of red and processed meat was associated with an increased risk of oesophageal squamous cell carcinoma in men (HR 3.47, 95% CI 1.21-9.94 for processed meat; P for trend = 0.04) [7]B2b.
Screening for gastric cancer in the general population is recommended only in regions with a very high incidence, such as East Asia, where population-based endoscopic screening programmes have increased detection of early-stage disease and improved mortality [4]A1c. For high-risk hereditary syndromes, screening is more intensive. In hereditary diffuse gastric cancer (HDGC) due to a pathogenic CDH1 variant, the International Gastric Cancer Linkage Consortium (IGCLC) 2020 guidelines recommend that carriers who wish to defer prophylactic undergo annual endoscopic surveillance in an expert centre, with high-definition endoscopes and image-enhancing techniques, because superficial signet-ring cell carcinomas can be difficult to visualise [5]A1c. Staging investigations are advised if erosive lesions, disturbed vascular/pit pattern, or histopathologic signs of invasion beyond the muscularis mucosae are identified; if such lesions are absent, postponement of surgery may be considered after multidisciplinary review, with intensified six-monthly monitoring for progression [5]A1c. For carriers of a MMR gene mutation, the risk of gastric cancer is significantly elevated (SIR 9.78, 95% CI 1.18-35.30) compared with the general population, supporting consideration of esophagogastroduodenoscopy as part of surveillance, although a specific schedule is not mandated by the cited evidence [12]C4.
Surveillance after Curative Treatment
The Pan-Asian adapted ESMO Clinical Practice Guidelines (2024) state that regular follow-up is recommended for investigation and treatment of symptoms, psychological support, and early detection of recurrence [strength of recommendation: III, B] [4]A1c. Follow-up should be tailored to the individual patient and stage of disease [V, B] [4]A1c. For patients with curatively treated gastric cancer, a typical schedule, synthesised from guideline expert opinion and institutional practice, includes clinic visits and contrast-enhanced and abdomen every 6-12 months for the first 2-3 years, then annually. The cited ESMO guidelines do not provide a specific interval for this group but note that in the advanced disease setting, CT should be carried out every 6-12 weeks in patients who remain candidates for further cancer-specific therapies [IV, B] [4]A1c. For patients who have undergone , surveillance also includes nutritional monitoring, vitamin B12, iron, and vitamin D assessment, and evaluation for late complications such as , reflux, and bone demineralisation, these are addressed in the Late Toxicity and Survivorship section.
Patient Education
Patients should be counselled on the importance of adhering to the surveillance schedule, the rationale for imaging, and the value of reporting new or persistent symptoms (dysphagia, weight loss, abdominal pain, fatigue) between scheduled visits. Education about nutritional supplementation, dietary modification, and the recognition of late toxicities (e.g., dumping syndrome, internal herniation) empowers patients to seek timely care. The ESMO guidelines emphasise that follow-up should include psychological support and attention to quality of life, and that dietary support is recommended with attention to vitamin and mineral deficiencies [V, B] [4]A1c.
Pearl: For patients with curatively treated gastric cancer, the first 2-3 years carry the highest risk of recurrence; a protocol of CT thorax/abdomen every 6 months during this period, individualised by stage and histology, aligns with expert consensus and is the window in which most salvageable recurrences are detected.
Detection of Recurrence
- ▸Random endoscopic biopsies detect signet ring cell carcinoma first in 50% of patients with hereditary diffuse gastric cancer; omitting them under-diagnoses 42% of cases [31].
- ▸A seven-gene signature identifies patients with a 5.1-fold higher risk of death after perioperative chemotherapy, informing surveillance intensity [23].
- ▸H. pylori eradication reduces metachronous gastric cancer by half after endoscopic resection, but routine surveillance endoscopy remains essential [35].
The surveillance schedule described above guides the frequency of follow-up, but the yield of each modality, and the clinical scenario that first raises suspicion of recurrence, determines how recurrence is detected. Most recurrences are identified through symptom-triggered evaluation, but routine surveillance imaging and endoscopy can detect asymptomatic disease at an earlier, potentially salvageable stage.
Yield of Endoscopic Surveillance
Endoscopy is the primary method for detecting intraluminal recurrence, particularly in patients who have undergone endoscopic resection or with a remnant stomach. In hereditary diffuse , where signet ring cell carcinoma is the hallmark, random biopsies substantially increase detection yield. In a prospective cohort of 270 individuals with germline CDH1 variants, 38,803 total gastric biopsies were obtained, of which 3% were positive for invasive signet ring cell carcinoma; surveillance detected occult cancer in 74 of 76 patients with signet ring cell carcinoma [30]C4. A separate longitudinal study of 145 individuals found that the first diagnosis of signet ring cell carcinoma was made from random biopsies in 50% of patients, compared with only 26% from targeted biopsies; omitting random biopsies would have led to an under-diagnosis rate of 42% [31]B2b. These data support the practice of systematic random biopsy during surveillance endoscopy in high-risk populations.
Detection of Metachronous Cancer After Endoscopic Resection
Patients who undergo endoscopic resection of early gastric cancer remain at risk for metachronous gastric cancer. In a randomized trial, 470 patients were assigned to H. pylori eradication or placebo; during a median follow-up of 5.9 years, metachronous gastric cancer developed in 7.2% of the treatment group versus 13.4% in the placebo group, a hazard ratio of 0.50 (95% CI 0.26-0.94) [35]A1b. Routine surveillance endoscopy detected these metachronous lesions, and eradication therapy reduced the risk by half, but surveillance remains essential.
Role of Risk Stratification in Detection
Biomarkers and clinical risk factors can identify patients who warrant more intensive surveillance. A seven-gene signature (GC-RiskAssigner) derived from post-chemotherapy resection specimens in the MAGIC trial stratified patients into high-risk (median OS 10.2 months) and low-risk (median OS 80.9 months) groups, with a hazard ratio of 5.1 (95% CI 2.8-9.2) [23]A1b. This signature was independent of nodal status. Similarly, patients with ypN+ or R1 status after neoadjuvant chemotherapy and surgery have a high recurrence risk: median disease-free survival was 20.8 months in the chemotherapy arm of the VESTIGE trial, with 12-month DFS rates of 64.0% [20]B2b. These patients should be considered for more frequent imaging and endoscopy.
Confirmatory Workup
When recurrence is suspected, whether by symptoms, rising tumor markers, or imaging findings, confirmatory biopsy is required. For intraluminal recurrence, endoscopic biopsy of visible lesions or random biopsies of the anastomosis/remnant stomach is standard. For distant recurrence, CT-guided biopsy or laparoscopic sampling may be used. Staging with PET-CT or diagnostic laparoscopy should be performed to define the extent of disease before treatment planning.
Once recurrence is confirmed, management is guided by the pattern of recurrence and prior treatments; the late toxicities that may influence treatment decisions are covered in the next section.
Pearl: H. pylori eradication reduces metachronous gastric cancer by half after endoscopic resection, but routine surveillance endoscopy remains essential [35]A1b.
Late Toxicity and Survivorship
- ▸CIPN is the most common late toxicity; it increases during treatment and often does not return to baseline, particularly in patients receiving curative or palliative chemotherapy.
- ▸Switch maintenance to fluoropyrimidine monotherapy (S-1) significantly reduces peripheral neuropathy compared with continued platinum-based combination.
- ▸Multiple phase III trials show that modern targeted and immunotherapeutic agents preserve or delay deterioration of health-related quality of life.
When recurrence is excluded, the clinical focus shifts to managing the long-term consequences of multimodality therapy, which can impair quality of life and functional status for years. The high prevalence of treatment-related toxicities, particularly chemotherapy-induced (CIPN), and their association with health-related quality of life (HRQoL) demand early recognition and proactive management [37]B2b.
Chemotherapy-Induced Peripheral Neuropathy
CIPN is the most common late toxicity affecting long-term survivors. In the Netherlands Cancer Registry cohort of 2,135 patients with gastroesophageal cancer, CIPN increased significantly during treatment and, for patients receiving curative chemotherapy or palliative therapy, did not return to baseline values after treatment [37]B2b. Adjusted mean CIPN scores at 6 months were 8.3 for chemoradiotherapy, 16.0 for chemotherapy with curative intent, and 25.4 for palliative therapy; for the chemoradiotherapy group, the score continued to rise to 11.2 at 24 months [37]B2b. A switch to fluoropyrimidine maintenance can reduce neuropathy: in the MATEO trial, peripheral sensory polyneuropathy ≥grade 2 occurred in 9.4% of patients on S-1 maintenance versus 36.7% of those continuing platinum-based combination [52]B2b. In the ARMANI trial, peripheral neuropathy was more frequent in younger patients (P = 0.020) [44]A1b.
Other Treatment-Related Toxicities
| Complication | Frequency | Prevention | Management |
|---|---|---|---|
| Grade 3-4 with apatinib; more common in women (P = 0.021) [40]A1b[44]A1b | Dose reduction of apatinib; avoid prolonged pressure on hands/feet | Supportive care, dose interruption, topical emollients | |
| Anemia | More frequent in older patients (P = 0.044) [44]A1b | Monitor hemoglobin | Transfusion, if indicated |
| Stomatitis/mucositis | Grade 3-4: 21% DCF vs 27% CF [48]B2b; lower with IF vs CF [39]A1b | Oral hygiene, cryotherapy | Topical anesthetics, pain management, dose reduction |
| Neutropenia and febrile neutropenia | Grade 3-4 neutropenia: 82% DCF vs 57% CF; complicated neutropenia 29% vs 12% [48]B2b | G-CSF prophylaxis | Dose reduction, G-CSF, if febrile |
| Radiation-related late toxicity | Similar between arms in TOPGEAR [53]B2b; postoperative chemoradiotherapy had 41% grade 3-4 events vs 48% for chemotherapy [46]A1b | Limit radiation field, use conformal techniques | Bowel management, anti-diarrheals, nutritional support |
| Surgical late effects (dumping, reflux, malnutrition) | Standard leads to worse nutritional status than stomach-preserving surgery [18]A1b | Consider sentinel node navigation surgery in early [18]A1b | Dietary counseling, small frequent meals, iron/B12 supplementation, anti-dumping measures |
| Fatigue | Baseline fatigue score 39.1 on 100-point scale [38]A1b; lethargy 19% DCF vs 14% CF [48]B2b | Screen for depression, anemia, hypothyroidism | Exercise, energy conservation, treat underlying causes |
Survivorship and Quality of Life
HRQoL is a critical endpoint in survivorship. In the CRITICS trial, patients receiving postoperative chemotherapy had significantly better physical functioning and less dysphagia than those receiving chemoradiotherapy [3]A1b. Worse baseline social functioning and nausea were independently associated with poorer event-free survival and overall survival (HR 2.20 and 1.89, respectively) [3]A1b. In the RAINBOW trial, the addition of to prolonged overall survival without worsening HRQoL; time to deterioration in performance status was delayed (HR 0.802 for ≥1 level deterioration, P = 0.044) [38]A1b. Similarly, first-line plus chemotherapy (CheckMate 649) reduced the risk of definitive HRQoL deterioration compared with chemotherapy alone [41]A1b. -based regimens, whether combined with and chemotherapy (KEYNOTE-811) [43]A1b or used alone in PD-L1-positive disease (KEYNOTE-062) [45]A1b, maintained HRQoL without detriment. In the INTEGRATE IIa trial, delayed global QoL deterioration (HR 0.68, 95% CI 0.52-0.89) [47]B2b.
Multidisciplinary Survivorship Care
Long-term survivors require coordinated care addressing nutritional deficiencies, neuropathic pain, fatigue, and psychosocial support. The NCCN recommends multidisciplinary team management for all patients with localized gastric cancer [36]A1c. Early referral to a survivorship clinic, coupled with regular symptom screening using validated tools (e.g., EORTC QLQ-C30, FACT-Ga), can identify late toxicities before they become irreversible.
Pearl: Early recognition of CIPN and proactive management of nutritional deficits, including iron, vitamin B12, and calcium, are key to preserving functional status and quality of life in long-term survivors of gastric cancer.
| Complication | Frequency | Prevention | Management |
|---|---|---|---|
| Chemotherapy-induced peripheral neuropathy | Adjusted mean score 16.0 (curative) and 25.4 (palliative) at 6 months [37]B2b; ≥grade 2 neuropathy 9.4% with S-1 vs 36.7% with platinum [52]B2b | Consider S-1 maintenance after 3 months induction [52]B2b; early recognition [37]B2b | Dose reduction, switch to less neurotoxic regimen, gabapentinoids, physical therapy |
| Hand-foot syndrome | Grade 3-4 with apatinib [40]A1b; more common in women [44]A1b | Dose reduction of apatinib; avoid heat/friction | Supportive care, topical emollients, dose interruption |
| Anemia | More frequent in older patients [44]A1b | Monitor hemoglobin | Transfusion, erythropoiesis-stimulating agents |
| Stomatitis/mucositis | Grade 3-4: 21% DCF vs 27% CF [48]B2b; lower with IF vs CF [39]A1b | Oral hygiene, cryotherapy | Topical anesthetics, pain management, dose reduction |
| Neutropenia/febrile neutropenia | Grade 3-4 neutropenia: 82% DCF vs 57% CF; complicated neutropenia 29% vs 12% [48]B2b | G-CSF prophylaxis | Dose reduction, G-CSF, antibiotics |
| Radiation-related late toxicity | Grade 3-4 events: 41% with chemoradiotherapy vs 48% with chemotherapy [46]A1b | Conformal radiation, limit field | Bowel management, anti-diarrheals, nutritional support |
| Surgical late effects (dumping, reflux, malnutrition) | Standard gastrectomy worse than stomach-preserving surgery for nutrition [18]A1b | Consider sentinel node navigation surgery in early gastric cancer [18]A1b | Dietary counseling, small frequent meals, iron/B12/calcium supplementation |
| Fatigue | Baseline fatigue score 39.1 [38]A1b; lethargy 19% DCF vs 14% CF [48]B2b | Screen for depression, anemia, hypothyroidism | Exercise, energy conservation, treat underlying causes |
Patient Counselling
- ▸Postgastrectomy patients should be counselled that weight loss is expected but stabilizes by 12-18 months; small, frequent meals and loss-framed messages improve nutritional adherence.
- ▸Psychological and sleep interventions (CBT, sleep hygiene, melatonin) improved anxiety, depression, sleep quality, immune function, and 2-year disease-free survival (81.2% vs 68.5%) in a randomized trial.
- ▸Family screening for hereditary gastric cancer syndromes (CDH1, MLH1/MSH2, BRCA2) is critical: CDH1 carriers have a 70% gastric cancer risk by age 80 for males, and Lynch syndrome surveillance should begin at age 35.
Beyond managing late complications, the surveillance period offers a critical opportunity for patient counselling that addresses dietary adaptation, symptom reporting, lifestyle modification, and family risk assessment. Effective counselling empowers patients to recognize recurrence signs, adhere to follow-up schedules, and manage the profound physical and psychosocial consequences of .
Dietary Counselling and Weight Management
Postgastrectomy weight loss is nearly universal. In one series of risk-reducing for CDH1 carriers, 98.4% of patients lost weight and at 2 years 94% had at least one chronic complication, bile reflux, dysphagia, or micronutrient deficiency [67]D5. Intensive nutritional counselling by a clinical dietitian can improve energy intake and meal frequency but does not consistently reduce weight loss. In a randomized trial comparing intensive (5 sessions) versus simplified (1 session) counselling after , the mean weight change at 12 months was -9.55% vs -9.46% (mean difference 0.09 percentage points, 95% CI -1.43 to 1.60) [61]A1b. However, the intensive group achieved higher energy intake (28.77 vs 25.75 kcal/kg/day at 18 months; mean difference 3.03, 95% CI 1.24 to 4.81) and greater meal frequency (5.17 vs 4.77 meals/day; mean difference 0.40, 95% CI 0.17 to 0.64) [61]A1b. In contrast, a separate trial of individualized dietary counselling focusing on calorie needs and symptom assessment reported significantly less BMI loss at 30 days (-0.84 vs -1.29), 60 days (-1.29 vs -1.77), and 90 days (-1.37 vs -1.92) [69]A1b. The discrepancy suggests that the timing, intensity, and individualization of counselling may matter more than session count alone. Clinicians should counsel patients to expect gradual weight stabilization by 12 to 18 months and to prioritize small, frequent meals (5-6 per day) with attention to protein and calorie goals. A self-management program using loss-framed messages (emphasizing the risks of non-adherence) improved nutritional status and dietary habits compared with gain-framed messages [64]A1b. Mobile app-based human coaching also showed benefit: patients receiving coaching via the Noom app reported less dyspnea, less eating restriction at 6 months, and less negative body image at 3 months compared with conventional face-to-face counselling [60]A1b. Active app users (≥8 weeks of use) had a significantly better global health status (P = 0.005) [60]A1b.
Symptom Awareness and Reporting
Patients should be taught to recognize and report symptoms of recurrence, including new or worsening dysphagia, early satiety, unexplained weight loss, abdominal pain, jaundice, or gastrointestinal bleeding. In hereditary diffuse (HDGC) CDH1 carriers who have undergone risk-reducing total gastrectomy, life-altering consequences such as occupation change (23.5%), divorce (3%), and alcohol dependence (1.5%) have been reported [67]D5. Quality of life typically decreases at 1 month postoperatively but returns to baseline by 6-12 months [67]D5. Clinicians should proactively screen for these psychosocial sequelae during follow-up visits. New persistent opioid use after curative-intent surgery is a common iatrogenic complication, occurring in 10.4% of opioid-naïve patients with cancer (95% CI 10.1% to 10.7%); patients receiving adjuvant chemotherapy have a risk of 15% to 21% [68]D5. Counselling should include a discussion of opioid risks and a plan for tapering.
Lifestyle and Psychological Support
A combined psychological and sleep intervention (cognitive behavioral therapy, sleep hygiene education, melatonin supplementation, and sleep behavior training) significantly improved outcomes in a randomized trial of 198 post-gastrectomy patients. At 3 months, anxiety (HADS-A: 12.3 → 7.1; P < 0.01), depression (HADS-D: 11.8 → 6.5; P < 0.01), and sleep quality (PSQI: 10.5 → 6.2; P < 0.001) all improved. Critically, the intervention group also showed enhanced immune function (CD4⁺/CD8⁺ ratio: 1.78 → 1.44; P = 0.001), decreased inflammation (IL-6: 12.4 → 8.2 pg/mL, P = 0.001; TNFα: 9.3 → 6.1 pg/mL, P = 0.003), and improved survival: 2-year disease-free survival 81.2% vs 68.5% (P = 0.005), overall survival 88.5% vs 76.7% (P = 0.003), and tumor recurrence rate 18.8% vs 31.5% (P = 0.006) [63]A1b. These findings argue strongly for integrating psychological and sleep management into routine surveillance counselling. Self-efficacy-centered comprehensive interventions that include dietary guidance, psychological counselling, symptom management, and exercise guidance have also been shown to improve nutritional status, self-efficacy, self-management ability, and quality of life [62]A1b. Multimodal prehabilitation programs (structured exercise, nutritional support, psychological counselling, and smoking/alcohol cessation) reduce postoperative pneumonia and overall complications [70]B2b[73]B3b. In elderly patients aged ≥75 years, a multimodal perioperative care program was associated with a lower incidence of overall complications (21% vs 40%), pneumonia (4% vs 9%), and delirium (3% vs 7%) [73]B3b.
Hereditary Risk Assessment and Family Screening
For patients with hereditary gastric cancer syndromes, family counselling is an essential component of follow-up. In CDH1 mutation carriers, the cumulative risk of gastric cancer by age 80 is 70% (95% CI 59% to 80%) for males and 56% (95% CI 44% to 69%) for females; female carriers also have a 42% breast cancer risk (95% CI 23% to 68%) [71]D5. These figures should be discussed with both the patient and at-risk relatives, along with the option of risk-reducing total gastrectomy. The NCCN guidelines recommend genetic counselling and testing for relatives of individuals with pathogenic variants in CDH1, BRCA1/2, and other genes associated with gastric cancer risk [54]A1c. In (MLH1/MSH2 carriers), gastric cancer is the third most frequent malignancy, and regular gastric surveillance starting at age 35 is recommended regardless of family history [66]D5. Multigene panel testing is now recommended for patients meeting criteria for hereditary gastrointestinal cancer syndromes [58]A1c. Clinicians should document the family history thoroughly and refer affected families to a genetics service.
Controversies and Guideline Disagreement
| Question | Position A | Position B | Strength | Implication |
|---|---|---|---|---|
| Is intensive nutritional counselling superior to simplified counselling for weight preservation? | No; intensive counselling did not reduce weight loss (MD 0.09 percentage points, 95% CI -1.43 to 1.60) [61]A1b | Yes; individualized dietary counselling reduced BMI loss at 30, 60, and 90 days [69]A1b | Moderate, conflicting results from two RCTs | The optimal intensity and individualization of dietary counselling remain unclear; a single session may be sufficient for some patients, but tailored approaches benefit those with total/proximal gastrectomy |
| Should psychological and sleep interventions be part of standard surveillance? | Yes; a combined CBT, sleep hygiene, and melatonin program improved survival outcomes (DFS 81.2% vs 68.5%, OS 88.5% vs 76.7%) [63]A1b | No formal guideline recommendation exists for routine incorporation | Moderate, single RCT with strong effect | Clinicians should consider integrating psychological and sleep support, particularly in patients with distress or sleep disturbance |
Pearl: For postgastrectomy patients, a single session of dietary counselling may be as effective as intensive follow-up for weight preservation, but individualized counselling reduces BMI loss in patients undergoing total or proximal gastrectomy [61]A1b[69]A1b; integrating psychological and sleep interventions can improve not only quality of life but also survival outcomes [63]A1b.
| Domain | Message | Evidence |
|---|---|---|
| Dietary | Aim for 5-6 small meals/day; prioritize protein (1.2-1.5 g/kg/day) and calorie goals (25-30 kcal/kg/day); expect gradual weight stabilization by 12-18 months | [61]A1b[69]A1b |
| Symptom reporting | Report new dysphagia, early satiety, unexplained weight loss, abdominal pain, jaundice, or GI bleeding immediately | [67]D5 |
| Opioid use | Opioid-naïve patients have a 10.4% risk of new persistent opioid use; adjuvant chemotherapy increases risk to 15-21% | [68]D5 |
| Psychological | Screen for anxiety, depression, and sleep disturbance; consider referral for CBT and sleep hygiene education | [63]A1b |
| Lifestyle | Encourage smoking cessation, alcohol moderation, and regular physical activity; multimodal prehabilitation reduces complications | [70]B2b[73]B3b |
| Hereditary risk | Offer genetic counselling to at-risk relatives; CDH1 carriers need gastric and breast surveillance; Lynch syndrome carriers need gastric surveillance starting at age 35 | [54]A1c[66]D5[71]D5 |
Related Pages
Part of the Gastric Cancer family. Cross-cutting management is split across dedicated child pages:
- , diagnostic page (definition, epidemiology, staging, biomarkers, prognosis)
- Gastric Cancer Surgical Management , operations by stage, fertility-sparing options, sentinel node mapping, adjuvant triggers (Sedlis / Peters)
- Gastric Cancer Radiation Management , EBRT + image-guided brachytherapy + concurrent chemoradiation, dose / fractionation, OAR constraints
- , concurrent / adjuvant / metastatic chemotherapy, targeted therapy, immune checkpoint inhibitors
- Gastric Cancer Palliative Care , early integration, symptom management, palliative procedures, end-of-life care
- Gastric Cancer Recurrent and Metastatic Disease , local-regional salvage, distant metastatic systemic therapy, oligometastatic disease
Pearl: Use these links to hop between management modalities; the parent Gastric Cancer page carries diagnosis + staging that informs every decision here.
References
- [1]
Muro K, Van Cutsem E, Narita Y et al.. “Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with metastatic gastric cancer: a JSMO-ESMO initiative endorsed by CSCO, KSMO, MOS, SSO and TOS.” Annals of oncology : official journal of the European Society for Medical Oncology (2019). PMID: 30475956 ↗
L1GUIDELINECited in: Surveillance Schedule - [2]
Dijksterhuis WPM, Latenstein AEJ, van Kleef JJ et al.. “Cachexia and Dietetic Interventions in Patients With Esophagogastric Cancer: A Multicenter Cohort Study.” Journal of the National Comprehensive Cancer Network : JNCCN (2021). PMID: 33418527 ↗
L2PROSPECTIVE_COHORTCited in: Surveillance Schedule - [3]
van Amelsfoort RM, Walraven I, Kieffer J et al.. “Quality of Life Is Associated With Survival in Patients With Gastric Cancer: Results From the Randomized CRITICS Trial.” Journal of the National Comprehensive Cancer Network : JNCCN (2022). PMID: 35276669 ↗
L1RCTCited in: Surveillance Schedule, Late Toxicity and Survivorship - [4]
Shitara K, Fleitas T, Kawakami H et al.. “Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer.” ESMO open (2024). PMID: 38458658 ↗
L1GUIDELINECited in: Surveillance Schedule - [5]
Blair VR, McLeod M, Carneiro F et al.. “Hereditary diffuse gastric cancer: updated clinical practice guidelines.” The Lancet. Oncology (2020). PMID: 32758476 ↗
L1GUIDELINECited in: Surveillance Schedule - [6]
Shimazu T, Wakai K, Tamakoshi A et al.. “Association of vegetable and fruit intake with gastric cancer risk among Japanese: a pooled analysis of four cohort studies.” Annals of oncology : official journal of the European Society for Medical Oncology (2014). PMID: 24618149 ↗
L2PROSPECTIVE_COHORTCited in: Surveillance Schedule - [7]
Keszei AP, Schouten LJ, Goldbohm RA et al.. “Red and processed meat consumption and the risk of esophageal and gastric cancer subtypes in The Netherlands Cohort Study.” Annals of oncology : official journal of the European Society for Medical Oncology (2012). PMID: 22351741 ↗
L2PROSPECTIVE_COHORTCited in: Surveillance Schedule - [8]
Janjigian YY, Shitara K, Ajani JA et al.. “Nivolumab plus chemotherapy as first-line treatment for advanced gastric, gastroesophageal junction, and esophageal adenocarcinoma: 5-year follow-up results from CheckMate 649.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 41687718 ↗
L1RCTCited in: Surveillance Schedule - [9]
Park SH, Lim DH, Sohn TS et al.. “A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 33278599 ↗
L1RCTCited in: Surveillance Schedule, Detection of Recurrence - [10]
Fazio N, Biffi R, Maibach R et al.. “Preoperative versus postoperative docetaxel-cisplatin-fluorouracil (TCF) chemotherapy in locally advanced resectable gastric carcinoma: 10-year follow-up of the SAKK 43/99 phase III trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 26712905 ↗
L1RCTCited in: Surveillance Schedule - [11]
Ryu MH, Baba E, Lee KH et al.. “Comparison of two different S-1 plus cisplatin dosing schedules as first-line chemotherapy for metastatic and/or recurrent gastric cancer: a multicenter, randomized phase III trial (SOS).” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 26216386 ↗
L1RCTCited in: Surveillance Schedule, Detection of Recurrence - [12]
Win AK, Young JP, Lindor NM et al.. “Colorectal and other cancer risks for carriers and noncarriers from families with a DNA mismatch repair gene mutation: a prospective cohort study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2012). PMID: 22331944 ↗
L4PROSPECTIVE_COHORTCited in: Surveillance Schedule - [13]
Kang YK, Yook JH, Park YK et al.. “PRODIGY: A Phase III Study of Neoadjuvant Docetaxel, Oxaliplatin, and S-1 Plus Surgery and Adjuvant S-1 Versus Surgery and Adjuvant S-1 for Resectable Advanced Gastric Cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34133211 ↗
L1RCTCited in: Surveillance Schedule - [14]
Yoshida K, Kodera Y, Kochi M et al.. “Addition of Docetaxel to Oral Fluoropyrimidine Improves Efficacy in Patients With Stage III Gastric Cancer: Interim Analysis of JACCRO GC-07, a Randomized Controlled Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2019). PMID: 30925125 ↗
L1RCTCited in: Surveillance Schedule - [15]
Smalley SR, Benedetti JK, Haller DG et al.. “Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2012). PMID: 22585691 ↗
L1RCTCited in: Surveillance Schedule - [16]
Kang YK, Kim HD, Yook JH et al.. “Neoadjuvant Docetaxel, Oxaliplatin, and S-1 Plus Surgery and Adjuvant S-1 for Resectable Advanced Gastric Cancer: Updated Overall Survival Outcomes From Phase III PRODIGY.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 38996201 ↗
L1RCTCited in: Surveillance Schedule - [17]
Lee CK, Kim HS, Jung M et al.. “Open-Label, Multicenter, Randomized, Biomarker-Integrated Umbrella Trial for Second-Line Treatment of Advanced Gastric Cancer: K-Umbrella Gastric Cancer Study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37883723 ↗
L1RCTCited in: Surveillance Schedule - [18]
Kim YW, Min JS, Yoon HM et al.. “Laparoscopic Sentinel Node Navigation Surgery for Stomach Preservation in Patients With Early Gastric Cancer: A Randomized Clinical Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2022). PMID: 35324317 ↗
L1RCTCited in: Surveillance Schedule, Detection of Recurrence, Late Toxicity and Survivorship - [19]
Fuchs CS, Niedzwiecki D, Mamon HJ et al.. “Adjuvant Chemoradiotherapy With Epirubicin, Cisplatin, and Fluorouracil Compared With Adjuvant Chemoradiotherapy With Fluorouracil and Leucovorin After Curative Resection of Gastric Cancer: Results From CALGB 80101 (Alliance).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2017). PMID: 28976791 ↗
L1RCTCited in: Surveillance Schedule, Detection of Recurrence - [20]
Lordick F, Mauer ME, Stocker G et al.. “Adjuvant immunotherapy in patients with resected gastric and oesophagogastric junction cancer following preoperative chemotherapy with high risk for recurrence (ypN+ and/or R1): European Organisation of Research and Treatment of Cancer (EORTC) 1707 VESTIGE study.” Annals of oncology : official journal of the European Society for Medical Oncology (2024). PMID: 39542422 ↗
L2RCT_PHASE2Cited in: Surveillance Schedule, Detection of Recurrence - [21]
Kim HS, Kim HJ, Kim SY et al.. “Second-line chemotherapy versus supportive cancer treatment in advanced gastric cancer: a meta-analysis.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 23942775 ↗
L2SR_COHORTCited in: Detection of Recurrence - [22]
Bang YJ, Ruiz EY, Van Cutsem E et al.. “Phase III, randomised trial of avelumab versus physician's choice of chemotherapy as third-line treatment of patients with advanced gastric or gastro-oesophageal junction cancer: primary analysis of JAVELIN Gastric 300.” Annals of oncology : official journal of the European Society for Medical Oncology (2018). PMID: 30052729 ↗
L1RCTCited in: Detection of Recurrence - [23]
Smyth EC, Nyamundanda G, Cunningham D et al.. “A seven-Gene Signature assay improves prognostic risk stratification of perioperative chemotherapy treated gastroesophageal cancer patients from the MAGIC trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2018). PMID: 30481267 ↗
L1RCTCited in: Detection of Recurrence - [24]
Jeung HC, Moon YW, Rha SY et al.. “Phase III trial of adjuvant 5-fluorouracil and adriamycin versus 5-fluorouracil, adriamycin, and polyadenylic-polyuridylic acid (poly A:U) for locally advanced gastric cancer after curative surgery: final results of 15-year follow-up.” Annals of oncology : official journal of the European Society for Medical Oncology (2007). PMID: 18029971 ↗
L1RCTCited in: Detection of Recurrence - [25]
Kang YK, Ryu MH, Park SH et al.. “Efficacy and safety findings from DREAM: a phase III study of DHP107 (oral paclitaxel) versus i.v. paclitaxel in patients with advanced gastric cancer after failure of first-line chemotherapy.” Annals of oncology : official journal of the European Society for Medical Oncology (2018). PMID: 29438463 ↗
L1RCTCited in: Detection of Recurrence - [26]
Shitara K, Ito S, Misawa K et al.. “Genetic polymorphism of IGF-I predicts recurrence in patients with gastric cancer who have undergone curative gastrectomy.” Annals of oncology : official journal of the European Society for Medical Oncology (2011). PMID: 21690232 ↗
L3COHORTCited in: Detection of Recurrence - [27]
Shen L, Shan YS, Hu HM et al.. “Management of gastric cancer in Asia: resource-stratified guidelines.” The Lancet. Oncology (2013). PMID: 24176572 ↗
L1GUIDELINECited in: Detection of Recurrence - [28]
Lee J, Lim DH, Kim S et al.. “Phase III trial comparing capecitabine plus cisplatin versus capecitabine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 22184384 ↗
L1RCTCited in: Detection of Recurrence - [29]
Van Cutsem E, Boni C, Tabernero J et al.. “Docetaxel plus oxaliplatin with or without fluorouracil or capecitabine in metastatic or locally recurrent gastric cancer: a randomized phase II study.” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 25416687 ↗
L2RCT_PHASE2Cited in: Detection of Recurrence - [30]
Asif B, Sarvestani AL, Gamble LA et al.. “Cancer surveillance as an alternative to prophylactic total gastrectomy in hereditary diffuse gastric cancer: a prospective cohort study.” The Lancet. Oncology (2023). PMID: 36990610 ↗
L4PROSPECTIVE_COHORTCited in: Detection of Recurrence - [31]
Lee CYC, Olivier A, Honing J et al.. “Endoscopic surveillance with systematic random biopsy for the early diagnosis of hereditary diffuse gastric cancer: a prospective 16-year longitudinal cohort study.” The Lancet. Oncology (2022). PMID: 36509094 ↗
L2PROSPECTIVE_COHORTCited in: Detection of Recurrence - [32]
Han MA, Oh MG, Choi IJ et al.. “Association of family history with cancer recurrence and survival in patients with gastric cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2012). PMID: 22271486 ↗
L3COHORTCited in: Detection of Recurrence - [33]
Wu CW, Hsiung CA, Lo SS et al.. “Nodal dissection for patients with gastric cancer: a randomised controlled trial.” The Lancet. Oncology (2006). PMID: 16574546 ↗
L1RCTCited in: Detection of Recurrence - [34]
Sakuramoto S, Sasako M, Yamaguchi T et al.. “Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine.” The New England journal of medicine (2007). PMID: 17978289 ↗
L1RCTCited in: Detection of Recurrence - [35]
Choi IJ, Kook MC, Kim YI et al.. “Helicobacter pylori Therapy for the Prevention of Metachronous Gastric Cancer.” The New England journal of medicine (2018). PMID: 29562147 ↗
L1RCTCited in: Detection of Recurrence - [36]
Ajani JA, D'Amico TA, Bentrem DJ et al.. “Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology.” Journal of the National Comprehensive Cancer Network : JNCCN (2022). PMID: 35130500 ↗
L1GUIDELINECited in: Late Toxicity and Survivorship - [37]
van Velzen MJM, Pape M, Sprangers MAG et al.. “Chemotherapy-Induced Peripheral Neuropathy in Patients With Gastroesophageal Cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2024). PMID: 38977016 ↗
L2PROSPECTIVE_COHORTCited in: Late Toxicity and Survivorship - [38]
Al-Batran SE, Van Cutsem E, Oh SC et al.. “Quality-of-life and performance status results from the phase III RAINBOW study of ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients with previously treated gastric or gastroesophageal junction adenocarcinoma.” Annals of oncology : official journal of the European Society for Medical Oncology (2016). PMID: 26747859 ↗
L1RCTCited in: Late Toxicity and Survivorship - [39]
Dank M, Zaluski J, Barone C et al.. “Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction.” Annals of oncology : official journal of the European Society for Medical Oncology (2008). PMID: 18558665 ↗
L1RCTCited in: Late Toxicity and Survivorship - [40]
Li J, Qin S, Xu J et al.. “Randomized, Double-Blind, Placebo-Controlled Phase III Trial of Apatinib in Patients With Chemotherapy-Refractory Advanced or Metastatic Adenocarcinoma of the Stomach or Gastroesophageal Junction.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2016). PMID: 26884585 ↗
L1RCTCited in: Late Toxicity and Survivorship - [41]
Moehler M, Xiao H, Blum SI et al.. “Health-Related Quality of Life With Nivolumab Plus Chemotherapy Versus Chemotherapy in Patients With Advanced Gastric/Gastroesophageal Junction Cancer or Esophageal Adenocarcinoma From CheckMate 649.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37713657 ↗
L1RCTCited in: Late Toxicity and Survivorship - [42]
Park SH, Nam E, Park J et al.. “Randomized phase II study of irinotecan, leucovorin and 5-fluorouracil (ILF) versus cisplatin plus ILF (PILF) combination chemotherapy for advanced gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2007). PMID: 18083691 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [43]
Janjigian YY, Kawazoe A, Xu J et al.. “Pembrolizumab with trastuzumab and chemotherapy for HER2-positive advanced gastric cancer: health-related quality-of-life analysis from the randomized KEYNOTE-811 trial.” ESMO open (2025). PMID: 41033280 ↗
L1RCTCited in: Late Toxicity and Survivorship - [44]
Fazio R, Randon G, Bergamo F et al.. “Impact of age and sex on the efficacy and safety of ramucirumab plus paclitaxel as switch maintenance versus continuation of first-line oxaliplatin-based chemotherapy: a subgroup analysis of the ARMANI phase III trial.” ESMO open (2025). PMID: 40540760 ↗
L1RCTCited in: Late Toxicity and Survivorship - [45]
Van Cutsem E, Valderrama A, Bang YJ et al.. “Quality of life with first-line pembrolizumab for PD-L1-positive advanced gastric/gastroesophageal junction adenocarcinoma: results from the randomised phase III KEYNOTE-062 study.” ESMO open (2021). PMID: 34371381 ↗
L1RCTCited in: Late Toxicity and Survivorship - [46]
Cats A, Jansen EPM, van Grieken NCT et al.. “Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial.” The Lancet. Oncology (2018). PMID: 29650363 ↗
L1RCTCited in: Late Toxicity and Survivorship - [47]
Pavlakis N, Shitara K, Sjoquist K et al.. “INTEGRATE IIa Phase III Study: Regorafenib for Refractory Advanced Gastric Cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 39365958 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [48]
Van Cutsem E, Moiseyenko VM, Tjulandin S et al.. “Phase III study of docetaxel and cisplatin plus fluorouracil compared with cisplatin and fluorouracil as first-line therapy for advanced gastric cancer: a report of the V325 Study Group.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2006). PMID: 17075117 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [49]
Roth AD, Fazio N, Stupp R et al.. “Docetaxel, cisplatin, and fluorouracil; docetaxel and cisplatin; and epirubicin, cisplatin, and fluorouracil as systemic treatment for advanced gastric carcinoma: a randomized phase II trial of the Swiss Group for Clinical Cancer Research.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2007). PMID: 17664469 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [50]
Raimondi A, Lonardi S, Murgioni S et al.. “Tremelimumab and durvalumab as neoadjuvant or non-operative management strategy of patients with microsatellite instability-high resectable gastric or gastroesophageal junction adenocarcinoma: the INFINITY study by GONO.” Annals of oncology : official journal of the European Society for Medical Oncology (2024). PMID: 39637944 ↗
L2NON_RANDOMIZED_TRIALCited in: Late Toxicity and Survivorship - [51]
Brenner B, Shah MA, Karpeh MS et al.. “A phase II trial of neoadjuvant cisplatin-fluorouracil followed by postoperative intraperitoneal floxuridine-leucovorin in patients with locally advanced gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2006). PMID: 16788003 ↗
L2NON_RANDOMIZED_TRIALCited in: Late Toxicity and Survivorship - [52]
Stocker G, Lorenzen S, Ettrich T et al.. “S-1 maintenance therapy in Caucasian patients with metastatic esophagogastric adenocarcinoma-final results of the randomized AIO MATEO phase II trial.” ESMO open (2023). PMID: 37270871 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [53]
Leong T, Smithers BM, Michael M et al.. “Preoperative Chemoradiotherapy for Resectable Gastric Cancer.” The New England journal of medicine (2024). PMID: 39282905 ↗
L2RCT_PHASE2Cited in: Late Toxicity and Survivorship - [54]
Daly MB, Pal T, Berry MP et al.. “Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology.” Journal of the National Comprehensive Cancer Network : JNCCN (2021). PMID: 33406487 ↗
L1GUIDELINECited in: Patient Counselling - [55]
McNair AG, Brookes ST, Davis CR et al.. “Communicating the results of randomized clinical trials: do patients understand multidimensional patient-reported outcomes?” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2010). PMID: 20065187 ↗
L1RCTCited in: Patient Counselling - [56]
Kim JH, Kim HS, Seo WY et al.. “External validation of nomogram for the prediction of recurrence after curative resection in early gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2011). PMID: 21566150 ↗
L4RETROSPECTIVE_COHORTCited in: Patient Counselling - [57]
Fan W, Tao Y, Shi J et al.. “Effects of New Media-Based Education on the Treatment of Helicobacter pylori Infection: Systematic Review and Meta-Analysis.” Journal of medical Internet research (2025). PMID: 41130587 ↗
L1SR_MA_RCTCited in: Patient Counselling - [58]
Carballal S, Balaguer F, Bujanda L et al.. “Use of multi-gene panels in patients at high risk of hereditary digestive cancer: position statement of AEG, SEOM, AEGH and IMPaCT-GENÓMICA consortium.” Gastroenterologia y hepatologia (2023). PMID: 37315767 ↗
L1GUIDELINECited in: Patient Counselling - [59]
Xu J, Dong GL, Sheng L. “Roy adaptation model-based patient education for elderly patients undergoing laparoscopic radical gastrectomy.” Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2026). PMID: 41524904 ↗
L1RCTCited in: Patient Counselling - [60]
Eom BW, Han M, Yoon HM et al.. “Improvement in Quality of Life After Early Interactive Human Coaching via a Mobile App in Postgastrectomy Patients With Gastric Cancer: Prospective Randomized Controlled Trial.” JMIR mHealth and uHealth (2025). PMID: 41411643 ↗
L1RCTCited in: Patient Counselling - [61]
Lee AR, Bae JM, Choi MG et al.. “Nutritional Counseling for Patients With Gastric Cancer After Subtotal Gastrectomy: A Randomized Clinical Trial.” Journal of gastric cancer (2025). PMID: 41093778 ↗
L1RCTCited in: Patient Counselling - [62]
Zhou H, Bao R, Qiu L et al.. “Self-efficacy centered comprehensive interventions and effects in patients undergoing radical surgery for gastric cancer.” Frontiers in medicine (2025). PMID: 40776917 ↗
L1RCTCited in: Patient Counselling - [63]
Wang G, Pan S. “Psychological Interventions and Sleep Improvement for Patients with Gastric Cancer: Effects on Immune Function, Inflammation, and Tumor Progression-A Randomized Controlled Trial.” Annals of surgical oncology (2025). PMID: 40603815 ↗
L1RCTCited in: Patient Counselling - [64]
Lee JY, Oh EG, Jang Y et al.. “Effectiveness of self-management program for gastric cancer patients: A randomized controlled trial comparing gain vs. loss message framing.” Patient education and counseling (2024). PMID: 39047331 ↗
L1RCTCited in: Patient Counselling - [65]
Li Q, Chen C, Wang X. “Perioperative nutritional interventions for gastric cancer patients: a meta-analysis of surgical outcomes.” Frontiers in nutrition (2025). PMID: 41235306 ↗
L1SR_MA_RCTCited in: Patient Counselling - [66]
Goecke T, Schulmann K, Engel C et al.. “Genotype-phenotype comparison of German MLH1 and MSH2 mutation carriers clinically affected with Lynch syndrome: a report by the German HNPCC Consortium.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2006). PMID: 16908935 ↗
L5OTHERCited in: Patient Counselling - [67]
Gallanis AF, Gamble LA, Samaranayake SG et al.. “Costs of Cancer Prevention: Physical and Psychosocial Sequelae of Risk-Reducing Total Gastrectomy.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37903316 ↗
L5OTHERCited in: Patient Counselling - [68]
Lee JS, Hu HM, Edelman AL et al.. “New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2017). PMID: 29048972 ↗
L5OTHERCited in: Patient Counselling - [69]
Yan H, He F, Wei J et al.. “Effects of individualized dietary counseling on nutritional status and quality of life in post-discharge patients after surgery for gastric cancer: A randomized clinical trial.” Frontiers in oncology (2023). PMID: 36923419 ↗
L1RCTCited in: Patient Counselling - [70]
Perwaiz A, Gupta A, Mittal V et al.. “Prospective Evaluation of Multimodal Prehabilitation in Esophagogastric Cancer Surgery: Enhancing Patient Outcomes.” World journal of surgery (2025). PMID: 40186345 ↗
L2NON_RANDOMIZED_TRIALCited in: Patient Counselling - [71]
Hansford S, Kaurah P, Li-Chang H et al.. “Hereditary Diffuse Gastric Cancer Syndrome: CDH1 Mutations and Beyond.” JAMA oncology (2015). PMID: 26182300 ↗
L5OTHERCited in: Patient Counselling - [72]
Kang S, Kim DH, Kim NH et al.. “Clinical Outcomes and Prognostic Factors in Older Adult Patients Aged ≥75 Years With Early Gastric Cancer After Endoscopic Resections: A Nationwide Cohort Study.” Journal of gastric cancer (2026). PMID: 42411165 ↗
L3COHORTCited in: Patient Counselling - [73]
Fujiya K, Fuseya H, Yonenaga Y et al.. “Association of a Multimodal Perioperative Care Program With Postoperative Complications in Elderly Patients Undergoing Gastrectomy for Gastric Cancer.” Annals of gastroenterological surgery (2026). PMID: 42395131 ↗
L3COHORTCited in: Patient Counselling