Gastric cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up
- Study type
- Clinical guideline
- Study name
- ESMO Gastric 2022
- Design
- Clinical guideline of the European Society for Medical Oncology (ESMO) with grading of level of evidence (I to V) and strength of recommendation (A to E)
- Source
- Ann Oncol · 2022
In plain words
This guideline is the main European reference for doctors who treat stomach cancer. In simple terms: in disease that can be operated on (except very early cases), chemotherapy before and after surgery together with complete surgery in an experienced centre is recommended. In advanced disease, tests such as HER2, PD-L1 and MSI are done on the tumour sample to choose the right treatment; for example, trastuzumab for HER2-positive tumours and immunotherapy (nivolumab) with chemotherapy for tumours with high PD-L1. There are also effective options for later lines of treatment.
Key guideline recommendations
- I, A
For stage IB to III gastric cancer, perioperative treatment (before and after surgery) with radical gastrectomy is recommended.
- II, B
Patients should have D2 surgery in a high-volume surgical centre.
- I, A; ESMO-MCBS v1.1: 4
Nivolumab-chemotherapy is recommended for advanced, untreated gastric, gastro-oesophageal junction and oesophageal cancer with PD-L1 CPS ≥5.
- I, A; ESMO-MCBS v1.1: 3; ESCAT: I-A
Trastuzumab-chemotherapy is recommended in patients with HER2-positive tumours.
- I, A; ESMO-MCBS v1.1: 2
Ramucirumab-paclitaxel is recommended for second-line treatment of gastric cancer. Single-agent ramucirumab is also an option [I, B; ESMO-MCBS v1.1: 1].
- II, A; ESMO-MCBS v1.1: 3; ESCAT: I-B
Pembrolizumab is recommended for second-line treatment of patients with MSI-H/dMMR gastric cancer.
- I, D
Trastuzumab treatment beyond first-line therapy is not recommended in HER2-positive advanced gastric cancer.
- I, A; ESMO-MCBS v1.1: 3
For patients previously treated with two lines of drugs, trifluridine-tipiracil is recommended. Alternative treatments include a taxane or irinotecan [II, B].
Study population
Patients with gastric cancer at all stages: diagnosis, staging, localised disease, perioperative and adjuvant treatment, advanced and metastatic disease (first line to later lines), supportive care and follow-up.
Clinical significance and place in guidelines
ESMO has updated this guideline as a "Living Guideline" on its website (ESMO Gastric Cancer Living Guideline v1.4, September 2024). On 15 October 2026, a new combined ESMO guideline entitled "Gastric and oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up" (Al-Batran SE et al., Ann Oncol 2026; DOI: 10.1016/j.annonc.2026.09.015; PMID: 42880714) was published online; it covers gastric and oesophageal cancer together and replaces the 2022 version; its full text has not yet been reviewed for this summary. The recommendations below therefore relate to the 2022 version, and treatments approved since then (such as zolbetuximab, first-line pembrolizumab or perioperative durvalumab) are not reflected in it.
Limitations
The 2022 version was written before the results of the SPOTLIGHT, GLOW, KEYNOTE-859, MATTERHORN and DESTINY-Gastric04 trials and has been replaced by the 2026 guideline. The text of the recommendations here was taken from the recommendations table of the Pan-Asian adapted ESMO guideline (Shitara et al., ESMO Open 2024; DOI: 10.1016/j.esmoop.2023.102226), which reproduces the main ESMO 2022 recommendations and states in its text that these recommendations were adopted unchanged (or quotes the original text); the full text of the Annals of Oncology paper was not directly available.
This summary was prepared by the editorial team from the published paper; the original paper is the final reference. Read the original abstract on PubMed.