Stomach cancer

In Romania, about 4,000 new cases of stomach cancer are diagnosed annually, more frequently among men (2,500) than women (1,500 cases).

Stomach cancer, also called gastric cancer, is a malignant tumour that occurs when a group of abnormal cells develop inside the stomach.

These cells have the ability to invade tissues and spread to distant organs.

Symptoms of stomach cancer

Gastric cancer often presents with non-specific symptoms and because of this most patients present to the doctor with advanced disease. These signs of stomach cancer are often similar to those seen in patients with gastritis or ulcers. That’s why gastric cancer – often – is diagnosed late.

Early symptoms of stomach cancer may include:

  • Persistent indigestion or abdominal discomfort;
  • Meteorism and frequent gas;
  • Heartburn;
  • Feeling full very quickly when you eat;
  • Feeling bloated immediately after eating;
  • Pain in the stomach or chest (sternum);
  • Feeling sick/nausea.

Alarming symptom

It is important to check for any possible symptoms of stomach cancer as soon as possible.

A number of alarming symptoms have been identified so far:
  • You have difficulty swallowing;
  • Vomiting (which may be bloody);
  • You have indigestion in combination with one or more of the following:
    • Weight loss;
    • Sickness;
    • Anaemia;
    • You are over 55 and develop persistent indigestion;
    • You develop indigestion and have one or more of the following in your medical history:
      • A family history of stomach cancer;
      • Previous surgery for stomach ulcers;
      • Barrett’s esophagus – a condition in which abnormal cells develop on the inner lining of the esophagus;
      • Pernicious anaemia;
      • Dysplasia – a build-up of abnormal cells that are not actually cancerous, but may develop into cancerous cells later;
      • Gastritis – inflammation of the lining of the stomach.
    • You experience yellowing of the eyes and skin (jaundice);
    • Develop a visibly swollen portion in the upper abdomen.

Advanced stomach cancer

Symptoms of more advanced stomach cancer may include:

  • Blood in stool or black stool;
  • Loss of appetite;
  • Weight loss without an apparent cause;
  • Fatigue;
  • Feeling of heaviness in the stomach;
  • Anaemia.

Causes and risk factors for stomach cancer

Cancer starts with a change in the structure of DNA. DNA is a component found in every cell of living things and is essential for identifying each organism. DNA also provides cells with a set of basic information, such as the timing of growth and reproduction.

A change in DNA structure is known as a mutation and can alter the instructions that control cell growth. This means that the cells continue to grow instead of stopping when they should, which leads to cells reproducing uncontrollably, producing a piece of tissue called a tumour.

It is not yet known exactly what triggers DNA changes that lead to stomach cancer and why only a small number of people develop stomach cancer.

However, there are a significant number of risk factors for gastric cancer, namely:


The risk of developing stomach cancer increases with age. Most cases occur in people over 55 years of age with an average age of around 70 at diagnosis.


Smokers may be twice as likely to develop stomach cancer as non-smokers. This is because cigarette smoke will always be swallowed on inhalation and end up in the stomach, and tobacco contains many harmful substances that can damage cells.

The more you smoke and the longer you smoke, the greater the risk. Regular smokers are 1 ½ times more likely to develop stomach cancer than non-smokers.

H. Pylori

H. Pylori is a type of bacteria commonly found in the majority of the world’s population.

In most people, the bacteria is harmless, but most often H. Pylori causes conditions such as stomach ulcers, recurrent bouts of indigestion or chronic inflammation of the stomach lining (atrophic gastritis).

Research has found that people with severe atrophic gastritis have the highest risk of developing stomach cancer, although this risk is very small.


A diet high in salt, pickled vegetables (such as pickled onions or piccalilli), salted fish and smoked meat (such as parsnips or smoked beef) increases the risk of gastric cancer.

Countries where this type of diet is popular, such as Japan and China, have a higher number of stomach cancer cases than normally expected.

Family history

The likelihood of developing gastric cancer is quite high if there is a close relative (e.g. a parent, brother/sister) with this disease. According to some studies, the incidence of stomach cancer in another family member increases by about 1 ½ .

The explanation for why this condition is related to the degree of relatedness is not yet clear; it is assumed that the possible connection between family members and the development of stomach cancer is due to the fact that they share the same risk factors.

In about 1 in 50 cases, tests have shown that individuals have genetic mutations (changes in genetic material that can affect smaller or larger regions along one or more genes) in the gene coding for E-cadherin (CDH1). E-cadherin is a member of the cadherin family, proteins that play an essential role in establishing and maintaining the polarity of epithelial cells. Gastric cancer shows reduced expression of E-cadherin relative to normal cells. This causal effect between loss of CDH1 expression and tumour development has been demonstrated using carcinoma cell lines and transgenic models not only in this type of cancer, but also in intestinal, breast and ovarian cancers.

Stomach cancer research has also shown that people with blood type A are at high risk of developing this type of tumour. Since blood types are inherited from parents and do not change during life, this is an argument that family history may be a risk for cancer.

On the other hand, there are certain genetic diseases such as Peutz Jeghers syndrome, hereditary non-polyposis colorectal cancer, familial adenomatous polyposis that are predisposing factors for the development of stomach cancer. Of these three conditions listed above, familial adenomatous polyposis (FAP) makes gastric tumour more likely. FAP causes hundreds of polyps (small growths) to form in the digestive system (especially in the colon), leading to the risk of developing bowel cancer.

Other type of cancer in history

If you have had another type of cancer, such as oesophageal cancer or non-Hodgkin’s lymphoma (a form of cancer that develops in white blood cells in the autoimmune system), you are at increased risk of developing stomach cancer.

There are other cancers that make it more likely for both men and women to develop stomach cancer. For men, the risk of stomach cancer is higher if there is a history of prostate, bladder, bowel or testicular cancer. For women, the risk of developing stomach cancer increases if they have previously been diagnosed with ovarian, breast or cervical cancer.

Certain medical conditions

If you have certain medical conditions (such as those listed below), they may increase your risk of developing stomach cancer.

  • Oesophagitis: inflammation of the oesophagus caused by a reflux of stomach acid.
  • Gastro-oesophageal reflux disease (GERD): a severe form of oesophagitis.
  • Pernicious anaemia: a deficiency of vitamin B12, which occurs when the body cannot absorb the vitamin properly.
  • Peptic stomach ulcers: a type of ulcer of the stomach lining usually caused by an H. pylori infection.
  • Barrett’s esophagus: abnormal changes in the cells of the esophagus. This condition also increases the risk of oesophageal cancer.

Surgery affecting the stomach

If you have had a history of one or more surgeries on your stomach or in a certain region of your stomach, you are more likely to develop gastric cancer.

This may include surgery to remove part of the stomach (known as a partial gastrectomy), surgery to partially remove the vagus nerve (the nerve that carries information from the brain to organs such as the heart, lungs and digestive system) or surgery to treat ulcers.

How stomach cancer spreads

Stomach cancer can spread in 3 ways:

  • Direct – cancer can spread outside the stomach and to neighbouring tissues and organs such as the pancreas, colon and small intestine.
  • By lymphatic system – the lymphatic system is a series of lymph nodes (or nodules) that are located throughout the body, similar to the blood circulatory system; lymph nodes produce many specialised cells that are needed by the immune system to fight infection.
  • Through the blood – which in most cases will cause the cancer to spread from the stomach to the liver.

Stomach cancer that spreads to another part of the body is known as metastatic stomach cancer.

Diagnosing stomach cancer

If you have symptoms similar to those of stomach cancer, you should see your GP as soon as possible. They will discuss your symptoms with you and examine your stomach for lumps or areas of tenderness.

Hospital tests

If your GP thinks you may have stomach cancer, he or she will refer you to a specialist for tests. These tests may include blood tests and a chest X-ray to assess your general health. You may also want to have a stool test to see if there is any blood in the stool.

The different tests you can perform to diagnose stomach cancer are outlined below:

Endoscopy or endoscopic ultrasound

This is a procedure in which a specialist examines the inside of the stomach using a device known as an endoscope. The endoscope, which is a long, thin, flexible tube fitted at the end with a light and a camera.

If you have to have an endoscopy, you should not eat or drink anything for four to eight hours before the procedure; this is done to get the stomach and duodenum (upper part of the small intestine) emptied./p>

During the endoscopy you will be awake, but you will be given a sedative intravenously to make you feel drowsy and relaxed. It is also possible to spray a local anaesthetic on the back of the neck to numb the region. The actual endoscopy will take about 15 minutes, although it is advisable to allow about two hours for this procedure.

The endoscope will then be passed down the throat and into the stomach so that the specialist can observe for stomach ulcers or signs of cancer. If any possible cancerous tissue is found, the specialist will take a sample of it for testing. The sample collection is also called a biopsy. The biopsy will then be examined under a microscope in a laboratory, and the results can be used to determine whether the cells are cancerous (malignant) or non-cancerous (benign). Results are usually expected in 7 to 10 days.

If your specialist suspects that you may have cancer in the upper portion of your stomach, you should have an ultrasound scan at the same time as the endoscopy, a procedure called an endoscopic ultrasound. This technique uses high-frequency sound waves to image the stomach and is usually used to view the fetus in the womb.

If you will be performing an endoscopic ultrasound, the procedure involves attaching an ultrasound probe to the end of the endoscope before it is inserted down the throat. The scan will help to stage any cancer in the upper stomach.

After the endoscopy or endoscopic ultrasound, you will not be able to drive for several hours because of the sedative administered. You may also feel a sore throat, which will go away in a few days.

Eso-gastro-duodenal transit

Eso-gastro-duodenal barium transit examination uses a fluid containing a substance called barium, which makes the stomach visible on an X-ray. Normally, certain organs such as the stomach are not seen on X-rays as they are made up of soft tissue that is dense enough to prevent X-rays from passing through. However, when such organs are filled with barium, the substance blocks the X-rays and they will appear white on the X-ray image.

If you will need to perform such an eso-gastro-duodenal transit examination, you will not be able to eat or drink anything for at least six hours before the procedure so that your stomach and duodenum (upper part of the small intestine) are empty. You may be given an injection to relax the muscles of your digestive system.

You will then lie down on an X-ray table and the specialist will give you a thick, white liquid containing barium to drink. As the barium fills the stomach, the specialist will be able to see the stomach on an X-ray monitor, as well as any ulceration or abnormal growth. It is possible that the table you will be sitting on will be tilted slightly during the test so that the bar fills all portions of the stomach.

The barium procedure takes about 15 minutes. After this you will be able to eat and drink as normal, although you may need to drink more water to help flush the bile out of your system. You may feel unwell after the gastro-duodenal transit procedure; the barium may also cause constipation. It is also possible that the stools will be white for a few days after the procedure as the barium is removed from the system.

Further analysis

If you are diagnosed with stomach cancer, you may need to undergo several tests to identify the stage and extent of the condition. Your oncologist. (cancer specialist) will discuss this with you.

Stage is used to describe the spread of the cancer at the time of diagnosis and grade shows how aggressive the spread is. However, it is not always possible to accurately stage the disease until treatment is initiated and surgery is performed.

Staging of stomach cancer

A staging method for stomach cancer uses a numerical system to measure local invasion by direct extension into nearby tissues, regional extension via lymphatic vessels and distant spread. The stage of the cancer describes how far the disease has developed before the diagnosis is made, as well as documenting the extent of the disease.

Stage O (carcinoma in situ): the tumour process is lymphocytic only in the gastric mucosa layer

Stage IA

  • The cancer is in the inner lining of the stomach and no lymph nodes are involved.

Stage IB

  • The tumour has spread beyond the gastric mucosa to one or two lymph nodes.
  • The lymph nodes are not affected, but the cancer has spread to the muscles surrounding the inner lining.

Stage IIA

  • The cancer is still contained in the stomach lining but has now spread to 3-6 lymph nodes;
  • The disease spread to the surrounding muscles and 1-2 lymph nodes;
  • The lymph nodes are not affected, but the cancer has spread to the outer layer of the stomach (the serous layer).

Stage IIB

  • The cancer is still contained in the mucosa, but has now spread to 7 or more lymph nodes;
  • The disease spread to the muscles and 3-6 lymph nodes;
  • The disease spread to the outer layer of the stomach as well as 1-2 lymph nodes;
  • The lymph nodes are still unaffected, but the cancer has spread outside the stomach..

Stage IIIA

  • The cancer has spread to adjacent muscles and 7 or more lymph nodes;
  • The cancer has spread to the outer layer of the stomach as well as 3-6 lymph nodes;
  • The cancer has spread outside the stomach as well as to 1-2 lymph nodes.

Stage IIIB

  • The cancer has spread to the outer layer of the stomach and to 7 or more lymph nodes;
  • The cancer has spread outside the stomach as well as to 3-6 lymph nodes;
  • The cancer has spread further outside the stomach to adjacent tissue and can also affect up to 2 lymph nodes.

 Stage IIIC

  • The cancer has spread beyond the stomach and to 7 or more lymph nodes;
  • The cancer has spread beyond the stomach to nearby tissues, organs or lymph nodes.

Stage IV

The cancer has spread to another body organ, such as the liver or lungs.

Most cases of stomach cancer are stage III when diagnosed, which means that a complete cure is usually not possible.

There are three grades of stomach cancer:

  • Low grade – the cancer will spread slowly;
  • Medium grade – the cancer will spread a little faster;
  • High grade – the cancer is very aggressive and is likely to spread rapidly.

Treatment of stomach cancer

People with cancer need to receive care from a multidisciplinary team. This is a team of specialists working together to provide the best treatment and care and making decisions within an Oncology Commission. The decision will take into account:

  • • Type and size of cancer;
  • • Its grade (stage – read more in the section);
  • • General health;
  • • If the cancer has spread to other organs of the body.

The main treatments for stomach cancer are:

  • Surgery
  • Chemotherapy
  • Radiotherapy

You can follow one or a combination of these treatments. The type of treatment or combination of treatments will depend on how the cancer was diagnosed and the stage and extent of the cancer.

The first goal of treatment, where possible, is to completely remove (remove) the tumour and any other cancer cells from the body. If this is not possible, doctors will focus on trying to prevent the tumour from growing and causing further damage to the body. This is usually achieved through a combination of surgery and chemotherapy.

In some cases, it is impossible both to eliminate the cancer and to slow its progression. In this case, treatment will aim to relieve symptoms and make you as comfortable as possible. This is usually done by using radiotherapy. In some cases surgery and chemotherapy may be used.

Surgery for stomach cancer

If you are diagnosed with stomach cancer at an early stage, you may need surgery to try to remove the cancer.

Surgery to remove part of the stomach is known as a partial gastrectomy and surgery to remove the entire stomach is known as a total gastrectomy. In some cases, the surgeon may also remove part of the oesophagus as well as the entire stomach, a procedure called oesophago-gastricectomy.

During both operations, the surgeon will also remove the lymph nodes (tissues that play a role in the body’s immune defence) that are closest to the stomach cancer. It may have spread to these lymph nodes. Removing the lymph nodes helps prevent the cancer from recurring, as there is a high probability that the disease has spread to the lymphatic system.

Partial gastrectomy

If the cancer is located in the lower part of the stomach, a partial gastrectomy will be performed, in which only part of the stomach will be removed. This means that the lower part of the stomach will be removed, making the stomach smaller than before surgery. So the surgery will not affect the back of the stomach, where the oesophagus enters the stomach.

Total gastrectomy or oesophago-gastrectomy

If the cancer is located in the middle or upper part of the stomach, a total gastrectomy, a procedure that removes the entire stomach, may be needed. If the cancer is near the end of the oesophagus, where it meets the stomach, part of the oesophagus may be removed. This type of surgery is known as esophago-gastric surgery.

Surgery to relieve symptoms

If the gastric cancer has spread beyond the stomach, it is most likely not possible to remove it by surgery.

When the tumour invades the deeper layers of the stomach, a blockage can be triggered that prevents proper digestion of food. A blocked stomach shows symptoms such as stomach pain, vomiting and feeling too full after eating.

Several options can be considered to improve these signs:

  • A stent may be inserted at the level of the blockage. The stent is a tube that is inserted into the stomach during an endoscopy. After insertion, the stent will expand into that site and open the stomach.
  • A partial or total gastrectomy may be performed to reduce the blockage.
  • Bypasssurgery can be performed. In bypasssurgery, the part above the blockage joins the duodenum (the upper portion of the small intestine), thus isolating the blocked part of the stomach from the digestive system. This allows food to move through the unblocked part of the stomach and into the intestines without coming into contact with the blockage.

Post-surgery period

Any type of surgery for stomach cancer will involve extensive surgery and a long recovery period. If you are having surgery for stomach cancer, you need to stay in hospital for about two weeks. You will also need a few more weeks to recover at home.

Chemotherapy for stomach cancer

Chemotherapy is a specialised treatment for cancer that uses drugs to stop the growth of cancer cells. These drugs are known to be cytotoxic, which means they rapidly target cancer cells, preventing them from dividing and multiplying. As it circulates through the system, the drug can target cancer cells in the stomach, as well as any other cells that may have spread elsewhere in the body.

Sometimes chemotherapy is recommended before surgery to reduce the amount of cancer that needs to be removed by surgery. Chemotherapy should also be carried out after surgery to destroy any remaining cancer cells and to prevent the cancer from recurring.

If you need chemotherapy, the drug can be given orally as tablets or intravenously (by injection or a vein infusion directly into the bloodstream) or a combination of the two.

Chemotherapy is usually carried out in cycles, with each cycle lasting about three weeks.

Intravenous chemotherapy is administered in hospital or outpatient, while oral chemotherapy can be done at home.

Because cancer treatment sometimes involves taking very powerful drugs, chemotherapy has a number of adverse side effects, one of which is phlebitis (the ‘burning’ of the veins over which the treatment is administered). To avoid this, a special medical device called an implantable prolonged venous access chamber is recommended.

This implantable chamber is actually a small reservoir that communicates directly with a catheter. The camera is mounted subcutaneously, usually in the subclavicular region, and is connected with a catheter inserted into one of the large veins. The implantable chamber for chemotherapy is fitted under local anaesthesia by the surgeon on the recommendation of the oncologist.

Side effects of chemotherapy

Chemotherapy helps prevent certain cells, such as cancer cells, from growing rapidly.

However, there are other naturally occurring cells in the body that divide and multiply rapidly, including hair follicles and red and white blood cells. Chemotherapy also destroys these non-cancerous cells, which causes different side effects, including:

  • Hair loss;
  • Feeling sick (dizziness) and feeling sick (vomiting);
  • Loss of appetite;
  • Pain around the mouth;
  • Anaemia (this can cause fatigue and dyspnoea due to lack of haematides);
  • Increased vulnerability to infection.

Dacă este nevoie de chimioterapie, efectele secundare pe care le veţi experimenta vor depinde de tipul medicamentului citotoxic pe care îl luaţi, numărul de sesiuni de tratament  de care aveţi nevoie şi reacţia individuală la tratament. Vi se va spune pe cine trebuie să contactaţi dacă prezentaţi efecte secundare în urma chimioterapiei şi este foarte important ca aceste informaţii de contact să fie înregistrate cu grijă.

Dacă prezentaţi ameţeală şi stare de vomă în urma chimioterapiei, s-ar putea să vi se prescrie și medicamente împotriva stării de rău pentru a combate aceste efecte. Astfel de medicaţie poate fi administrată intravenos (prin injecţie directă în sistemul sanguin) în acelaşi moment cu tratamentul chimioterapic.

Efectele secundare ale chimioterapiei durează doar atât cât durează şi sesiunea de tratament. Odată ce tratamentul este finalizat, celulele care cresc rapid în mod natural se vor reface singure.

Cu scopul de a ameliora efectele secundare ale chimioterapiei, medicii oncologi au la dispoziție mai multe terapii de sprijin:

– medicul poate prescrie o gamă largă de medicamente pentru a controla durerea, în funcție de starea generală de sănătate a pacientului;

– medicul poate face recomandări de nutriție esențiale pentru a menține sau a restabili sistemul imunitar general al pacientului, de obicei foarte scăzut în timpul chimioterapiei;

– medicul poate recomanda un suport psihologic pentru a face față  stresului provocat de boală.

Clinicile moderne oferă această gamă de servicii, care de altfel reprezintă la ora actuală o necesitate deplin integrată în tratamentul oncologic.

Radiotherapy for stomach cancer

Radiotherapy uses high-energy X-rays, and, like chemotherapy, works by targeting fast-growing cancer cells. Radiotherapy is increasingly used to treat stomach cancer.

With the latest IMRT technology, and even more so with the latest VMAT technology, it is now possible to protect the organs at risk that are close to the stomach from being affected by the treatment itself.

For example, it is possible to undergo combination chemotherapy-radiotherapy treatment after surgery to help prevent stomach cancer from recurring.

If you need radiotherapy after surgery, treatment will start after a few months to give your body time to recover.

Radiotherapy is a pain-free procedure in which you are positioned under a machine while it directs radiation at your stomach. You will be positioned by your radiotherapist so that the machine targets only cancer cells and avoids as much healthy tissue as possible.

Treatment normally consists of radiotherapy sessions for 5 days a week for about 5 weeks. Each session will last only a few minutes. Once the procedure is complete, the radiation does not remain in your system, so you can be around other people between treatments without being affected in any way.

Side effects of radiotherapy

Radiotherapy is used to relieve the symptoms of advanced stomach cancer. Relatively low doses are usually used so that you do not experience any significant side effects.

If applied in combination with chemotherapy then the dosage will be higher and you may experience the following side effects:

  • Dizziness, with or without vomiting;
  • Diarrhoea;
  • Fatigue;
  • Stomach pain;
  • Irritation or blackening of the skin at the site of treatment.

Doctors will provide you with all the support you need to alleviate the impact of these side effects in your daily life.

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