Stomach cancer (also known as gastric cancer) is a disease in which the cells forming the inner lining of the stomach become abnormal and start to divide uncontrollably, forming a mass called a tumor.
The stomach is a J-shaped organ that lies in the left and central portion of the abdomen. The stomach produces many digestive juices and acids that mix with the food and aid in the process of digestion. There are five regions of the stomach that doctors refer to when determining the origin of stomach cancer. These are:
- the cardia, area surrounding the cardiac sphincter which controls movement of food from the esophagus into the stomach;
- the fundus, upper expanded area adjacent to the cardiac region;
- the antrum, lower region of the stomach where it begins to narrow;
- the prepyloric, region just before or nearest the pylorus;
- and the pylorus, the terminal region where the stomach joins the small intestine.
Cancer can develop in any of the five sections of the stomach. Symptoms and outcomes of the disease will vary depending on the location of the cancer.
Based on previous data from the National Cancer Institute and the United States Census, the American Cancer Society estimates that 21, 700 Americans will be diagnosed with stomach cancer during 2001 and approximately 13, 000 deaths will result from the disease. In most areas, men are affected by stomach cancer nearly twice as often as women. Most cases of stomach cancer are diagnosed between the ages of 50 and 70 but in families with a hereditary risk of stomach cancer, younger cases are more frequently seen.
Stomach cancer is one of the leading causes of cancer deaths in several areas of the world, most notably Japan and other Asian countries. In Japan it appears almost ten times as frequently as in the United States. The number of new stomach cancer cases is decreasing in some areas, however, especially in developed countries. In the United States, incidence rates have dropped from 30 individuals per 100, 000 in the 1930s, to only 8 in 100, 000 individuals developing stomach cancer by the 1980s. The use of refrigerated foods and increased consumption of fresh fruits and vegetables, instead of preserved foods with high salt content, may be a reason for the decline.
Causes and symptoms
While the exact cause for stomach cancer has not been identified, several potential factors have lead to increased numbers of individuals developing the disease and therefore, significant risk has been associated. Diet, work environment, exposure to the bacterium Helicobacter pylori, and a history of stomach disorders such as ulcers or polyps are some of these believed causes.
Studies have shown that eating foods with high quantities of salt and nitrites increases the risk of stomach cancer. The diet in a specific region can have a great impact on its residents. Making changes to the types of foods consumed has been shown to decrease likelihood of disease, even for individuals from countries with higher risk. For example, Japanese people who move to the United States or Europe and change the types of foods they eat have a far lower chance of developing the disease than do Japanese people who remain in Japan and do not change their dietary habits. Eating recommended amounts of fruit and vegetables may lower a person's chances of developing this cancer.
A high risk for developing stomach cancers has been linked to certain industries as well. The best proven association is between stomach cancer and persons who work in coal mining and those who work processing timber, nickel, and rubber. An unusually large number of these workers have been diagnosed with this form of cancer.
Several studies have identified a bacterium (Helicobacter pylori) that causes stomach ulcers (inflammation in the inner lining of the stomach). Chronic (long-term) infection of the stomach with these bacteria may lead to a particular type of cancer (lymphomas or mucosa-associated lymphoid tissue [MALT]) in the stomach.
Another risk factor is the development of polyps, benign growths in the lining of the stomach. Although polyps are not cancerous, some may have the potential to turn cancerous. People in blood group A are also at elevated risk for this cancer for unknown reasons. Other speculative causes of stomach cancer include previous stomach surgery for ulcers or other conditions, or a form of anemia known as pernicious anemia.
Stomach cancer is a slow-growing cancer. It may be years before the tumor grows very large and produces distinct symptoms. In the early stages of the disease, the patient may only have mild discomfort, indigestion, heartburn, a bloated feeling after eating, and mild nausea. In the advanced stages, a patient will have loss of appetite
Unfortunately, many patients diagnosed with stomach cancer experience pain for two or three years before informing a doctor of their symptoms. When a doctor suspects stomach cancer from the symptoms described by the patient, a complete medical history will be taken to check for any risk factors. A thorough physical examination will be conducted to assess all the symptoms. Laboratory tests may be ordered to check for blood in the stool (fecal occult blood test) and anemia (low red blood cell count), which often accompany gastric cancer.
In some countries, such as Japan, it is appropriate for patients to be given routine screening examinations for stomach cancer, as the risk of developing cancer in that society is very high. Such screening might be useful for all high-risk populations. Due to the low prevalence of stomach cancer in the United States, routine screening is usually not recommended unless a family history of the disease exists.
Whether as a screening test or because a doctor suspects a patient may have symptoms of stomach cancer, endoscopy or barium x-rays are used in diagnosing stomach cancer. For a barium x ray of the upper gastrointestinal tract, the patient is given a chalky, white solution of barium sulfate to drink. This solution coats the esophagus, the stomach, and the small intestine. Air may be pumped into the stomach after the barium solution in order to get a clearer picture. Multiple x rays are then taken. The barium coating helps to identify any abnormalities in the lining of the stomach.
In another more frequently used test, known as upper gastrointestinal endoscopy, a thin, flexible, lighted tube (endoscope) is passed down the patient's throat and into the stomach. The doctor can view the lining of the esophagus and the stomach through the tube. Sometimes, a small ultrasound probe is attached at the end of the endoscope. This probe sends high frequency sound waves that bounce off the stomach wall. A computer creates an image of the stomach wall by translating the pattern of echoes generated by the reflected sound waves. This procedure is known as an endoscopic ultrasound or EUS.
Endoscopy has several advantages, in that the physician is able to see any abnormalities directly. In addition, if any suspicious-looking patches are seen, biopsy forceps can be passed painlessly through the tube to collect some tissue for microscopic examination. This is known as a biopsy. EUS is beneficial because it can provide valuable information on depth of tumor invasion.
After stomach cancer has been diagnosed and before treatment starts, another type of x-ray scan is taken. Computed tomography (CT) is an imaging procedure that produces a three-dimensional picture of organs or structures inside the body. CT scans are used to obtain additional information in regard to how large the tumor is and what parts of the stomach it borders; whether the cancer has spread to the lymph nodes; and whether it has spread to distant parts of the body (metastasized), such as the liver, lung, or bone. A CT scan of the chest, abdomen, and pelvis is taken. If the tumor has gone through the wall of the stomach and extends to the liver, pancreas, or spleen, the CT will often show this. Although a CT scan is an effective way of evaluating whether cancer has spread to some of the lymph nodes, it is less effective than EUS in evaluating whether the nodes closest to the stomach are free of cancer. However, CT scans, like barium x rays, have the advantage of being less invasive than upper endoscopy.
Laparoscopy is another procedure used to stage some patients with stomach cancer. This involves a medical device similar to an endoscope. A laparoscopy is a minimally invasive surgery technique with one or a few small incisions, which can be performed on an outpatient basis, followed by rapid recovery. Patients who may receive radiation therapy or chemotherapy before surgery may undergo a laparoscopic procedure to determine the precise stage of cancer. The patient with bone pain or with certain laboratory results should be given a bone scan.
Benign gastric neoplasms are tumors of the stomach that cause no major harm. One of the most common is called a submucosal leiomyoma. If a leiomyoma starts to bleed, surgery should be performed to remove it. However, many leiomyomas require no treatment. Diagnosis of stomach cancers should be conducted carefully so that if the tumor does not require treatment the patient is not subjected to a surgical operation.
Clinical staging and prognosis
More than 95% of stomach cancers are caused by adenocarcinomas, malignant cancers that originate in glandular tissues. The remaining 5% of stomach cancers include lymphomas and other types of cancers. It is important that gastric lymphomas be accurately diagnosed because these cancers have a much better prognosis than stomach adenocarcinomas. Approximately half of the people with gastric lymphomas survive five years after diagnosis. Treatment for gastric lymphoma involves surgery combined with chemotherapy and radiation therapy.
Staging of stomach cancer is based on how deep the growth has penetrated the stomach lining; to what extent (if any) it has invaded surrounding lymph nodes; and to what extent (if any) it has spread to distant parts of the body (metastasized). The more confined the cancer, the better the chance for a cure.
One important factor in the staging of adenocarcinoma of the stomach is whether or not the tumor has invaded the surrounding tissue and, if it has, how deep it has penetrated. If invasion is limited, prognosis is favorable. Diseased tissue that is more localized improves the outcome of surgical procedures performed to remove the diseased area of the stomach. This is called a resection of the stomach.
Several distinct ways of classifying stomach cancer according to cell type have been proposed. The Lauren classification is encountered most frequently. According
Because symptoms of stomach cancer are so mild, treatment often does not commence until the disease is well advanced. The three standard modes of treatment for stomach cancer include surgery, radiation therapy, and chemotherapy. While deciding on the patient's treatment plan, the doctor takes into account many factors. The location of the cancer and its stage are important considerations. In addition, the patient's age, general health status, and personal preferences are also taken into account.
In the early stages of stomach cancer, surgery may be used to remove the cancer. Surgical removal of adeno-carcinoma is the only treatment capable of eliminating the disease. Laparoscopy is often used before surgery to investigate whether or not the tumor can be removed surgically. If the cancer is widespread and cannot be removed with surgery, an attempt will be made to remove blockage and control symptoms such as pain or bleeding. Depending on the location of the cancer, a portion of the stomach may be removed, a procedure called a partial gastrectomy. In a surgical procedure known as total gastrectomy, the entire stomach may be removed. However, doctors prefer to leave at least part of the stomach if possible. Patients who have been given a partial gastrectomy achieve a better quality of life than those having a total gastrectomy and typically lead normal lives. Even when the entire stomach is removed, the patients quickly adjust to a different eating schedule. This involves eating small quantities of food more frequently. High-protein foods are generally recommended.
Partial or total gastrectomy is often accompanied by other surgical procedures. Lymph nodes are frequently removed and nearby organs, or parts of these organs, may be removed if cancer has spread to them. Such organs may include the pancreas, colon, or spleen.
Preliminary studies suggest that patients who have tumors that cannot be removed by surgery at the start of therapy may become candidates for surgery later. Combinations of chemotherapy and radiation therapy are sometimes able to reduce disease for which surgery is not initially appropriate. Preliminary studies are being performed to determine if some of these patients can become candidates for surgical procedures after such therapies are applied.
Whether or not patients undergoing surgery for stomach cancer should receive chemotherapy is a controversial issue. Chemotherapy involves administering anti-cancer drugs either intravenously (through a vein in the arm) or orally (in the form of pills). This can either be used as the primary mode of treatment or after surgery to destroy any cancerous cells that may have migrated to distant sites. Most cancers of the gastrointestinal tract do not respond well to chemotherapy, however, adenocarcinoma of the stomach and advanced stages of cancer are exceptions.
Chemotherapy medicines such as doxorubicin, mitomycin C, and fluorouracil, used alone, provide benefit to at least one in five patients. Combinations of agents may provide even more benefit, although it is not certain that this includes longer survival. For example, some doctors use what is called the FAM regimen, which combines fluorouacil, doxorubicin, and mitomycin. Some doctors prefer using fluorouracil alone to FAM since side effects are more moderate. Another combination some doctors are using involves high doses of the medications methotrexate, fluorouacil, and doxorubicin. Other combinations that have shown benefit include the ELF regimen, a combination of leucovorin, fluorouracil, and etoposide. The EAP regimen, a combination of etopo-side, doxorubicin, and cisplatin is also used.
Although chemotherapy using a single medicine is sometimes used, the best response rates are often achieved with combinations of medicines. Therefore, in addition to studies exploring the effectiveness of new medicines there are other studies attempting to evaluate how to best combine existing forms of chemotherapy to bring the greatest degree of help to patients.
Radiation therapy is often used after surgery to destroy the cancer cells that may not have been completely removed during surgery. To treat stomach cancer, external beam radiation therapy is generally used. In this procedure, high-energy rays from a machine that is outside of the body are concentrated on the area of the tumor. In the advanced stages of stomach cancer, radiation therapy is used to ease the symptoms such as pain and bleeding. However, studies of radiation treatment for stomach cancer have shown that the way it has been used it has been ineffective for many patients.
Researchers are actively assessing the role of chemotherapy and radiation therapy used before a surgical
Overall, approximately 20% of patients with stomach cancer live at least five years following diagnosis. Patients diagnosed with stomach cancer in its early stages have a far better prognosis than those for whom it is in the later stages. In the early stages, the tumor is small, lymph nodes are unaffected, and the cancer has not migrated to the lungs or the liver. Unfortunately, only about 20% of patients with stomach cancer are diagnosed before the cancer had spread to the lymph nodes or formed a distant metastasis.
It is important to remember that statistics on prognosis may be misleading. Newer therapies are being developed rapidly and five-year survival has not yet been measured with these. Also, the largest group of people diagnosed with stomach cancer are between 60 and 70 years of age, suggesting that some of these patients die not from cancer but from other age-related diseases. As a result, some patients with stomach cancer may be expected to have longer survival than did patients just ten years ago.
Coping with cancer treatment
Many patients experience feelings of depression, anxiety, and fatigue when dealing with the knowledge and treatments associated with stomach cancer. Side effects such as nausea and vomiting may also present during treatment. Understanding what to expect as a result of the various treatments and learning about alternative methods for reducing these symptoms may improve the effectiveness of treatments and provide a more positive outlook in regard to the individual's situation. A doctor or other health professional should be consulted to develop strategies for managing any negative symptoms or feelings.
Avoiding many of the risk factors associated with stomach cancer may prevent its development. Excessive amounts of salted, smoked, and pickled foods should be avoided, as should foods high in nitrates. A diet that includes recommended amounts of fruits and vegetables is believed to lower the risk of several cancers, including stomach cancer. The American Cancer Society recommends eating at least five servings of fruits and vegetables daily and choosing six servings of food from other plant sources, such as grains, pasta, beans, cereals, and whole grain bread.
Abstaining from tobacco and excessive amounts of alcohol will reduce the risk for many cancers. In countries where stomach cancer is common, such as Japan, early detection is important for successful treatment.
Following gastrectomy or partial gastrectomy it is important for the patient to carefully follow doctor's orders about what foods are eaten and when they should be eaten. In particular, the patient may be asked to have small, frequent meals.
Braunwald, Eugene, et al. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2001.
Herfindal Eric T., and Dick R. Gourley. Textbook of Therapeu tics: Drug and Disease Management, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
Humes, H. David, ed-in-chief. Kelley's Textbook of Internal Medicine. Philadelphia: Lippincott Williams & Wilkins, 2000.
Pazdur, Richard et al. Cancer Management: A Multidiscipli-nary Approach: Medical, Surgical, & Radiation Oncolo gy, 4th ed. Melville, NY: PRR, 2000.
Souhami, Robert, and Jeffrey Tobias. Cancer and Its Manage ment, 3rd ed. London: Blackwell Science, 1998.
Steen, Grant, and Joseph Mirro. Childhood Cancer: A Hand book from St. Jude Children's Research Hospital. Cambridge, MA: Perseus Publishing, 2000.
What You Need to Know About Stomach Cancer. PDQ Treat ment—Patients: Gastric Cancer. The National Cancer Institute. (800) 4-CANCER. <http://www.nci.nih.gov>.
Stomach Cancer: Detection and Symptoms. Stomach Cancer: Prevention and Risk Factors. Stomach Cancer: Treat ment. Stomach Cancer: What Is It? American Cancer Society. (800) ACS-2345. <http://www.cancer.org>.
National Coalition for Cancer Survivorship. 1010 Wayne Ave., 7th Floor, Silver Spring, MD 20910-5600. (301) 650-9127 or (877) NCCS-YES. <http://www.cansearch.org>.
Lata Cherath, Ph.D.
—Malignant cancers that originate in the tissues of glands or that form glandular structures.
—A condition in which iron levels in the blood are low.
Barium x ray (upper GI)
—An x-ray test of the upper part of the gastrointestinal (GI) tract (including the esophagus, stomach, and a small portion of the small intestine) after the patient is given a white, chalky barium sulfate solution to drink. This substance coats the upper GI and the x rays reveal any abnormality in the lining of the stomach and the upper GI.
—Removal of a tissue sample for examination under the microscope to check for cancer cells.
—Treatment of cancer with synthetic drugs that destroy the tumor either by inhibiting the growth of the cancerous cells or by killing the cancer cells.
Endoscopic ultrasound (EUS)
—A medical procedure in which sound waves are sent to the stomach wall by an ultrasound probe attached to the end of an endoscope. The pattern of echoes generated by the reflected sound waves are translated into an image of the stomach wall by a computer.
External radiation therapy
—A tumor that moves into another organ of the body.
—An abnormal growth that develops on the inside of a hollow organ such as the colon, stomach, or nose.
—Treatment using high-energy radiation from x-ray machines, cobalt, radium, or other sources.
—A medical procedure in which a thin, lighted, flexible tube (endoscope) is inserted down the patient's throat. Through this tube the doctor can view the lining of the esophagus, stomach, and the upper part of the small intestine.
QUESTIONS TO ASK THE DOCTOR
- Has the cancer spread to the lymph nodes?
- Has the cancer spread to the lungs, liver, or spleen?
- (After endoscopy or barium x-rays and CT scan have been completed)Would I benefit from endoscopic ultrasound or laparoscopy?
- (If surgery is recommended) Do recent studies show that it might be a good idea to also use chemotherapy or radiation therapy?
- (If gastrectomy or partial gastrectomy was performed) How should I alter my diet and eating patterns?
- (Following surgery) What foods should I be eating? Is there a registered dietitian I can speak with on a regular basis about what I should eat?
Table Of Contents
- Causes and symptoms
- Clinical staging and prognosis
- Coping with cancer treatment
- Special concerns
- Barium x ray (upper GI)
- Endoscopic ultrasound (EUS)
- External radiation therapy
- Radiation therapy
- Total gastrectomy
- Upper endoscopy
- QUESTIONS TO ASK THE DOCTOR