Cancer Research UK : Symptoms and Treatment of Stomach Cancer

Symptoms and Treatment of Stomach Cancer

Early stage stomach cancer may be symptom-less or have vague and non-specific symptoms such as indigestion, tiredness or loss of appetite. Consequently it is difficult to differentiate between benign conditions and early cancer by symptoms alone.

Fewer than 2% of patients presenting to their GP with dyspepsia for the first time are estimated to have gastric cancer.1 Government guidelines have been published on identifying patients who should be referred urgently to a specialist or for endoscopy within a 2-week period.2

These are patients over 55 with dyspepsia or for those of any age who have the classic ‘alarm’ symptoms of dysphagia, vomiting, loss of appetite, weight loss or symptoms associated with gastrointestinal bleeding.3

Unfortunately the majority of patients present with advanced disease: their symptoms may include nausea, vomiting, pain, weight loss, and, in the case of GOJ disease, dysphagia.

Surgery is the primary form of treatment and may be useful for palliation. Around half of patients have some form of surgery but due to the late diagnosis of the disease in the UK only around 20% of patients have curative resections.4

Whenever possible, partial gastrectomy rather than total gastrectomy should be carried out as the less extensive procedure has fewer complications and no survival disadvantage has yet been shown.5 One survey of 23 NHS hospitals has shown that 37% of stomach cancer patients have a resection.3

Postoperative mortality is higher in western countries than in Japan and a recent study has shown perioperative mortality rates of 14% in south-west England3 although some surgeons achieve rates of 5% or below.6

The lowest rates were associated with surgeons who carried out the highest volume of work and government recommendations are that patients should be treated in centralised specialist oesophago-gastric oncology units.

Debate continues about the optimum extent of lymph node resection for curative surgery. D1 dissection (local nodes) remains the standard, but D2 dissection (locoregional nodes) is gaining acceptance in the UK, particularly for more advanced operable cancers.7,8 Modified D2 resection does not involve removal of the pancreas or spleen. One recent Welsh study cited cumulative 5-year survival after resection for stage 3 cancer of 8% following D1 resection compared to 33% after modified D2 resection.9

Current consensus is that removal of adjacent organs during gastrectomy should only be carried out if necessary for complete resection of tumour.5,7

Benefit has been clearly demonstrated for the use of pre-operative chemotherapy. In a recent trial perioperative chemotherapy with the ECF regimen improved overall 5-year survival from 23% to 36% when compared to surgery alone.10

Further research is investigating the use of targeted biological therapies, such as bevacizumab (Avastin), in combination with ECF chemotherapy.11

Different forms of adjuvant chemotherapy and radiotherapy have also been investigated. A large systematic review has shown adjuvant chemotherapy to provide a small survival advantage ,12 although this is not regarded as standard therapy.7

Radiotherapy combined with chemotherapy given post-operatively has also shown positive results13 and this treatment strategy is regarded as the standard practice in North America. The benefits of various chemo-radiotherapy schedules used both pre-operatively and post-operatively are being tested in ongoing trials.

More than two-thirds of gastric cancer patients will have unresectable disease. For this group, a review has shown that palliative chemotherapy is superior to supportive care alone.14 However, even the most intensive regimes are unlikely to extend median survival above a year.14

ECF or ECX chemotherapy is the standard regimen used within the UK.14 Docetaxel based regimens are commonly used in North America. Trials are ongoing to evaluate different chemotherapy combinations and biological agents.

There are various treatment options which are aimed at providing symptom control alone, these include; radiotherapy to control gastric bleeding or pain from bone metastases, stent insertion or laser therapy for dysphagia, and surgery for the palliation of intestinal obstruction.

References for stomach cancer symptoms and treatment

NHS Centre for Reviews and Dissemination, Effective Health Care Bulletin: Management of upper gastro-intestinal cancers. 2000, University of York: York.
National Institute for Clinical Excellence (NICE), Clinical Guideline 27: Referral for suspected cancer. June 2005.
Bachmann, M.O., et al., Cohort study in South and West England of the influence of specialization on the management and outcome of patients with oesophageal and gastric cancers. Br J Surg, 2002. 89(7): p. 914-22
Thames Cancer Registry, Cancer in South East England 2004. 2006, King's College London: London.
Bailey, C., Stomach cancer. Clin Evid, 2006(15): p. 765-71
NHS Executive, Guidance on Commissioning Cancer Services: Improving Outcomes in Upper Gastro-intestinal Cancers. 2001, Department of Health.
Scottish Intercollegiate Guidelines Network (SIGN), Management of oesophageal and gastric cancer. 2006. p.27
McCulloch, P., et al., Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer. Br J Surg, 2005. 92(1): p. 5-13
Edwards, P., et al., Prospective comparison of D1 vs modified D2 gastrectomy for carcinoma. Br J Cancer, 2004. 90(10): p. 1888-92
Cunningham, D., et al., Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med, 2006. 355(1): p. 11-20
Tabernero, J., et al., Novel targeted therapies in the treatment of gastric and esophageal cancer. Ann Oncol, 2005. 16(11): p. 1740-8
Mari, E., et al., Efficacy of adjuvant chemotherapy after curative resection for gastric cancer: a meta-analysis of published randomised trials. A study of the GISCAD (Gruppo Italiano per lo Studio dei Carcinomi dell'Apparato Digerente). Ann Oncol, 2000. 11(7): p. 837-43.
Macdonald, J.S., et al., Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med, 2001. 345(10): p. 725-30.
Wohrer, S.S., M. Raderer, and M. Hejna, Palliative chemotherapy for advanced gastric cancer. Ann Oncol, 2004. 15(11): p. 1585-95

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References for stomach cancer symptoms and treatment

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