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Although the incidence of stomach cancer has declined dramatically in the United States and Western Europe in the last 60 years, the disease remains a serious problem in much of the rest of the world, where it's a leading cause of cancer death.
This global variation is almost certainly linked to two factors that play a major role in the development of stomach cancer — infection with Helicobacter pylori (H. pylori) bacteria and diet, especially the type of diet that's high in salted, smoked and pickled foods common in areas that lack refrigeration as a means of preserving food.
Stomach cancer is more readily treated when caught early. Unfortunately, by the time stomach cancer causes symptoms, it's often at an advanced stage and may have spread beyond the stomach. Yet there is encouraging news. You can reduce your risk of stomach cancer by making a few changes in your lifestyle.
One early sign of stomach cancer is microscopic internal bleeding, which is usually only detected by tests that check your stool for blood. You may also feel tired if this bleeding causes the loss of too many healthy red blood cells (anemia). Early stomach cancer may also cause symptoms such as heartburn and abdominal pain, which can be mistaken for other, more common problems.
When the cancer is more advanced, you may experience signs and symptoms such as:
Having one or more of these signs and symptoms doesn't necessarily mean you have stomach cancer. Other more common conditions, especially peptic ulcers, can cause similar problems.
Your stomach is a muscular sac located in the upper middle of your abdomen, just below your ribs. The stomach walls are lined with three layers of powerful muscles that mix food with enzymes and acids produced by glands in the stomach's inner lining. Your stomach's delicate tissues are protected from this acidic mix by a thick, jelly-like mucus that coats the stomach lining.
Types of stomach cancer
Gastrointestinal stromal tumors (GISTs). Doctors believe that these rare tumors develop from cells called interstitial cells of Cajal, which are part of your autonomic nervous system. Your autonomic nervous system consists of the nerves that regulate the part of your nervous system that you can't control, such as your heart rate, blood pressure and intestinal function.
Although GISTs can occur anywhere from the esophagus to the rectum, most are found in the stomach. Yet GISTs are not the same as other gastric cancers, differing not only in the cells in which they originate but also in their prognosis and treatment. A majority of GISTs have a specific genetic mutation that allows for treatment with a new form of cancer-specific therapy.
Why stomach cancer develops
Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. Some of the genes in your DNA promote cell division and some slow cell division or program cells to die at the right time. Still other genes control processes that help repair DNA. When DNA is damaged, these genes may not function properly, causing cells to grow out of control and eventually form a tumor — a mass of malignant cells.
Although the causes of many types of cancer aren't clear, researchers have made progress in pinpointing factors that damage DNA in stomach cells and in understanding how that damage leads to cancer. These factors include:
H. pylori infection. A majority of the world's population is infected with corkscrew-shaped bacteria called Helicobacter pylori (H. pylori) that live deep in the mucous layer that coats the lining of the stomach. Although it's not entirely clear how the bacteria are transmitted, it's likely they spread from person to person through the oral-fecal route or are ingested in contaminated drinking water. H. pylori infection frequently occurs in childhood and can last throughout life if not treated. It's the primary cause of stomach ulcers.
Having ulcers doesn't necessarily put you at higher risk of stomach cancer, but having H. pylori infection does. That's because long-term infection causes inflammation that can lead to precancerous changes in the stomach lining. One of these changes is atrophic gastritis, a condition in which the acid-producing glands are slowly destroyed. It's likely that low acid levels prevent cancer-causing toxins from being properly broken down or flushed out of your stomach.
Having H. pylori infection makes you more likely to develop stomach cancer than someone who doesn't have the infection. Even so, most people with H. pylori don't get stomach cancer, and researchers believe that genetic factors make some people more susceptible to the disease.
Other risk factors for stomach cancer include:
Stomach cancer is treatable if caught early. Unfortunately, it rarely causes symptoms in the beginning stages. When symptoms do occur, they're often vague and can easily be mistaken for other, more common but less serious problems such as a stomach virus or heartburn. Less than one in five stomach cancers are diagnosed before they have spread outside the stomach.
See your doctor if you have a persistent feeling of discomfort in the upper or middle region of your abdomen, especially if it occurs in conjunction with fatigue and weight loss.
And see your doctor right away if you develop black, tarry stools or if you vomit after meals. Although not always indicators of stomach cancer, these signs may result from other conditions that require medical care.
To help diagnose stomach cancer and rule out other possibilities, your doctor may recommend one or more of the following diagnostic tests:
Upper endoscopy. This procedure allows your doctor to see abnormalities in your upper gastrointestinal (GI) tract that may not be visible on X-rays. For the test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus, stomach and the first part of your small intestine. Your throat is usually numbed before you're asked to swallow the endoscope, and you'll usually receive intravenous medication to ensure that you're comfortable during the procedure.
If any tissue in your upper intestinal tract looks suspicious, your doctor can remove a small sample (biopsy) using instruments inserted through the endoscope. The sample is then sent to a lab for examination by a pathologist.
Upper endoscopy takes about 20 to 30 minutes, although you won't be sent home until the medication wears off — usually one to two hours later. Risks of the procedure are rare and include bleeding and perforation of the stomach lining. The most common complication is a slight sore throat from swallowing the endoscope.
Stomach X-ray (barium upper GI series). This test uses a series of X-rays to examine your esophagus, your stomach and the first part of your small intestine.
Before the test, you'll drink a thick liquid (barium) that temporarily coats the lining of your stomach so that it shows up clearly on the X-rays. You may also be asked to swallow a gas-producing liquid or pill, such as sodium bicarbonate, which stretches the stomach and separates its folds, thereby providing a better view of the inner lining.
After the test you can eat normally and resume your usual activities, although you'll need to drink extra water to help flush the barium from your system. The most common complication of the procedure is temporary constipation.
If you receive a diagnosis of stomach cancer, your doctor is likely to recommend additional tests to help determine the extent of the disease (staging tests) and the best course of treatment. These may include:
The kind of treatment you receive for stomach cancer depends on a number of factors, including the location of the cancer, how advanced it is, your overall health and your own preferences. Especially when cancer is advanced, choosing a treatment plan is a major decision, and it's important to take time to evaluate your choices.
You may also want to consider seeking a second opinion. This can provide additional information to help you feel more certain about the option you're considering.
The goal of any treatment is always to eliminate the cancer completely. When that isn't possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.
Stomach cancer treatment options include the following:
Surgery. This is the most common treatment for stomach cancer. Depending on the extent of the cancer, your doctor may remove part (subtotal, or partial, gastrectomy) or all (total gastrectomy) of your stomach as well as some of the surrounding tissue. Lymph nodes near the tumor also are often removed during surgery. After a subtotal gastrectomy, the remaining part of your stomach is connected to your esophagus and your small intestine. If your entire stomach is removed, your surgeon attaches your esophagus directly to your small intestine. A 2006 study suggested that chemotherapy before and after surgery may improve outcomes for certain people, so discuss this with your doctor.
When stomach cancer is caught at an early stage and your surgeon is able to remove the entire tumor, a complete recovery is possible. Unfortunately, diagnosis usually doesn't occur until stomach cancer has spread through the stomach wall to nearby lymph nodes or other organs. At this point, it's not possible to remove all the cancer surgically, but your doctor may still recommend an operation to alleviate pain, bleeding or obstruction. In some cases of advanced stomach cancer, a laser beam directed through an endoscope can vaporize most of the tumor and relieve obstruction without an operation.
After gastrectomy, some people experience leakage or obstruction where the intestinal tract has been reconstructed. More common problems associated with partial or total gastrectomy include diarrhea, vomiting and dumping syndrome, which occurs when the small intestine fills too quickly with undigested food. Signs and symptoms of dumping may occur immediately after eating (early dumping) or several hours after a meal (late dumping) and include nausea, vomiting, diarrhea, cramping and dizziness.
Chemotherapy. This treatment uses drugs to help kill cancer cells. Injected into a vein or taken orally, chemotherapy medications travel through your bloodstream and are often used to eliminate cancer cells that may remain after surgery or to treat cancers that have spread to other parts of the body. Chemotherapy may also be used to control cancer growth, prolong life or relieve symptoms of advanced disease. Although it sometimes may be the only treatment needed, doctors most often use chemotherapy in conjunction with other therapies. For example, in locally advanced stomach cancer, which occurs when the tumor affects only the stomach and nearby tissues, chemotherapy and radiation (radiotherapy) may be offered after surgery to help increase survival and improve quality of life.
A 2006 study found that people whose stomach cancer hadn't spread had better outcomes when chemotherapy was used both before and after surgery to remove the cancer. In the study, people with stomach cancer were randomly assigned to receive surgery alone or to receive three cycles of chemotherapy before surgery and three cycles of chemotherapy after recovering from surgery. People in this study who received surgery combined with chemotherapy lived somewhat longer and had a lower risk of the cancer returning than did people who received surgery only.
Because anti-cancer drugs affect healthy cells as well as cancerous ones — especially fast-growing cells in your digestive tract and bone marrow — side effects such as nausea and vomiting, fatigue, and an increased risk of infection due to a shortage of white blood cells are common. Although not everyone experiences these side effects, chemotherapy can sometimes feel like another illness and is often the part of treatment about which people are most apprehensive. But newer anti-nausea medications can prevent or reduce most nausea. Sometimes acupuncture or relaxation techniques, such as guided imagery, meditation and deep breathing, also may help control nausea and vomiting. Chemotherapy is normally administered in cycles, with periods of treatment alternating with periods of recovery during which your body can recover. Ask your treatment team about the side effects of any treatment you're considering and the best ways to minimize those effects.
Targeted drug therapy
The Food and Drug Administration has approved the anti-leukemia drug imatinib mesylate (Gleevec) to treat gastrointestinal stromal tumors (GISTs) that contain a specific genetic mutation. Imatinib, which is taken in capsule form once a day, belongs to a class of medications that target a specific genetic mutation within cancer cells but leave healthy tissue relatively untouched. Side effects tend to be milder than with other types of cancer therapy and include fluid retention (edema), nausea, muscle cramps and rash.
Imatinib is effective only for GISTs that have a specific genetic mutation and even then, it isn't for everyone — surgical removal remains the primary therapy for this type of cancer. Despite promising results in some people, imatinib isn't effective in all cases nor are the long-term effects known.
Clinical trials
If you have advanced stomach cancer, you may want to consider participating in a clinical trial. This is a study that's used to test new forms of therapy — typically new drugs, different approaches to surgery or radiation treatments, and novel methods such as gene therapy. If the therapy being tested proves to be safer or more effective than current treatments, it will become the new standard of care.
The treatments used in clinical trials haven't yet proved effective. They may have serious or unexpected side effects, and there's no guarantee you'll benefit from them.
On the other hand, cancer clinical trials are closely monitored by the federal government to ensure they're conducted as safely as possible. And they offer access to treatments that wouldn't otherwise be available to you.
If you're interested in finding out more about clinical trials, talk to your treatment team. You can also call the National Cancer Institute's Cancer Information Service at 800-4-CANCER, or 800-422-6237. The call is free and trained specialists are available to answer your questions.
Although it may not be possible to prevent stomach cancer, the following steps can help reduce your risk:
After gastrectomy, it's not uncommon to experience nausea, vomiting, diarrhea, weight loss, nutritional deficiencies and dumping syndrome, which occurs when food enters your small intestine too quickly. These side effects usually result from eating more at one time than your digestive system can tolerate and can often be controlled with changes in the amount, frequency and kinds of food you eat.
You may also develop nutritional deficiencies because you're no longer able to absorb certain vitamins. Vitamin B-12, for example, can only be absorbed when it's attached to a protein produced in your stomach (intrinsic factor). For that reason, you'll need to receive vitamin B-12 injections for life. Your doctor may also recommend supplementing your diet with other nutrients, especially folic acid, iron and calcium.
Although coping with the effects of gastrectomy can be challenging, the following measures may help improve or relieve your symptoms:
A diagnosis of cancer can be extremely challenging. Remember that no matter what your concerns or prognosis, you're not alone. These strategies and resources may make dealing with cancer easier:
Talking about end-of-life issues
Although it can be extremely difficult, discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for verbal and written instructions you give concerning your medical care should you become unable to speak for yourself.
One type of advance directive is known as a durable power of attorney (POA) for health care. In this case, you sign a legal document authorizing a person you respect and trust to make legally binding medical decisions for you if you're unable to do so. A POA is often recommended because the appointed person can make decisions in situations not covered in a regular advance directive. Whatever you decide, put your wishes in writing. Laws regarding advance directives and POAs vary from state to state, but a written document is more likely to be respected.
Coming to terms with your illness
Having a serious illness may be the hardest thing you've ever dealt with. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands life-threatening illnesses, such as a medical social worker, psychologist or chaplain. Many people also take steps to ensure that their end-of-life wishes are known and respected.
In fact, the greatest fears of many people with a life-threatening illness include being subjected to treatments they don't want, becoming a burden to their loved ones, and spending their last weeks or months in a hospital away from familiar surroundings. The welcome news is that many more choices now exist for people with a terminal illness.
Hospice care, for example, provides a special course of treatment to terminally ill people. This allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in a hospice residence. It also provides emotional, social and spiritual support for people who are ill and those closest to them. Although most people under hospice care remain in their own homes, the program is available anywhere — including nursing homes and assisted living centers. For those who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.
