Introduction

A diagnosis of cancer of the stomach carries a fairly dismal prospect; in women, these tumors are the 4th most common causes of cancer deaths, and in men they are 3rd equal (with cancer of the colon). This may be because the diagnosis is often made fairly late, when the condition is advanced. This summary of a British Medical Journal review covers the signs and symptoms, the risk factors, steps to diagnosis, treatment, and likely outcome for this type of cancer.

Also called gastric carcinoma or carcinoma of the stomach, this cancer has its peak occurrence around 60 years of age. Men get it twice as often as women.

Risk factors

A chronic bacterial infection, Helicobacter pylori, is largely responsible for stomach ulcers. It can also cause a type of gastritis (chronic atrophic gastritis) that's an important risk factor for stomach cancer. Other risk factors include a family history of the condition (abnormalities in a specific gene have been described), the presence of non-malignant gastric polyps, pernicious anemia, and after a partial gastrectomy to treat ulcers.

Symptoms & signs

The main symptom is pain in the upper stomach area, similar to that of an ulcer. Vomiting may relieve it. Constant pain, especially if it goes through to the back, suggests the tumor may be spreading locally. Sometimes symptoms are delayed until the tumor has spread to other organs (often the liver), when there is loss of appetite, nausea, and weight loss. If the tumor bleeds, there may be vomiting of blood (often very dark colored), or passage in the stools (when it is black). Loss of blood can lead to anemia, with tiredness and shortness of breath.

Physical examination may not be very helpful, beyond showing the secondary signs -- weight loss, anemia, etc. Occasionally a lump may be felt in the upper stomach area, or the liver may be enlarged. Rarely, an enlarged lymph node can be felt just above the left collarbone.

Investigations

Endoscopy (passage of a tube down the gullet into the stomach, under anesthesia) allows direct observation of the tumor, as well as biopsy (taking several small pieces of tissue for microscopic examination). Some experts recommend endoscopy for all patients over 45 with constant indigestion symptoms.

A 'barium meal' involves a series of X-rays at various times after the patient has swallowed a liquid that makes the stomach lining visible. It is particularly useful in showing whether the tumor is causing any obstruction to the passage of food. Both endoscopy and a barium meal should be done, and repeated if symptoms don't get better with gastric ulcer treatment, even if they are negative the first time around.

A CAT scan (computed tomography) or further investigations (e.g. laparoscopy or endoscopic ultrasound) will be necessary to assess spread of the tumor in patients intended for surgery.

Treatment

If there is no evidence of local spread from the stomach, or secondary deposits (metastases) in other organs, surgical removal of the stomach can result in a cure. Chemotherapy is an important alternative for cases where gastrectomy is not feasible; irradiation is not a suitable form of treatment.

There are a number of other interventions that can be used to make life more comfortable for patients where the tumor has progressed beyond the reach of surgery. They include partial gastrectomy, insertion of a stent (a firm tube) to hold open a passage for food, and nerve blocks for severe pain. Palliative care, using a hospice-based team approach, is recommended for advanced cases.

The outlook

By the time they come to the physician, as many as half of all patients with stomach cancer are incurable. After gastrectomy, if the disease appears to be confined to the stomach, about 70% of patients are alive five years later. If the cancer has spread, the prospects are correspondingly bad. Quite clearly, cancer of the stomach is a condition where early diagnosis is imperative. Risk factors should be avoided, if possible, and attention must be paid to early warning symptoms, especially in people over 45.