Gastric cancer: team, nutrition and surgical prep

A 68-year-old woman, a retired teacher, seeks care because she has lost 9 kg in four months, feels full after the first few bites and has anemia that does not improve with iron. Endoscopy shows an ulcerated lesion in the body of the stomach and the biopsy confirms adenocarcinoma. The CT scan shows no distant metastases, but suggests extensive wall thickening and enlarged lymph nodes. She lives alone, eats little, walks slowly and asks the surgeon when she can have surgery, because she wants to "get this out soon". The surgeon replies that the team needs to talk first. The scene is fictional and was written for teaching.

This text uses the case as a clinical reasoning scenario for students and health professionals. The topic is the organization of care in localized gastric cancer: how surgery, clinical oncology, endoscopy, pathology, radiology and nutrition divide the tasks between diagnosis and surgery, and why preparing the patient is part of the treatment. The text does not replace your country's guideline or your service's protocol. If you play the case of the day on NEXO, you will recognize the pattern: the clue that seems to call for haste is not always the one that defines the best path.

Key points

• Discussion at a multidisciplinary meeting was associated with better survival in a national gastric cancer cohort.
• Malnutrition and cachexia are common at diagnosis and weigh on complications after gastrectomy.
• Prehabilitation, which combines exercise, nutrition and psychological support, can reduce complications even when it lasts only a few weeks.
• Staging laparoscopy looks for peritoneal metastases that CT does not show and changes the strategy.
• Frailty and sarcopenia in older people help predict complications and survival, and deserve assessment before surgery.
• Care continues after surgery, with vitamin B12 replacement after total gastrectomy and nutritional follow-up.

Why the stomach calls for a team

Gastric cancer often arrives late. The early symptoms, such as discomfort after eating, loss of appetite and tiredness, are confused with common problems, and many people only seek help when they have already lost weight. When the diagnosis finally happens, the patient has at the same time a tumor that needs treatment and a body that is losing reserves. The patient in the scene sums up this double problem: the disease seems localized, but she eats little, has lost muscle and lives alone.

No single specialty solves both parts. Endoscopy defines the location and extent of the lesion in the mucosa and, in very early tumors, can be the treatment itself. Pathology confirms the histological type and tests the biomarkers that will guide systemic therapy. Radiology looks for distant disease. Surgery assesses what is technically possible and when. Clinical oncology decides whether there is an indication for chemotherapy before the operation. Nutrition measures the deficit and builds a plan so that the patient reaches surgery in better condition. Nursing, physical therapy and social work complete the picture with the patient's real routine.

When these views work in sequence, each one discovers on its own what the previous one already knew, and time is lost. When they work together, the order of the steps becomes clear: confirm the extent, decide the strategy, prepare the body and only then operate. The text on interprofessional clinical reasoning discusses this division of tasks in general terms.

The patient's haste and the tumor's haste

The request to "get it out soon" is understandable and deserves an honest answer. In most locally advanced tumors, operating the next day is not the best strategy, because chemotherapy before surgery is part of the treatment and because a malnourished patient has more complications. Explaining that the weeks of preparation also treat the cancer helps anxiety give way to adherence. The post on affective bias shows how emotion, in the patient and in the team, can pull decisions toward the wrong side.

What the multidisciplinary meeting changes

Sweden has recommended discussion at a multidisciplinary meeting for all patients with gastric cancer since 2015. A national study of 7813 patients diagnosed between 2006 and 2021 showed that 68 in 100 were discussed at a meeting, according to the cohort by Engborg and colleagues. In the adjusted analysis, receiving a treatment recommendation at the meeting was associated with better survival, with a hazard ratio of 0.89, and median survival was 12.0 months in the discussed group versus 5.9 months in the non-discussed group, according to the same national study.

The most uncomfortable finding of the study is who was left out. Patients aged 80 to 89 and patients with worse functional status were less likely to go through the meeting, according to the analysis by Engborg. Precisely those who most need a careful decision, because they have more risks and less margin for error, are the ones who tend to be decided outside the meeting. It is a form of age bias that the text on implicit bias in diagnosis helps to recognize.

The meeting is not a guarantee of a better outcome in every scenario. In a Chinese hospital, a matched analysis of 378 operated patients showed that the group discussed by the team received more chemotherapy before surgery, 39 versus 28 in 100, and more laparoscopic surgery, but with no clear difference in survival at one and three years, according to the study by Chen and colleagues. The useful reading is that the meeting changes the choices; the effect on survival depends on who is discussed, what is decided and how the decision is carried out.

How to build the agenda for the gastric case

A short agenda, repeated in every case, prevents oversights. Each item has an owner, and the conclusion records the strategy and the date of the next reassessment.

• Endoscopy findings, with the location, extent and photos of the lesion.
• Pathology report with histological type and available biomarkers.
• Imaging staging and indication for staging laparoscopy.
• Nutritional status, weight loss and frailty screening.
• Proposed strategy, with chemotherapy, surgery or endoscopic treatment.
• Preparation plan, owners and date of reassessment.

Endoscopy and pathology at the starting point

Endoscopy is the exam that opens the case and, in some patients, is also the treatment. In very early tumors, restricted to the most superficial layer and with favorable criteria, endoscopic submucosal dissection removes the lesion without abdominal surgery. A Korean study in 22 hospitals compared this technique with surgery in 4241 people aged 75 or older with early gastric cancer who met the criteria for curative resection, according to the analysis by Kim and colleagues. Overall survival at five years was 85 in 100 in the endoscopic group and 83 in 100 in the surgical group, with no significant difference, according to the same study.

The trade-off has a cost, and the team needs to tell the patient about it. Gastric cancer recurrence at five years was about 9 in 100 after endoscopy and less than 1 in 100 after surgery, but about 77 in 100 of the recurrences in the endoscopic group were new lesions at another point in the stomach, most treated again by endoscopy, according to the analysis by Kim. For an older person, preserving the stomach may be worth the commitment to regular surveillance endoscopies.

Pathology does more than confirm cancer. The report gives the histological type and the degree of differentiation and, increasingly, the biomarkers that guide systemic treatment. PD-L1 expression, measured by the combined score that counts tumor and immune cells, is used to indicate immunotherapy in gastric cancer, according to the review by Cho and colleagues. The same review notes that PD-L1 expression varies between areas of the tumor and between the primary tumor and metastases, which makes the quality and number of biopsy fragments important, according to the review on PD-L1.

In practice, the endoscopist who knows what pathology will need collects enough fragments the first time. This avoids repeating the exam, saves weeks and reduces the chance that an inconclusive result delays the decision.

Staging laparoscopy

CT is good for metastases in the liver and lungs, but it usually fails on small implants in the peritoneum, the membrane lining the abdominal cavity. Finding these implants during a gastrectomy means a surgery that should not have been done. Staging laparoscopy, performed before defining treatment, allows direct inspection of the cavity and collection of fluid for cytology.

A European consensus brought together surgeons from several centers to standardize the procedure, because guidelines diverged on when to indicate it and barely said how to do it, according to the European consensus on staging laparoscopy. The group agreed that peritoneal lavage for cytology should be done in all patients undergoing the exam, and that free fluid should be collected when present, according to the same consensus.

In European practice, the exam is still underused. In the GASTRODATA cohort, with 1726 patients with locally advanced gastric cancer at 24 centers, only 33 in every 100 underwent staging laparoscopy, according to the study by Sędłak and colleagues. Those who did not undergo the exam were older, had more associated diseases and received chemotherapy before surgery far less often, 35 versus 79 in every 100, according to the GASTRODATA cohort. Because the study is observational, it cannot be said that the exam caused the difference; it does show, however, that skipping the step usually comes together with less complete treatment.

For the patient in the scene, with a thickened wall and enlarged lymph nodes, laparoscopy gains weight. If there are implants in the peritoneum, the strategy changes to systemic treatment, and gastrectomy is no longer the first step.

• Systematic inspection of the entire cavity, including surfaces of the liver, diaphragm and pelvis.
• Peritoneal lavage for cytology in all patients examined.
• Collection of free fluid when there is ascites.
• Biopsy of any suspicious lesion.
• Standardized report, so that the meeting discusses the same finding with the same language.

Malnutrition and cachexia, the silent problem

The tumor in the stomach interferes directly with eating: it causes early satiety, pain, nausea and sometimes obstruction. At the same time, the inflammation produced by the disease speeds up muscle loss. In a study in Costa Rica with newly diagnosed patients, the GLIM criteria identified malnutrition in 74 in every 100, and more than half of the malnourished had the severe form, according to the validation by Sánchez-Corrales and colleagues. The GLIM criteria combine weight loss, low body mass index or muscle mass with reduced intake or inflammation, and had moderate agreement with the global subjective assessment, the reference standard in oncology, with sensitivity and specificity of about 82 in every 100, according to the same study.

Cachexia, the more complex form of disease-related weight loss, is also common and predicts complications. At a Russian center, 76 of 147 patients with resectable gastric cancer had cachexia before surgery, which is about 52 in every 100, according to the study by Lyadov and colleagues. Cachexia was independently associated with more general complications, severe complications and surgical site infection, according to the same cohort.

In Colombia, at a referral center with a prehabilitation program, malnourished patients had more total complications, more surgical site infection and more intensive care admission, according to the study by Suescun Fajardo and colleagues. The message from the three studies is the same: malnutrition is not a detail in the medical record, it is a surgical risk factor that can be measured and, in part, corrected.

Nutritional screening that the team can repeat

Screening needs to be simple to happen in every case. The nutritionist deepens the assessment, but the first suspicion can come from any member of the team.

• Weight loss in the last six months, in kilograms and as a proportion of usual weight.
• How much the patient can eat today compared with before the disease.
• Symptoms that interfere with eating, such as early satiety, nausea, pain or vomiting.
• Signs of muscle loss, grip strength and gait speed.
• Available inflammation markers and albumin, interpreted in context.
• Support at home to prepare meals and follow the plan.

Prehabilitation: weeks that count

Prehabilitation is the active preparation of the patient before surgery, combining exercise, nutrition and psychological support. The idea is to use the interval between diagnosis and the operation, which already exists because of staging and chemotherapy, so that the patient arrives stronger.

A Chinese randomized trial tested a short, one-week program in patients who were going for radical gastrectomy. The 30-day complication rate was 9 in 100 in the prehabilitation group versus 26 in 100 in the control group, with the largest drop in pulmonary infections, according to the trial by Mu and colleagues. The prepared group also returned to eating and walking earlier and had a shorter hospital stay, about 7.8 versus 9.8 days on average, according to the same trial. It is a single-center study, with 131 patients analyzed, and it needs confirmation in other settings.

In the Russian study with cachectic patients, home-based prehabilitation improved functional capacity, favored weight gain and was associated with less surgical site infection, 8 versus 24 in 100 in the control group, according to the analysis by Lyadov. The home-based format matters to those who live far from the hospital or have difficulty traveling, like the patient in the scene.

Prehabilitation works best when each component has an owner. The dietitian sets the calorie and protein target and recommends supplements when food is not enough. Physiotherapy or physical education prescribes aerobic and strength exercise suited to the patient's condition. Psychology addresses anxiety and adherence. Nursing checks whether the plan is being followed and alerts the team when something goes off track.

Component	Main lead	What it measures	Example target
Nutrition	Dietitian	Intake, weight, muscle mass	Reach the daily protein target with food and supplement
Exercise	Physiotherapy or physical education	Walking distance, strength	Walk every day and do light strength training
Psychological support	Psychology	Anxiety, adherence	Understand the plan and keep the preparation routine
Clinical conditions	Clinical team, anesthesia	Anemia, diabetes, lung function	Correct anemia and adjust medications before surgery
Follow-up	Nursing	Compliance with the plan	Weekly contact and early warning of worsening

Frailty, sarcopenia and the older person

Age alone says little about the risk of a gastrectomy. What matters is reserve: strength, muscle mass, cognition, autonomy and associated diseases. A systematic review of 1831 patients aged 65 or older operated for gastric cancer found sarcopenia before surgery in about 22 in 100, and sarcopenia was associated with worse overall survival, with a hazard ratio of 1.93, according to the meta-analysis by Terayama and colleagues.

Combining the two measures helps even more. In 508 patients aged 70 or older who underwent a thorough geriatric assessment and CT before gastrectomy, 16 in 100 had moderate or severe complications within 30 days, and the group with frailty and sarcopenia at the same time had a higher independent risk of complications, according to the study by Lee and colleagues. Both those with one of the conditions and those with both had worse overall survival, with hazard ratios of 2.17 and 3.11, according to the same study.

The CT used in staging already allows measuring muscle mass at the level of the third lumbar vertebra, with no extra exam. The geriatric assessment adds what imaging does not show: autonomy, mood, cognition and support network. With this information, the team can choose between less extensive surgery, a longer preparation or, in early tumors, endoscopic treatment.

This assessment is not meant to exclude older people from treatment. It is meant to choose the treatment each person can get through. The Swedish cohort showed that the oldest tend to stay out of the meeting; the geriatric assessment is a concrete way to bring them back to the table.

Perioperative chemotherapy and reassessment

In locally advanced tumors, the strategy most used in many countries is chemotherapy before and after surgery. A common regimen splits the cycles into two halves, four before and four after gastrectomy. Because some patients cannot complete the postoperative cycles, some centers began giving all cycles before surgery, a strategy called total neoadjuvant therapy.

A systematic review with exploratory meta-analysis gathered three retrospective studies with 425 patients. Total neoadjuvant therapy was associated with greater completion of planned chemotherapy, with no increase in severe surgical complications, but with no significant difference in complete pathological response or in the complete resection rate, according to the review by Jardim and colleagues. The authors rate the certainty of evidence as low and await randomized trials, according to the same review. For the team, the message is that the sequence of cycles is still a choice to discuss, not a fixed rule.

Whatever the regimen, preoperative chemotherapy creates a mandatory point of reassessment. The team checks the tumor response on imaging, weight, strength and tolerance of adverse effects. If the patient lost more weight during chemotherapy, the nutritional plan needs to be reinforced before scheduling surgery. If the disease has progressed, the strategy changes. This reassessment meeting is as important as the first one, and the text on retrospective bias and outcome bias recalls why it is worth recording the reasoning at each step, not only the outcome.

In advanced tumors that receive immunotherapy, immune effects require attention from several specialties. The post on enfortumab vedotin and pembrolizumab gives an example, in another tumor, of how the team monitors this type of toxicity.

After gastrectomy

Surgery changes the way of eating forever. Without the stomach, or with part of it, the patient needs smaller and more frequent meals, must learn to avoid symptoms after eating and must track weight closely. Muscle loss that began before surgery can continue afterward, and that is why nutritional follow-up does not end at discharge.

Total gastrectomy eliminates intrinsic factor, the protein needed to absorb vitamin B12, and the patient needs replacement for life. A scoping review gathered seven studies on oral replacement after total gastrectomy. Most used mecobalamin at daily doses of 500 to 1500 µg, and oral replacement normalized serum levels in most patients, with no biochemical inferiority compared with the injectable route in the comparative studies, according to the review by Rogaczewski and colleagues. The authors point to short follow-up and irregular symptom monitoring, which calls for periodic measurements to confirm the response, according to the same review.

Follow-up also includes iron, calcium and vitamin D, control of symptoms such as dumping syndrome and oncological surveillance with visits and tests defined by the team. In patients treated by endoscopy, regular endoscopic surveillance is part of treatment, because new lesions elsewhere in the stomach are frequent.

• Meal plan with small, frequent meals and a protein target.
• Vitamin B12 replacement for life after total gastrectomy, with periodic measurements.
• Control of iron, calcium and vitamin D.
• Weight and strength recorded at every visit.
• Oncological and endoscopic surveillance schedule with defined responsibilities.

How NEXO helps train this reasoning

NEXO uses fictitious cases with realistic clinical presentations, with up to six clues, to train step-by-step decision-making. In gastric cancer, the skill is similar: do not let the most visible clue, the lesion on endoscopy, erase the others, such as weight loss, strength, support at home and what the patient wants. The text on how to train differential diagnosis with clues shows how to organize this reasoning, and the post on overdiagnosis discusses when doing more does not mean doing better.

The Researcher track goes deeper into the mechanisms behind the clues, the Closer profile helps you measure your own accuracy, Curator organizes the curation of cases and Creators brings together those who produce medical content. The terms of use are at /economia.

Frequently asked questions

Why not operate right after the diagnosis?

Because, in locally advanced tumors, chemotherapy before surgery is part of the treatment, and because staging laparoscopy and nutritional preparation reduce the risk of an unnecessary or complicated surgery.

Does every gastric cancer need surgery?

No. Very early tumors with favorable criteria can be removed by endoscopy, and disease spread in the peritoneum or in other organs is treated first with systemic therapy.

What is prehabilitation?

It is active preparation before surgery, with exercise, nutrition and psychological support. Studies show fewer complications and faster recovery, though confirmation in larger studies is still needed.

Does advanced age prevent gastrectomy?

Not by itself. Frailty, sarcopenia and associated diseases weigh more than age and help choose the extent of treatment.

What is staging laparoscopy for?

To look for peritoneal implants that CT does not show. If they exist, the strategy changes and gastrectomy is no longer the first step.

Does anyone who had the whole stomach removed need vitamin B12 forever?

Yes. Without intrinsic factor, normal absorption of the vitamin no longer exists, and replacement, oral or injectable, should be maintained for life with periodic testing.

Final checklist

• Endoscopy with enough biopsies for pathology and biomarkers.
• Imaging staging and the indication for staging laparoscopy discussed.
• Case presented at a multidisciplinary meeting, including for older or frail patients.
• Nutritional screening, weight loss and muscle mass recorded.
• Prehabilitation plan with those responsible and goals.
• Reassessment scheduled after preoperative chemotherapy.
• Postoperative plan with B12 replacement, nutrition and surveillance.

Play the case of the day on NEXO and train yourself to weigh all the clues, not just the most visible one.

References

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4. Jardim RN, Alves VAA, Mazzotta AD, et al. Perioperative chemotherapy (FLOT 4 + 4) versus total neoadjuvant therapy (TNT; FLOT ×8) for resectable gastric cancer: A systematic review and exploratory meta-analysis. Surg Open Sci. 2026. PMID 41859180.
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10. Sánchez-Corrales P, Hernández-Murillo Y, Orozco-Rivera LE, et al. Validation of the GLIM Malnutrition Criteria in Patients With Gastric Cancer at the Time of Diagnosis. Gastroenterol Res Pract. 2026. PMID 42609532.
11. Sędłak K, Kobiałka S, Pelc Z, et al. Staging Laparoscopy in Gastric Cancer Patients Treated with Curative Intent: A European GASTRODATA Cohort Study. Ann Surg Oncol. 2025. PMID 40715623.
12. Suescun Fajardo OJ, Torres Gaviria S, Chona MC, et al. Postoperative outcomes in patients with gastric cancer undergoing prehabilitation in a high-complexity referral centre. World J Surg Oncol. 2026. PMID 42083030.
13. Terayama M, Ohashi M, Ri M, et al. Long-term impact of sarcopenia in older patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 2023. PMID 38021358.
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