Stomach Cancer

Cancer 101: Cancer Explained

Could It Be Stomach Cancer?

WebMD Live Events Transcript

John S. Macdonald, MD, from the St. Vincent's Comprehensive Cancer Center, joined us on April 13, 2005 to discuss stomach cancer: the risk factors, the symptoms, and the latest emerging treatments.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

This event is made possible by an educational grant from Aventis Pharmaceuticals, a member of the sanofi-aventis Group.

MODERATOR:
Welcome to WebMD Live, Dr. Macdonald. Thank you for joining us today. Who is the typical gastric
cancer patient? Who is most likely to be affected?

MACDONALD:
If you look in the United States, the average or median age for gastric cancer is about 65. People tend to be older. Of course, the demographics of the US population show we are getting older. The typical patient has not had previous disease in the stomach and there's no major association with the causation of gastric cancer and habits such as smoking, drinking alcohol; it does not seem to be typical with gastric cancer. However, people who have gastric cancer frequently have a history of a low grade infection in the stomach that can cause gastritis. This infection is caused by a particular bacterium called H. pylori.

MEMBER QUESTION:
Are there lifestyle choices that increase risk of stomach cancer?

MACDONALD:
In general, there are not. Stomach cancer appears to be more common in people in this country who are recent immigrants, who may have grown up in countries where they did not eat as much fresh food as in the United States. In the past, when gastric cancer was substantially more common in the U.S. before 1930, it was associated with the consumption of preserved foods like salted meats.

"One of the things that has always interested doctors studying stomach cancer is: why did the incidence of this disease decrease over the last 50, 60, 70 years? It appears the major reason has been related to less use of preserved foods and more use of frozen and fresh foods in the United States."

MEMBER QUESTION:
Doesn't the bacteria you mentioned, H. pylori, cause ulcers?

MACDONALD:
Now that's a good question. H. pylori is associated with ulcers also. There are some patients with ulcers who can be shown to have H. pylori as causation and when it is associated with the cause of gastric cancer the reason is the H. pylori contributes to a chronic gastritis or inflammation of the stomach.

MEMBER QUESTION:
So do people with ulcers have to be more concerned about developing stomach cancer?

MACDONALD:
Interestingly enough people with ulcers of the stomach don't seem to have a particular increase of stomach cancer. Sometimes there is confusion because cancers of the stomach can ulcerate but it's not that a stomach ulcer, a benign one, has transformed into a stomach cancer.

MEMBER QUESTION:
But what about gastritis? Is that a precursor to stomach cancer?

MACDONALD:
What is called chronic gastritis -- when there's inflammation in the stomach over many years and also with the presence of the H. pylori and the absence of acid in the stomach -- those kinds of patients have a higher incidence of stomach cancer.

MEMBER QUESTION:
How common is stomach cancer?

MACDONALD:
That's a very good question. If you look at 1900, stomach cancer was the most common cause of cancer death in the U.S. Now it is about the eighth most common, with about 25,000 new cases occur each year. In the world, about 800,000 cases occur each year. So it's very common around the world; less common in the U.S. One of the things that has always interested doctors studying stomach cancer is: why did the incidence of this disease decrease over the last 50, 60, 70 years? It appears the major reason has been related to less use of preserved foods and more use of frozen and fresh foods in the United States.

MEMBER QUESTION:
Does eating fresh foods help you avoid stomach cancer? We eat a lot of pickled fish and smoked fish, as well as smoked meats. Is this a problem? I'm concerned because of this disease being in the family (grandparents, etc.).

MACDONALD:
When you look at diet and cancer in general, it's very difficult to say that one particular person on a particular diet is going to get cancer. One of the things you can do is look at populations of people and for example, say that stomach cancer is significantly more common in countries like Japan where pickled and preserved foods in general are eaten; in the United States less pickled and preserved foods are eaten and stomach cancer is a less common disease.

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In regard to the question about hereditary cancer, it's quite uncommon to find there's a genetic predisposition to a particular kind of stomach cancer. It can seem that cancers run in families, because families experience the same environment and it's not genetically mandated that people would get the cancer.

MODERATOR:
What symptoms might someone experience with stomach cancer?

MACDONALD:
There are several symptoms that may occur. People can have pain in their upper abdomen from the cancer. People can become anemic because there is slow blood loss from the cancer. When someone is anemic they feel tired, may get short of breath with routine activities. Occasionally people have difficulty swallowing because cancer is near the upper part of the stomach and partially obstructs food going down in the stomach. Those tend to be the main symptoms. People with more advanced stomach cancer will sometimes lose weight because they have been unable to eat well for long periods of time.

"The thing that we worry about stomach cancer is a symptom called early satiety. What this means is that a meal that normally would not fill you up makes you feel full so that you eat a lesser portion of food and feel full."

MEMBER QUESTION:
Is stomach cancer incidence increased or decreased by medications such as Prevacid or Protonix? Do they mask symptoms?

MACDONALD:
Again, this is a very good question. We know that in stomach cancer associated with gastritis, one of the common findings is that the acid level of the stomach goes down. Drugs like Prevacid and Protonix also decrease the acid level in the stomach. If decreased acid were likely to cause stomach cancer, you would expect a higher likelihood of the disease in people taking medicines like Protonix or Prevacid. That does not appear to be the case.

The other concern about the masking of symptoms is potentially a problem, although it doesn't appear to be significant. In other words, if someone had pain from an ulcerated stomach tumor, would decreasing the acid in the stomach by using these drugs decrease the pain? That is a possibility, but is not of real clinical importance.

MEMBER QUESTION:
What does mean if your stomach still feels empty after you eat a full meal and you feel tired after that?

MACDONALD:
If your stomach feels empty after you eat a meal you're probably healthy. The thing that we worry about stomach cancer is a symptom called early satiety. What this means is that a meal that normally would not fill you up makes you feel full so that you eat a lesser portion of food and feel full. The reason for this is the tumor is occupying part of the stomach so there's not room for the food. I wouldn't worry about eating a meal and still feeling hungry.

MODERATOR:
How is stomach cancer diagnosed? What tests are done?

MACDONALD:
These days probably the most important test for the diagnosis of stomach cancer is upper endoscopy. What this means is a passing of a scope through the esophagus and down into the stomach. The doctor is looking for the presence of abnormalities, ulcers, tumors, etc., and the doctor can biopsy through the scope to confirm a diagnosis.

There are other diagnostic tests that occasionally can be helpful, and these include CAT scans of the abdomen and also an upper GI radiograph series where the patient will be asked to swallow a dye like barium for the stomach to be outlined and for tumors to be defined.

MEMBER QUESTION:
Who should be getting tested? And how often?

MACDONALD:
This is another good question. Since stomach cancer is a relatively uncommon disease in this country there is no screening program for stomach cancer like we have with, for example, mammography for breast cancer. Generally people who have symptoms, such as early satiety, weight loss that is unexplained, anemia, difficultly swallowing, will get upper endoscopy and stomach cancers may be noted at that time.

MEMBER QUESTION:
Does blood in the stool mean stomach cancer? Or just colon cancer?

MACDONALD:
Blood in the stool can occur from any site of bleeding in the gastrointestinal tract. In the U.S., where colon cancer is far more common than stomach cancer, with about 150,000 new cases of colon cancer occurring each year compared to 20 to 25,000 cases of stomach cancer, blood in the stool of course is more likely from colon cancer. What a doctor will do if someone has blood in the stool -- particularly if they are above the age of 50 -- is first do a colonoscopy. Statistically it is more likely the blood is coming from some abnormality in the colon. If the colonoscopy is negative for any disease, then an upper endoscopy in the stomach will be done to rule out any blood coming from the stomach going into the stool.

"People who have chronic GERD can sometimes develop something called Barrett's esophagus, which is a change in the lining of the esophagus that can make cancer more likely."

MEMBER QUESTION:
I have reflux caused from a hiatal hernia. Should I be concerned about possibly getting stomach cancer?

MACDONALD:
That's also a good question. There is one form of stomach cancer and lower esophageal cancer (and that means the lower part of the esophagus where it attaches to the stomach) that appears to be associated with reflux. That's called an adenocarcinoma of the distal esophagus and proximal stomach. Some of these patients have had a history of reflux symptoms of gastritis and esophagitis. They frequently undergo endoscopy to monitor the condition of the reflux and sometimes tumors are detected.

MEMBER QUESTION:
I was diagnosed with GERD and have been taking Prilosec for approximately eight years. I was on Pepcid for eight or nine years before that. My question pertains to pain in my stomach about 6 inches below the breast bone. I have it every day and it is much worse after eating. Recently even small amounts of food will cause pain and I feel very full for a long time, with a lot of nausea. I have talked to my primary care doctor several times and all she wants to do is switch the Prilosec for something else, which I have done a few times already. The pills help with the heartburn but not the other symptoms. I am F/43/280 lbs/5'7" and always trying to lose weight. Should I be checked for stomach cancer?

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MACDONALD:
It would be quite helpful for someone with your symptoms to have an upper endoscopy, which is, of course, a scope being passed down into the stomach so a doctor can see the symptoms of what is causing the difficulty in eating and the persistent pain in the upper area of the stomach and/or esophagus. People who have chronic GERD can sometimes develop something called Barrett's esophagus , which is a change in the lining of the esophagus that can make cancer more likely. So having an upper endoscopy would probably be a wise thing to do.

MEMBER QUESTION:
My concern is that two of my relatives have had this cancer and it seems that by the time it is found it is too late. Is it that it cannot be detected, the symptoms are not understood too well or that people wait?

MACDONALD:
I think all those things can be true in regard to stomach cancer. Because it is relatively uncommon, it's not one of the first things that either the patient or doctor would think of, and many of the symptoms, intermittent change in appetite for example, or change of weight loss, are nonspecific and don't direct the patient or doctor to think of stomach cancer as the cause.

Now with relatives with stomach cancer, it's important to be sure whether or not the patient had gastric carcinoma or some other tumor in the abdomen. Frequently family members will say something like my mother died of stomach cancer and in a sense that was true, but the tumor was not a gastric carcinoma but rather a tumor that occurred in the abdomen from some other organ, like the liver or pancreas. It's important that the family member had gastric carcinoma and indeed, not some other form of cancer.

MEMBER QUESTION:
I understand stomach cancer to be rare, but often fatal. What are the options if you are diagnosed?

MACDONALD:
The primary treatment of stomach cancer is to surgically remove the portion of the stomach with the cancer in it. If you can do that you have the potential of curing the patient. If a patient's stomach cancer has already spread to the point where it can't be completely removed surgically, the vast majority of those patients have incurable cancer. People with advanced stomach cancer that has spread to other organs can be helped with chemotherapy and can live longer because of chemotherapy, but cannot be cured.

"The primary treatment of stomach cancer is to surgically remove the portion of the stomach with the cancer in it. If you can do that you have the potential of curing the patient."

MEMBER QUESTION:
What's involved in a gastrectomy?

MACDONALD:
The total gastrectomy means the surgeon completely removes the stomach. He or she cuts the stomach off at the lower esophagus and at the lower end of the stomach or the duodenum. The stomach is therefore completely removed and a small pouch is surgically produced from the bowel to become a new stomach. Partial gastrectomy is an operation in which only part of the stomach with the tumor is removed and not the whole stomach.

MEMBER QUESTION:
My brother was diagnosed with stomach cancer in November 2004 after severe bleeding from his mouth. He underwent complete gastrectomy on December 12, 2004. The tumor grew though the stomach wall and penetrated into surrounding fat layer. In addition, eight lymph nodes were removed and three of those turned out to be involved. He was told that his cancer is at stage 3. He is undergoing a fairly standard preventive chemotherapy plus radiation treatment. My brother still has two more sessions of chemo (the next will start in a couple days). From what I read, the chances of complete remission with the treatment that my brother is getting are pretty low, and I want to find out whether more targeted and successful treatments are available.

MACDONALD:
The patient described has an approximately 80 percent chance of having the cancer come back if he only had the surgery. That chance of recurrence is reduced by about 15% to 20% by having the standard chemotherapy plus radiation that has been described. Therefore, a patient like this man can get significant benefit from this treatment, and as the questioner has pointed out, this is the standard treatment for patients with surgically resected stomach cancer.

The question of whether there better therapies is always being addressed in clinical trials but at present we don't have a better targeted therapy than chemotherapy and radiation that this patient is getting.

MEMBER QUESTION:
What new treatments are coming for stomach cancer? What is being tried in clinical trials now?

MACDONALD:
The new treatments for stomach cancer are related to a couple of areas. In patients who have cancer that has spread to other organs in the body, there are new chemotherapy agents that are being tested to see if they will improve outcome in these cases by reducing the size of the cancer. These kinds of patients are also being treated with what are called more targeted therapies -- drugs that are aimed at interrupting the growth of cancer but are not chemotherapy agents with all their toxicity.

The other area of research is related to preventing recurrence in cases in which the tumor has been surgically removed. These kind of experimental treatments involve new drugs being given with radiation to make the radiation more successful.

Finally, the other area that is of real interest in clinical research is using chemotherapy and radiation before surgical removal of a stomach cancer to make the tumors shrink down and improve the outcome for patients undergoing surgical resection of their cancer.

"I think it's important for people to understand that the use of chemotherapy and radiation after surgical removal of the stomach has been an important advance in the treatment of stomach cancer, since it substantially reduces the incidence of recurrence and death from cancer."

MODERATOR:
Dr. Macdonald, we are almost out of time. Before we wrap things up for today, do you have any final words for us?

MACDONALD:
Stomach cancer represents an important disease around the world and certainly an important disease in the U.S. I think it's important for people to understand that the use of chemotherapy and radiation after surgical removal of the stomach has been an important advance in the treatment of stomach cancer, since it substantially reduces the incidence of recurrence and death from cancer.

The other thing that is important is understanding the causation of cancers of the stomach. For example, that H. pylori may be important has led to clinical trials to test whether the use of antibiotics to eliminate H. pylori may decrease the occurrence of stomach cancers.

MODERATOR:
Our thanks to John S. Macdonald, MD, for joining us today.



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Reviewed on 4/18/2005 9:35:03 PM

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