Gastric Cancer Treatment

What is stomach cancer?

Stomach cancer (also called gastric cancer) starts in the stomach. After food has been chewed and swallowed, it passes down a tube called the esophagus and empties into the stomach. The stomach is a sack-like organ that holds food and mixes it with gastric juice to begin the process of digestion.

Stomach cancer, also called gastric cancer, begins when cells in the stomach become abnormal and grow uncontrollably. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

Cancer can start in any part of the stomach. Symptoms, treatment options, and the outlook for survival can all vary depending on where the cancer begins.

The stomach itself is made up offive layers. Starting from the inside and working out:

The innermost layer is called the mucosa – This is where the stomach acid and digestive juices are made
Next is a supporting layer called the submucosa
This is surrounded by the muscularis, a layer of muscle that moves and mixes the stomach contents.
The next 2 layers, the subserosa and the serosa (the outermost layer) act as wrapping for the stomach.

Most of the time stomach cancer starts in the mucosa.

Stomach cancer probably grows slowly over many years. Before a true cancer develops, there are usually changes that take place in the lining of the stomach. These early changes rarely produce symptoms and therefore often are not noticed.

Stomach cancer can spread in several different ways:

It can grow through the wall of the stomach and eventually grow into nearby organs.

It can also spread to the lymph nodesand then through the lymph system. If cancer spreads this way, the outlook for a cure gets worse.

When stomach cancer is more advanced, it can travel through the bloodstream and form deposits of cancer cells in organs such as the liver, lungs, and bones.

Most cancers of the stomach are of a type called adenocarcinomas. This cancer develops from cells that form the lining of the innermost layer, the mucosa. The term “stomach cancer” almost always refers to this type of cancer. Lymphomas, gastric stromal tumors, and carcinoid tumors are other, much less common, tumors that are found in the stomach.

What causes stomach cancer?

The major risk factors for stomach cancer are listed below:

Bacterial infection: Many doctors think that infection with bacteria called Helicobacter pylori may be a major cause of stomach cancer. Long-term infection with this germ can lead to inflammation and damage to the inner layer of the stomach, a possible pre-cancerous change. This bacterium is also linked to some types of lymphoma of the stomach. But most people who carry this germ in their stomachs never develop cancer.

Diet: An increased risk of stomach cancer is linked to diets high in smoked foods, salted fish and meats, and pickled vegetables. On the other hand, eating whole grain products and fresh fruits and vegetables that contain vitamins A and C appears to lower the risk of stomach cancer.

Tobacco and alcohol abuse: Smoking just about doubles the risk of stomach cancer for smokers. While some studies have linked alcohol use to stomach cancer, this is not certain.

Obesity: Being very overweight (obese) is a major cause of many cancers, including cancer of the stomach.

Earlier stomach surgery: Stomach cancer is more likely to occur in people who have had part of their stomach removed to treat other problems such as ulcers.

Pernicious anemia: In this disease, the stomach doesn’t make enough of a protein that allows the body to absorb vitamin B12 from foods. This can lead to anemia (a shortage of red blood cells). Patients with this disease also have a slightly increased risk of stomach cancer.

Menetrier disease: This rare disease involves changes in the stomach lining that in turn are linked to a risk of stomach cancer.

Gender: Stomach cancer is more common in menthan it is in women.

Ethnicity: The rate of stomach cancer is higher in Hispanics and African Americans than in non-Hispanic whites. The highest rates are seen in Asian/Pacific Islanders.

Age: There is a sharp increase in stomach cancer after the age of 50.

Type A blood: For unknown reasons, people with type A blood have a higher risk of getting stomach cancer.

Family history: People with several close relatives who have had stomach cancer are more likely to develop this disease. Also, some families have a gene change (mutation) that puts them at greater risk for getting colorectal cancer and a slightly higher risk of stomach cancer.

Stomach polyps: Polyps are small mushroom-like growths of the lining of the stomach. Most types of polyps do not increase the risk of stomach cancer. But one type (adenomatous polyps) sometimes develops into stomach cancer.

Geography: Stomach cancer is most common in Japan, China, Southern and Eastern Europe, and South and Central America. This disease is less common in Northern and Western Africa, Melanesia, South Central Asia, and North America.

Epstein-Barr virus: This virus causes “mono” (infectious mononucleosis). It has been found in the stomach cancers of some people.

While there are many risk factors for stomach cancer, we do not know exactly how these factors cause cells of the stomach to become cancerous. Scientists are trying to learn how and why certain changes take place in the lining of the stomach and what part H. pylori plays in stomach cancer.

What are the symptoms of this cancer?

People with stomach cancer may experience the following symptoms or signs. Sometimes, people with stomach cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Stomach cancer is usually not found at an early stage because it often does not cause specific symptoms. When symptoms do occur, they may be vague and can include:

Indigestion or heartburn

Pain or discomfort in the abdomen

Nausea and vomiting, particularly vomiting up of solid food shortly after eating

Diarrhea or constipation

Bloating of the stomach after meals

Loss of appetite

Sensation of food getting stuck in the throat with eating

Symptoms of advanced stomach cancer may include:

Weakness and fatigue

Vomiting blood or having blood in the stool

Unexplained weight loss

It is important to remember that these symptoms can also be caused by many other illnesses, such as a stomach virus or an ulcer. People with any of the symptoms listed above should talk with their doctor.

How do you diagnose stomach cancer?

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

The type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose stomach cancer:

Biopsy A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Endoscopy This test allows the doctor to see the inside of the body. The person may be sedated, and the doctor inserts a thin, lighted, flexible tube called a gastroscope or endoscope through the mouth, down the esophagus, and into the stomach and small bowel. The doctor can remove a sample of tissue during an endoscopy and check it for evidence of cancer.

Endoscopic ultrasound This test is similar to an endoscopy, but the gastroscope has a small ultrasound probe on the end that produces a detailed image of the stomach wall. An ultrasound uses sound waves to create a picture of the internal organs. The ultrasound image helps doctors determine how far the cancer has spread into the stomach and nearby lymph nodes, tissue, and organs, such as the liver.

X-ray An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.

Barium swallow In a barium swallow, a person swallows a liquid containing barium, and a series of x-rays are taken. Barium coats the lining of the esophagus, stomach, and intestines, so tumors or other abnormalities are easier to see on the x-ray.

Computed tomography (CT or CAT) scan A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI) An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Positron emission tomography (PET) scan.

A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Laparoscopy A laparoscopy is a minimally invasive surgery in which the surgeon inserts a scope into the abdominal cavity to evaluate spread of the stomach cancer to the lining of the abdominal cavity or liver. This pattern of spread of the cancer is not detected by CT or PET scan.

Staging

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis (chance of recovery

One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatment.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How far has the primary tumor extended into the stomach? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Recurrent cancer. Recurrent cancer is cancer that comes back after treatment. It may be a localized recurrence (comes back in the place where it started), or it may be a distant metastasis (comes back in another part of the body).

How do you treat stomach cancer ?

No matter what stage of stomach cancer you have, there is treatment. The choice of treatment you receive depends on many factors. The place and stage of the tumor are very important, of course. But other factors include your age, your overall health, and your personal wishes.

The main treatments for stomach cancer are:

Surgery

Chemotherapy

Radiation therapy

Often the best approach involves using 2 or more of these treatment methods. Your recovery is one goal of your cancer care team. If a cure is not possible, treatment is aimed at relieving symptoms such as trouble eating, pain, or bleeding. Before you start treatment it is important that you understand the goal of your treatment– whether it is to cure or to relieve symptoms.

Surgery

Depending on the type and stage of your cancer, surgery might be used to remove the cancer and that part of the stomach where it is attached. The surgeon will try to leave behind as much normal stomach as possible. At this time, surgery is the only way to cure stomach cancer. If you have stage 0, I, II, or IIII cancer, and if you are healthy enough, an attempt should be made to treat the cancer by completely removing it. Even if the cancer is too widespread to be completely removed by surgery, an operation could help prevent bleeding from the tumor or keep the stomach from becoming blocked. This type of surgery is known as palliative, meaning that it relieves or prevents symptoms but is not expected to cure the cancer.

There are three main types of surgery for stomach cancer:

Endoscopic mucosal resection: Resection refers to the removal of a tumor or part of an organ by cutting it out. With this method, the cancer is removed through the endoscope. This can be done only for very early cancers where the chance of spread to the lymph nodes is very low.

Subtotal(partial) gastrectomy: This approach can be used if the cancer is in the lower part of the stomach close to the intestines. Only part of the stomach is removed, sometimes along with the first part of the small intestine. Eating is much easier with this approach rather than when the whole stomach is removed.

Total gastrectomy: This method is used if the cancer is in the middle or upper part of the stomach. The surgeon removes the entire stomach. Because the stomach holds and digests food, when it is removed a person will fill up after only a few mouthfuls. To solve this problem, the surgeon will try to make a new “stomach” out of intestinal tissue. No matter how effective this is, people who have had a total gastrectomy can only eat a small amount of food at a time. Because of this, they must eat more often.

If surgery is done to cure the cancer, the lymph nodes and some of the fatty tissue (omentum) around the stomach are removed as well. If the cancer has spread beyond the stomach to the spleen, it will be removed too.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Patients with stomach cancer usually receive external-beam radiation therapy, which is radiation given from a machine outside the body. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells.

Side effects from radiation therapy include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body.

Chemotherapy can be given by mouth (orally) or injection. The goal of chemotherapy can be to destroy cancer remaining after surgery, slow the tumor’s growth, or to reduce cancer-related symptoms. It also may be combined with radiation therapy.

In addition, patients whose stomach tumors have too much of the protein HER2 (called HER2-positive cancer) may benefit from the addition of trastuzumab (Herceptin) to chemotherapy in advanced stomach cancer. For more information about targeted therapies, such as trastuzumab,

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Biological therapy

Biological therapy (also called immunotherapy) is a form of stomach cancer treatment that helps the body’s immune system attack and destroy cancer cells;
it may also help the body recover from some of the side effects of treatment. In clinical trials, doctors are studying biological therapy in combination with other treatments to try to prevent a recurrence of stomach cancer.
In another use of biological therapy, patients who have low blood cell counts during or after chemotherapy may receive colony-stimulating factors to help restore the blood cell levels.
Patients may need to stay in the hospital while receiving some types of biological therapy.
Advanced stomach cancer

Advanced stomach cancer has spread to other areas of the body and is generally treated the same way as earlier stages of the disease, with surgery, chemotherapy, or radiation therapy.

Doctors may also recommend ways to relieve symptoms, called supportive care or palliative care. For instance, surgery can prevent intestinal or stomach blockages. Chemotherapy or radiation therapy can also help relieve symptoms.

What are the side effects of treatment?

It is hard to limit the side effects of stomach cancer therapy so that only cancer cells are removed or destroyed. Because healthy cells and tissues also may be damaged, treatment for stomach cancer can cause unpleasant side effects.

The side effects of stomach cancer treatment are different for each person, and they may even be different from one treatment to the next.

Side effects of surgery

Gastrectomy is major surgery. For a period of time after the surgery, the person’s activities are limited to allow healing to take place.

For the first few days after surgery, the patient is fed intravenously (through a vein). Within several days, most patients are ready for liquids, followed by soft, then solid, foods.

Those who have had their entire stomach removed cannot absorb vitamin B12, which is necessary for healthy blood and nerves, so they need regular injections of this vitamin.

Patients may have temporary or permanent difficulty digesting certain foods, and they may need to change their diet.

Some gastrectomy patients will need to follow a special diet for a few weeks or months, while others will need to do so permanently.

Some gastrectomy patients have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly. This group of symptoms is called the dumping syndrome. Foods containing high amounts of sugar often make the symptoms worse. The dumping syndrome can be treated by changing the stomach cancer patient’s diet. Doctors often advise patients to eat several small meals throughout the day, to avoid foods that contain sugar, and to eat foods high in protein.

To reduce the amount of fluid that enters the small intestine, patients are usually encouraged not to drink at mealtimes. Medicine also can help control the dumping syndrome. The symptoms usually disappear in 3 to 12 months, but they may be permanent.

Following gastrectomy, bile in the small intestine may back up into the remaining part of the stomach or into the esophagus, causing the symptoms of an upset stomach. The patient’s doctor may prescribe medicine or suggest over-the-counter products to control such symptoms.

Side effects of chemotherapy

The side effects of chemotherapy depend mainly on the drugs the patient receives.

As with any other type of stomach cancer treatment, side effects also vary from person to person. In general, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body.

When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy.

Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result of chemotherapy, stomach cancer patients may have side effects such as loss of appetite, nausea, vomiting, hair loss, or mouth sores. These effects usually go away gradually during the recovery period between treatments or after the stomach cancer treatments stop.

Side effects of radiation therapy

Patients who receive radiation to the abdomen may have nausea, vomiting, and diarrhea.

The skin in the treated area may become red, dry, tender, and itchy. Patients should avoid wearing clothes that rub; loose-fitting cotton clothes are usually best. It is important for patients to take good care of their skin during treatment, but they should not use lotions or creams without the doctor’s advice.

Stomach cancer patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Side effects of biological therapy

The side effects of biological therapy vary with the type of treatment. Some cause flu-like symptoms, such as chills, fever, weakness, nausea, vomiting, and diarrhoea

Patients sometimes get a rash, and they may bruise or bleed easily. These problems may be severe, and patients may need to stay in the hospital during treatment.

Recovery & Follow Up

Rehabilitation and followup care is an important part of the overall stomach cancer treatment process. The goal of stomach cancer rehabilitation is to improve a person’s quality of life. The medical team, which may include doctors, nurses, a physical therapist, an occupational therapist, or a social worker, develops a stomach cancer rehabilitation plan to meet each patient’s physical and emotional needs, helping the patient return to normal activities as soon as possible.

Cancer patients and their families may need to work with an occupational therapist to overcome any difficulty in eating, dressing, bathing, using the toilet, or other activities. Physical therapy may be needed to regain strength in muscles and to prevent stiffness and swelling. Physical therapy may also be necessary if an arm or leg is weak or paralyzed, or if a patient has trouble with balance.

It is important for people who have had stomach cancer to continue to have examinations regularly after their stomach cancer treatment is over. Followup care ensures that any changes in health are identified, and if there is a recurrence of stomach cancer, it can be treated as soon as possible. Checkups may include a careful physical exam, imaging procedures, endoscopy, or lab tests.

Between scheduled appointments, people who have had stomach cancer should report any health problems to their doctor as soon as they appear

Living with stomach cancer

Living with a serious disease like stomach cancer is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful stomach cancer information and support services.

Cancer patients may worry about holding their job, caring for their family, or keeping up with their daily activities. Concerns about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses, and other members of the health care team can answer questions about stomach cancer treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy also can be helpful for patients who want to talk about their feelings or discuss their concerns about the future or about personal relationships.

Friends and relatives can be very supportive. Also, it helps many stomach cancer patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups for stomach cancer, where they can share what they have learned about coping with cancer and the effects of stomach cancer treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another — even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.