Metastatic (stage 4) stomach cancer

Find out about symptoms and complications of this advanced stage of stomach cancer. Learn about treatment options, including chemotherapy, surgery and targeted medicines.

Update Date: 18.09.2026

Overview
Symptoms
Causes
Risk factors
Complications
Diagnosis
Treatment
Lifestyle and home remedies
Coping and support
Preparing for an appointment

Overview

Stage 4 stomach cancer is cancer that starts in the stomach and spreads to a distant part of the body. It also is called metastatic stomach cancer or metastatic gastric cancer. The process of cancer spreading from where it started to another part of the body is called metastasis.

Metastatic stomach cancer is different from locally advanced stomach cancer, which has grown in or near the stomach but has not spread to distant parts of the body. It also is different from cancer that starts in another organ and spreads to the stomach. Metastatic cancer keeps the name of the cancer where it began.

Stomach cancer is a common cancer worldwide, and it is often diagnosed at an advanced stage. This is partly because early stomach cancer often causes no symptoms, or the symptoms can seem like those of common digestive conditions.

Stage 4 stomach cancer usually cannot be cured. But treatments can slow or control the cancer, relieve symptoms, improve quality of life and help people live longer. Certain features of the cancer may affect which treatments can be used.

Symptoms

Metastatic stomach cancer symptoms may come from the cancer in the stomach or from cancer that has spread to other parts of the body. Symptoms of stage 4 stomach cancer may include:

  • Losing weight without trying.
  • Ongoing pain, bloating or discomfort in the belly.
  • Feeling full after eating a small amount.
  • Nausea or vomiting.
  • Trouble swallowing.
  • Indigestion that doesn't go away.
  • Bleeding in the digestive tract.

As stomach cancer spreads, symptoms can depend on where the cancer has spread. The most common site of spread is the lining of the abdominal cavity, called the peritoneum. Cancer that spreads there can cause fluid to build up in the belly. This is called ascites.

Cancer that spreads to the liver can cause yellowing of the skin and whites of the eyes, called jaundice. It may make the liver larger. Swollen lymph nodes also may be a sign that the cancer has spread.

End-of-life symptoms

Near the end of life, symptoms may change as the body slows down. In people with advanced cancer, changes in the last weeks and days of life can include:

  • Increasing tiredness and weakness.
  • Sleeping more or being less alert.
  • Loss of appetite and eating or drinking less.
  • Shortness of breath.
  • Trouble swallowing.
  • Confusion or delirium.
  • Less urine output.

In the final hours or days, breathing also may change. Some people develop noisy breathing caused by fluid collecting in the throat or airways.

When to seek care

Talk with your healthcare professional if you have symptoms of stomach cancer that are new, getting worse or worrying you. These may include ongoing stomach pain, vomiting, trouble swallowing, blood in the stool, yellowing of the skin or eyes, or swelling in the belly.

Causes

It's not clear why some stomach cancers spread and become metastatic. Metastatic stomach cancer happens when cancer cells break away from the cancer in the stomach and travel to other parts of the body. Cancer cells can grow into nearby tissue. They also can enter blood vessels or lymph vessels and travel to other parts of the body. Stomach cancer most often spreads to the liver, lungs and lining of the abdominal cavity, called the peritoneum.

Risk factors

Risk factors for stomach cancer include:

Medical conditions and infections

  • Helicobacter pylori (H. pylori) infection. Long-term infection with this bacterium can cause inflammation and changes in the stomach lining that may lead to cancer.
  • Chronic atrophic gastritis. This is long-term inflammation that causes the stomach lining to become thinner. It increases the risk of stomach cancer.
  • Intestinal metaplasia. In this condition, cells in the stomach lining change to become more like cells that typically line the intestines. It increases the risk of stomach cancer.
  • Pernicious anemia. This autoimmune condition makes it hard for the body to absorb vitamin B-12. It is linked to an increased risk of stomach cancer.
  • Gastroesophageal reflux disease (GERD). GERD is linked to an increased risk of cancer in the upper part of the stomach.
  • Obesity. Obesity is linked to an increased risk of cancer in the upper part of the stomach.
  • Epstein-Barr virus (EBV) infection. EBV infection is associated with an increased risk of stomach cancer.

Personal and family factors

  • Older age. The risk of stomach cancer increases with age.
  • Male sex. Stomach cancer occurs more often in males than in females.
  • A family history of stomach cancer. Having a parent, sibling or child who has had stomach cancer raises the risk.
  • Certain inherited cancer syndromes. These include hereditary diffuse gastric cancer, gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS), Lynch syndrome, familial adenomatous polyposis, Peutz-Jeghers syndrome, and juvenile polyposis syndrome.
  • A history of gastric mucosa-associated lymphoid tissue (MALT) lymphoma. This type of lymphoma starts in the stomach lining. People who have gastric MALT lymphoma have an increased risk of later having a type of stomach cancer called adenocarcinoma.

Lifestyle and diet

  • Cigarette smoking. Smoking raises the risk of stomach cancer.
  • A diet high in salted, smoked, preserved or ultraprocessed foods. These foods are linked to a higher risk of stomach cancer.
  • A diet low in fruits and vegetables. Eating few fruits and vegetables is linked to increased stomach cancer risk.
  • Heavy alcohol use. Heavy alcohol use may raise the risk of stomach cancer.

Complications

Stage 4 stomach cancer can cause complications from the cancer in the stomach and from cancer that has spread to other parts of the body. These may include:

  • Bleeding. A stomach tumor can bleed into the digestive tract. Ongoing bleeding may lead to low red blood cell count, a condition known as iron deficiency anemia. Treatment may be needed to control the bleeding.
  • Blockage where the stomach empties into the small intestine. A tumor can block the passage, making it difficult for food to leave the stomach. This may cause nausea, vomiting and trouble eating.
  • Malnutrition. Stomach cancer can make it difficult to eat or take in enough nutrients.

  • Complications caused by cancer in other organs. Cancer that spreads to the liver can cause jaundice or swelling in the belly. Cancer that spreads to the lungs can cause shortness of breath.

    Cancer that spreads to the lining of the abdominal cavity, called the peritoneum, can lead to a buildup of fluid in the belly, called ascites.

Diagnosis

Tests can confirm stomach cancer and show whether it has spread to distant parts of the body. Other tests can give information that helps guide treatment.

Upper endoscopy and biopsy

Upper endoscopy uses a thin, flexible tube with a camera to look inside the esophagus and stomach. During the procedure, a healthcare professional can remove a small sample of tissue, called a biopsy. A health professional called a pathologist examines the tissue for cancer cells.

Endoscopic ultrasound (EUS) may be used to show how deeply the tumor has grown and whether nearby lymph nodes may be involved. It can give more information about how far the cancer has grown in and near the stomach.

Imaging tests

Imaging tests make pictures that may show the size of the cancer in the stomach. Imaging tests also help the healthcare team look for signs of cancer in nearby lymph nodes or in other parts of the body, such as the liver and lungs. Tests may include a CT scan, positron emission tomography (PET) and magnetic resonance imaging (MRI).

Staging laparoscopy

Imaging tests can miss very small areas of cancer on the lining of the abdominal cavity, called the peritoneum. Staging laparoscopy uses small cuts in the belly to let the healthcare team look directly inside for signs that the cancer has spread. During the procedure, areas that may contain cancer can be biopsied. Fluid also may be collected and checked for cancer cells. Finding cancer cells in this fluid means the cancer has spread.

Biomarker testing

Samples of the cancer also are tested for biomarkers. Biomarkers are genes, proteins or other features of cancer cells that can help predict whether certain treatments may work.

For metastatic stomach cancer, biomarker testing may look for features such as HER2, PD-L1, mismatch repair or microsatellite instability, and CLDN18.2. These features can help the healthcare team choose treatments that are more likely to work.

More-extensive testing of the cancer's genes also may be used. Next-generation sequencing (NGS) looks at many genes in the cancer cells at the same time. It may find additional gene changes in the tumor that could affect treatment.

Genetic testing

Genetic testing is different from tumor biomarker testing. It looks for gene changes that a person was born with and may have inherited from a parent.

If your personal or family history suggests an inherited cancer syndrome, your healthcare team may recommend this type of testing, called germline genetic testing. When more than one gene may be involved, a multigene panel may be used.

Treatment

Metastatic stomach cancer usually cannot be cured. But treatment can slow or control the cancer, ease symptoms, improve quality of life and help people live longer. Most people start with medicines that work throughout the body, called systemic therapy. If the cancer grows during or after treatment, other medicines may still be available.

Treatment depends on factors such as your overall health, previous treatments and the biomarkers found in the cancer.

Chemotherapy

Chemotherapy uses strong medicines to kill cancer cells or slow their growth. For metastatic stomach cancer, you usually get chemotherapy through a vein or by mouth so that it can reach cancer cells throughout the body.

A common first treatment combines two chemotherapy medicines. One option is fluorouracil (5-FU) with oxaliplatin, known as FOLFOX. Another is capecitabine with oxaliplatin, known as CAPOX. Chemotherapy often is combined with immunotherapy or targeted therapy depending on the cancer's biomarkers.

If the cancer grows despite treatment, other chemotherapy medicines may be used. These can include paclitaxel, docetaxel, irinotecan, and trifluridine and tipiracil.

Side effects depend on the medicines used. They may include nausea, diarrhea and low blood cell counts. Some medicines can cause hand-foot syndrome, which can make the hands and feet sore. Others can cause nerve damage, called peripheral neuropathy.

Your healthcare team may use medicines to help prevent nausea. The team monitors blood counts, kidney and liver function, and nerve symptoms during treatment.

Immunotherapy

Immunotherapy may be given with chemotherapy as part of the first treatment, depending on the features of the cancer. One of these features is PD-L1 level. PD-L1 is a protein that can help cancer cells hide from the immune system. The amount of PD-L1 in the cancer can help guide whether immunotherapy is likely to be useful. Medicines such as nivolumab or pembrolizumab may be used.

Immunotherapy also may be used later if the cancer grows after the first treatment.

Immunotherapy can cause the immune system to attack healthy tissues. Side effects may include a skin rash. Immunotherapy also can cause inflammation in organs such as the colon, liver, lungs, kidneys or thyroid.

Targeted therapy

Targeted therapy uses medicines that attack specific features of cancer cells. These medicines can block signals that cancer cells use to grow or survive. Targeted therapy often is combined with chemotherapy for metastatic stomach cancer.

Some targeted medicines may be used as part of the first treatment. Others may be used if the cancer grows during or after earlier treatment. Medicines used for metastatic stomach cancer include trastuzumab, zolbetuximab, ramucirumab, trastuzumab deruxtecan and zanidatamab.

Side effects vary by medicine. They may include nausea and vomiting, low blood cell counts, tiredness and high blood pressure. Some targeted medicines can cause more-serious side effects, such as lung inflammation.

Your healthcare team may test the cancer to figure out which targeted medicines are most likely to work.

Radiation therapy

Radiation therapy uses high-energy beams to damage cancer cells. In metastatic stomach cancer, radiation often is used to relieve symptoms caused by the tumor in the stomach. It can help control bleeding and pain. It also may help relieve a blockage that makes it difficult for food to pass through the stomach.

For some people whose cancer has spread to only a few distant areas, radiation or another treatment directed at those areas may be considered along with systemic therapy.

Surgery and procedures to ease symptoms

In people with distant metastases or peritoneal spread, surgery generally is used only to ease symptoms rather than to cure the cancer.

Surgery or other procedures may be used when the cancer causes bleeding, pain or a blockage. Options may include:

  • Stent placement. A thin, expandable tube called a stent can be placed to hold open a blocked passage into or out of the stomach.
  • Surgical bypass. Surgery can create a new pathway around a blockage so food can move through the digestive tract. One example is gastrojejunostomy, which connects the stomach to the small intestine.
  • Endoscopic treatment. An endoscopic procedure may be used to help open a blockage caused by the cancer.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

For a small group of people whose stomach cancer has spread to the peritoneum, surgery and HIPEC may be considered at specialized centers. The surgery, called cytoreductive surgery, removes as much visible cancer as possible. During HIPEC, heated chemotherapy is circulated in the abdominal cavity to treat cancer cells that may remain.

This approach is not standard treatment for most people with metastatic stomach cancer. Studies have mainly included people with a small amount of cancer in the peritoneum who first received systemic therapy. Whether it is right for you depends on factors such as the extent of peritoneal disease and whether visible cancer can be completely removed.

Palliative care

Palliative care is specialized care that focuses on easing symptoms and improving quality of life. It can be given at the same time as treatments intended to control the cancer. Early palliative care may help with symptoms, nutrition, emotional distress and decisions about treatment.

If you have metastatic stomach cancer, you may need help managing issues such as pain, nausea, trouble eating, weight loss, bleeding or a blockage in the stomach. Palliative care specialists work with the cancer care team to help manage these issues and support you and your family throughout treatment.

Lifestyle and home remedies

Eating well can be difficult with metastatic stomach cancer. The cancer itself and its treatments can cause loss of appetite, nausea, vomiting, feeling full quickly and weight loss. People with cancers of the digestive tract are at particular risk of malnutrition and loss of muscle mass.

The best eating plan depends on your symptoms and nutrition needs. The goal is usually to get enough calories, protein and other nutrients to maintain strength and support treatment.

These strategies may help:

  • Eat small meals and snacks throughout the day instead of three large meals.
  • Choose foods that are high in calories and protein when you are able to eat.
  • Drink fluids between meals if drinking with meals makes you feel full too quickly.
  • Try softer or easier-to-digest foods if swallowing or digestion is difficult.
  • Tell your healthcare team if nausea, vomiting, pain or other symptoms are making it hard to eat.
  • Ask to meet with a dietitian who has experience working with people who have cancer.

Weight loss during cancer treatment is not always helpful, even for people who started treatment at a higher body weight. Losing muscle can make it harder to tolerate treatment and may affect quality of life.

Coping and support

Living with metastatic stomach cancer can bring uncertainty about treatment, symptoms and the future. It may help to focus on the parts of your care that you can manage now.

You may find it helpful to:

  • Learn enough to make decisions about your care. Ask your healthcare professional to write down the details of your cancer. This can include the type, the stage and your treatment options. Use those details to find more information about stomach cancer. Learn about the benefits and risks of each treatment option.
  • Find a good listener. Talking with someone you trust about your hopes and worries can help. This could be a friend or family member. A counselor, medical social worker or clergy member also may offer helpful guidance and care.
  • Connect with other people with cancer. Ask your healthcare team about support groups in your area. Find support online through Mayo Clinic Connect, a community where you can interact with others for support, practical information and answers to everyday questions.
  • Stay active. Being diagnosed with cancer doesn't mean you have to stop doing the things you enjoy or usually do. If you feel well enough, you can continue activities you like.

Preparing for an appointment

If you have stage 4 stomach cancer, you likely will see specialists who treat advanced or metastatic disease. You might meet with:

  • A doctor who uses medicines to treat cancer, called an oncologist.
  • A doctor who treats diseases of the digestive system, called a gastroenterologist.
  • A doctor who removes stomach cancer using surgery, called a surgeon or surgical oncologist.
  • A doctor who uses radiation to treat cancer, called a radiation oncologist.

Here's some information to help you get ready for your appointment.

What you can do

Ask a family member or friend to go to your appointment with you. This person can help you remember the information you're told.

Make a list of:

  • Your symptoms and when they began.
  • Key medical information, including other conditions you have and your family medical history.
  • All medicines, vitamins or supplements you take, including doses.
  • Questions to ask your healthcare team.

Some basic questions to ask include:

  • Where has the cancer spread in my body?
  • How serious is my condition?
  • Can you explain the biopsy and biomarker test results to me?
  • Can I have a copy of my test results?
  • Will I need more tests?
  • What are the treatment options for my stomach cancer?
  • Is the goal of treatment to control the cancer, ease symptoms or both?
  • What are the possible side effects of each treatment?
  • How will each treatment affect my daily life and ability to eat?
  • How much time can I take to decide about treatment?
  • Are clinical trials available for me?

What to expect from your doctor

Be prepared to answer some basic questions about your symptoms and health, such as:

  • What are your symptoms?
  • Have you had trouble eating, swallowing or keeping down food?
  • Have you lost weight without trying?
  • Is there a family history of stomach cancer or other cancers, especially at a young age?
  • Have you or any relatives been tested for an inherited cancer syndrome?
  • Do you have any other health conditions, such as diabetes, heart disease or kidney disease?

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