Stomach cancer

Dr Daleen Geldenhuys educates us on stomach cancer and explains why nutritional support is imperative.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

What is stomach cancer?

There are several cancers that can originate in the stomach. These include MALT lymphomas, neuroendocrine tumours, and adenocarcinomas, which will be focused on below.  

Adenocarcinomas

Adenocarcinomas can vary in position in the stomach. It can be a localised ulcer in any part of the stomach or a widespread infiltration in the lining of the stomach, not showing a superficial ulcer, resulting in a unstretchable, hard stomach (linitis plastica). The cancer that arises in the junction between the oesophagus and stomach is included in the definition of stomach cancer.

Incidence and severity

Stomach cancer, also known as gastric cancer, is rare and can be familial. The prognosis of patients with stomach cancer is related to how big the tumour is and includes both nodal involvement and direct tumour extension through the gastric wall. Size and lymph node status determines the stage. However, the tumour grade may also provide some prognostic information.

In localised distal stomach cancer, more than 50% of patients can be cured. However, early-stage disease accounts for only 10 to 20% of all cases diagnosed. The remaining patients present with advanced disease in either regional (lymph nodes) or distant sites such as lung, liver, or even skeletal metastases.

The five-year overall survival rate in these patients ranges from almost no survival for patients with Stage 4 disease to almost 50% survival for patients with localised distal stomach cancers that can be surgically removed.

Even with apparent localised disease, the five-year survival rate of patients with proximal stomach cancer is only 10 to 15%. Although treatment of patients with advanced stomach cancer may result in palliation of symptoms and some prolongation of survival, long remissions are uncommon. 

The risk of stomach cancer is higher in people with:

• Helicobacter pylori gastric infection
• Advanced age and male sex
• Diet low in fruits and vegetables and high in salted, smoked, or preserved foods
• Chronic atrophic gastritis
• Intestinal metaplasia
• Pernicious anaemia
• Gastric polyps
• Family history of stomach cancer and familial polyposis
• Cigarette smoking
• Ménétrier disease (giant hypertrophic gastritis)
• Epstein-Barr virus infection

Symptoms

Most patients with stomach cancer are symptomatic. Weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis. Not everyone has heartburn. Approximately 25% of patients with stomach cancer have a history of gastric ulcer.

Weight loss is the most severe symptom. Not only is it more difficult to eat because of pain but the patient often complains of not being able to eat a normal-sized meal. The pain is often in the middle just below the breastbone. It can be vague early in the disease, but intractable pain is common as the disease progresses.

Pain and difficulty swallowing are common presenting symptoms in patients with cancers arising in the proximal stomach or atthe esophagogastric junction.Sometimes the oesophagus appears paralysed and can’t contract properly to deliver the food to the stomach. It may be because the tumour extends through the wall of the stomach or distal oesophagus disabling the complex nerves involved in swallowing.

Nausea or early satiety may result from the tumour mass. In cases of an aggressive form of diffuse-type stomach cancer called linitis plastica, these symptoms arise from the inability of the stomach to distend. Patients may also present with gastric outlet obstruction from an advanced distal tumour. The patient will be able to eat but will bring up most of the meal within half an hour.

The cancer may bleed (intensive bleeding or slow bleeding) that the patient will complain of symptoms of iron deficiency. There may also be a complaint of a palpable and painful stomach mass.

Treatment

If a patient presents with early cancer, an endoscopic mucosal resection may be performed with careful follow-up to ensure that regrowth is caught early, but mostly this is not the case.

For disease limited to a specific area, a partial gastrectomy can be performed where only a part of the stomach is removed. For extensive disease, a total gastrectomy is needed.

Chemotherapy can be given before surgery to ensure response to treatment, to facilitate a better surgical procedure and to ensure the patient can have better nutrition to prepare for a life without a stomach.

Medical therapy has advanced in a way where the cancer is typed, and certain mutations can be targeted and even given immunotherapy to ensure better survival and longer remission.

Radiation and concomitant chemotherapy are given after a successful surgical removal for prevention of recurrence.

Nutritional support is vital

Unfortunately, stomach cancer is a painful and aggressive cancer that needs meticulous pain control. Nutritional support is vital for survival and for the tolerance of therapy which will include most modalities of treatment.

It’s vital that symptoms such as easy weight loss, heartburn, pain, and a family history of cancer, be taken very seriously to ensure the best outcome for this disease.

Header image by Freepik