Gastric Cancer

Gastric cancer has undergone significant changes in the last 50 years. It remains the second commonest malignancy worldwide, but its incidence in western countries has markedly decreased. The pattern of disease in western countries has changed, particularly with a proximal migration towards the gastro-oesophageal junction. Most patients present at an advanced stage and have traditionally been considered to have few options, but progress in many aspects of the management of gastric cancer has challenged this somewhat nihilistic view. Evidence from the Japanese screening programmes of the 1960s and 1970s allowed a detailed understanding of early disease. Screening similar to the Japanese programmes is precluded in western countries because of the lower overall incidence, but many countries pursued programmes for early investigation in high-risk populations. This has influenced the stage at presentation but, at the same time, more effective staging techniques have enabled a more accurate assessment of the extent of disease. The results of surgery have improved, with standardization of procedures and centralization of surgical expertise, with less invasive procedures beginning to become more prominent in treatment planning. Many patients have limited long-term survival, but multi-method approaches have added significant improvements to survival in localized disease. Recent large clinical trials have shown a survival impact with perioperative chemotherapy or postoperative chemoradiotherapy. These improvements must be built on with other anticancer strategies (e.g. modifiers of biological response) to enable the best possible outcome.