Stomach cancer



In medicine, stomach cancer (also called gastric cancer) can develop in any
part of the stomach and may spread throughout the stomach and to other
organs. The cancer may grow along the stomach wall into the esophagus or
small intestine.

It also may extend through the stomach wall and spread to nearby lymph nodes
and to organs such as the liver, pancreas, and colon. Stomach cancer also
may spread to distant organs, such as the lungs, the lymph nodes above the
collar bone, and the ovaries.

When cancer spreads to another part of the body, the new tumor has the same
kind of abnormal cells and the same name as the primary tumor. For example,
if stomach cancer spreads to the liver, the cancer cells in the liver are
stomach cancer cells and the disease is metastatic stomach cancer, not liver
cancer.

A well known complication of stomach cancer is when it spreads to an ovary;
the tumor in the ovary is called a Krukenberg tumor. This tumor, named for
the doctor who first described it, is not a different disease; it is
metastatic stomach cancer - the cancer cells in a Krukenberg tumor are
stomach cancer cells, the same as the cancer cells in the primary tumor.

Symptoms

Stomach cancer can be hard to find early. Often there are no symptoms in the
early stages and, in many cases, the cancer has spread before it is found.
When symptoms do occur, they are often so vague that the person ignores
them. Stomach cancer can cause the following:

   * Indigestion or a burning sensation (heartburn);
   * Discomfort or pain in the abdomen;
   * Nausea and vomiting;
   * Diarrhea or constipation;
   * Bloating of the stomach after meals;
   * Loss of appetite;
   * Weakness and fatigue; and
   * Bleeding (vomiting blood or having blood in the stool).

Any of these symptoms may be caused by cancer or by other, less serious
health problems, such as a stomach virus or an ulcer. Only a doctor can tell
the cause. People who have any of these symptoms should see their doctor.
They may be referred to a gastroenterologist, a doctor who specializes in
diagnosing and treating digestive problems. These doctors are sometimes
called gastrointestinal (or GI) specialists.

Diagnosis

To find the cause of symptoms, the doctor asks about the patient's medical
history, does a physical exam, and may order laboratory studies. The patient
may also have one or all of the following exams:

Fecal occult blood test -- a check for hidden (occult) blood in the stool.
This test is done by placing a small amount of stool on a plastic slide or
on special paper. It may be tested in the doctor's office or sent to a
laboratory. This test is done because stomach cancer sometimes causes
bleeding that cannot be seen. However, noncancerous conditions also may
cause bleeding, so having blood in the stool does not necessarily mean that
a person has cancer.

Upper GI series -- x-rays of the esophagus and stomach (the upper
gastrointestinal, or GI, tract. The x-rays are taken after the patient
drinks a barium solution, a thick, chalky liquid. (This test is sometimes
called a barium swallow.) The barium outlines the stomach on the x-rays,
helping the doctor find tumors or other abnormal areas. During the test, the
doctor may pump air into the stomach to make small tumors easier to see.

Endoscopy -- an exam of the esophagus and stomach using a thin, lighted tube
called a gastroscope, which is passed through the mouth and esophagus to the
stomach. The patient's throat is sprayed with a local anesthetic to reduce
discomfort and gagging. Patients also may receive medicine to relax them.
Through the gastroscope, the doctor can look directly at the inside of the
stomach. If an abnormal area is found, the doctor can remove some tissue
through the gastroscope. Another doctor, a pathologist, examines the tissue
under a microscope to check for cancer cells. This procedure -- removing
tissue and examining it under a microscope -- is called a biopsy. A biopsy
is the only sure way to know whether cancer cells are present.

Staging

If the pathologist finds cancer cells in the tissue sample, the patient's
doctor needs to know the stage, or extent, of the disease. Staging exams and
tests help the doctor find out whether the cancer has spread and, if so,
what parts of the body are affected. Because stomach cancer can spread to
the liver, the pancreas, and other organs near the stomach as well as to the
lungs, the doctor may order a CT (or CAT) scan, an ultrasound exam, or other
tests to check these areas.

Staging may not be complete until after surgery. The surgeon removes nearby
lymph nodes and may take samples of tissue from other areas in the abdomen.
All of these samples are examined by a pathologist to check for cancer
cells. Decisions about treatment after surgery depend on these findings.

Treatment

The doctor develops a treatment plan to fit each patient's needs. Treatment
for stomach cancer depends on the size, location, and extent of the tumor;
the stage of the disease; the patient's general health; and other factors.

Many people who have cancer want to learn all they can about the disease and
their treatment choices so they can take an active part in decisions about
their medical care. The doctor is the best person to answer questions about
their diagnosis and treatment plan.

When a person is diagnosed with cancer, shock and stress are natural
reactions. These feelings may make it difficult for people to think of
everything they want to ask the doctor. Often, it helps to make a list of
questions. Also, to help remember what the doctor says, patients may take
notes or ask whether they may use a tape recorder. Some people also want to
have a family member or friend with them when they talk to the doctor -- to
take part in the discussion, to take notes, or just to listen. Patients
should not feel the need to ask all their questions or remember all the
answers at one time. They will have other chances to ask the doctor to
explain things and to get more information.

When talking about treatment choices, the patient may want to ask about
taking part in a research study. Such studies, called clinical trials, are
designed to improve cancer treatment. More information about clinical trials
is in the Clinical Trials section.

Patients and their loved ones are naturally concerned about the
effectiveness of the treatment. Sometimes they use statistics to try to
figure out whether the patient will be cured, or how long he or she will
live. It is important to remember, however, that statistics are averages
based on large numbers of patients. They cannot be used to predict what will
happen to a particular person because no two cancer patients are alike;
treatments and responses vary greatly. Patients may want to talk with the
doctor about the chance of recovery (prognosis). When doctors talk about
surviving cancer, they may use the term remission rather than cure. Even
though many patients recover completely, doctors use this term because the
disease can return. (The return of cancer is called a recurrence.) Getting a
Second Opinion

Treatment decisions are complex. Sometimes it is helpful for patients to
have a second opinion about the diagnosis and the treatment plan. (Some
insurance companies require a second opinion; others may pay for a second
opinion if the patient requests it.) There are several ways to find another
doctor to consult:

   * The patient's doctor may be able to suggest a specialist. Specialists
     who treat this disease include gastroenterologists, surgeons, medical
     oncologists and radiation oncologists.
   * The Cancer Information Service, at 1-800-4-CANCER, can tell callers
     about treatment facilities, including cancer centers and other programs
     supported by the National Cancer Institute.
   * Patients can get the names of doctors from their local medical society,
     a nearby hospital, or a medical school.

Methods of Treatment

Cancer of the stomach is difficult to cure unless it is found in an early
stage (before it has begun to spread). Unfortunately, because early stomach
cancer causes few symptoms, the disease is usually advanced when the
diagnosis is made. However, advanced stomach cancer can be treated and the
symptoms can be relieved. Treatment for stomach cancer may include surgery,
chemotherapy, and/or radiation therapy. New treatment approaches such as
biological therapy and improved ways of using current methods are being
studied in clinical trials. A patient may have one form of treatment or a
combination of treatments.

Surgery is the most common treatment for stomach cancer. The operation is
called gastrectomy. The surgeon removes part (subtotal or partial
gastrectomy) or all (total gastrectomy) of the stomach, as well as some of
the tissue around the stomach. After a subtotal gastrectomy, the doctor
connects the remaining part of the stomach to the esophagus or the small
intestine. After a total gastrectomy, the doctor connects the esophagus
directly to the small intestine. Because cancer can spread through the
lymphatic system, lymph nodes near the tumor are often removed during
surgery so that the pathologist can check them for cancer cells. If cancer
cells are in the lymph nodes, the disease may have spread to other parts of
the body.

Chemotherapy is the use of drugs to kill cancer cells. This type of
treatment is called systemic therapy because the drugs enter the bloodstream
and travel through the body.

Clinical trials are in progress to find the best ways to use chemotherapy to
treat stomach cancer. Scientists are exploring the benefits of giving
chemotherapy before surgery to shrink the tumor, or as adjuvant therapy
after surgery to destroy remaining cancer cells. Combination treatment with
chemotherapy and radiation therapy is also under study. Doctors are testing
a treatment in which anticancer drugs are put directly into the abdomen
(intraperitoneal chemotherapy). Chemotherapy also is being studied as a
treatment for cancer that has spread, and as a way to relieve symptoms of
the disease.

Most anticancer drugs are given by injection; some are taken by mouth. The
doctor may use one drug or a combination of drugs. Chemotherapy is given in
cycles: a treatment period followed by a recovery period, then another
treatment, and so on. Usually a person receives chemotherapy as an
outpatient (at the hospital, at the doctor's office, or at home). However,
depending on which drugs are given and the patient's general health, a short
hospital stay may be needed.

Radiation therapy (also called radiotherapy) is the use of high-energy rays
to damage cancer cells and stop them from growing. Like surgery, it is local
therapy; the radiation can affect cancer cells only in the treated area.
Radiation therapy is sometimes given after surgery to destroy cancer cells
that may remain in the area. Researchers are conducting clinical trials to
find out whether it is helpful to give radiation therapy during surgery
(intraoperative radiation therapy). Radiation therapy may also be used to
relieve pain or blockage.

The patient goes to the hospital or clinic each day for radiation therapy.
Usually treatments are given 5 days a week for 5 to 6 weeks.

Biological therapy (also called immunotherapy) is a form of 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.

Clinical Trials

Many patients with stomach cancer are treated in clinical trials (treatment
studies). Doctors conduct clinical trials to find out whether a new approach
is both safe and effective and to answer scientific questions. Patients who
take part in these studies are often the first to receive treatments that
have shown promise in laboratory research. In clinical trials, some patients
may receive the new treatment while others receive the standard approach. In
this way, doctors can compare different therapies. Patients who take part in
a trial make an important contribution to medical science and may have the
first chance to benefit from improved treatment methods. Researchers also
use clinical trials to look for ways to reduce the side effects of treatment
and to improve the quality of patients' lives.

Many clinical trials for people with stomach cancer are under way. Patients
who are interested in taking part in a trial should talk with their doctor.
The booklet Taking Part in Clinical Trials: What Cancer Patients Need To
Know explains the possible benefits and risks of treatment studies.

One way to learn about clinical trials is through PDQ¨, a computer database
developed by the National Cancer Institute. PDQ contains information about
cancer treatment and about clinical trials. The Cancer Information Service
can provide PDQ information to doctors, patients, and the public.

Side Effects of Treatment

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

The side effects of cancer treatment are different for each person, and they
may even be different from one treatment to the next. Doctors try to plan
treatment in ways that keep side effects to a minimum; they can help with
any problems that occur. For this reason, it is very important to let the
doctor know about any problems during or after treatment.

The National Cancer Institute booklets Radiation Therapy and You and
Chemotherapy and You have helpful information about cancer treatment and
coping with side effects.

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. The
doctor or a dietitian (a nutrition specialist) will explain any necessary
dietary changes.

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 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.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs the patient
receives. As with any other type of 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, patients may have side effects such as loss of appetite,
nausea, vomiting, hair loss, or mouth sores. For some patients, the doctor
may prescribe medicine to help with side effects, especially with nausea and
vomiting. These effects usually go away gradually during the recovery period
between treatments or after the treatments stop.

Radiation Therapy

Patients who receive radiation to the abdomen may have nausea, vomiting, and
diarrhea. The doctor can prescribe medicine or suggest dietary changes to
relieve these problems. 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.

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.

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 diarrhea. 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.

Nutrition for Cancer Patients

It is sometimes difficult for patients who have been treated for stomach
cancer to eat well. Cancer often causes loss of appetite, and people may not
feel like eating when they are uncomfortable or tired. It is hard for
patients to eat when they have nausea, vomiting, mouth sores, or the dumping
syndrome. Patients who have had stomach surgery are likely to feel full
after eating only a small amount of food. For some patients, the taste of
food changes. Still, good nutrition is important. Eating well means getting
enough calories and protein to help prevent weight loss, regain strength,
and rebuild normal tissues.

Doctors, nurses, and dietitians can offer advice for healthy eating during
and after cancer treatment. Patients and their families also may want to
read the National Cancer Institute booklet Eating Hints for Cancer Patients,
which contains many useful suggestions.

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