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Stomach cancer

Overview

Stomach cancer usually begins in the mucus-producing cells that line the stomach. This type of cancer is called adenocarcinoma.

For the past several decades, rates of cancer in the main part of the stomach (stomach body) have been falling worldwide. During the same period, cancer in the area where the top part of the stomach (cardia) meets the lower end of the swallowing tube (esophagus) has become much more common. This area of the stomach is called the gastroesophageal junction.

Stomach cancer

Stomach cancer most commonly begins in the cells that line the inside of the stomach.

Stomach cancer

Stomach cancer most commonly begins in the cells that line the inside of the stomach.

Stomach and pyloric valve

Your stomach is a muscular sac about the size of a small melon that expands when you eat or drink to hold as much as a gallon of food or liquid. Once your stomach pulverizes the food, strong muscular contractions (peristaltic waves) push the food toward the pyloric valve, which leads to the upper portion of your small intestine (duodenum).

Symptoms

Signs and symptoms of gastroesophageal junction cancer and stomach cancer may include:

  • Fatigue
  • Feeling bloated after eating
  • Feeling full after eating small amounts of food
  • Severe, persistent heartburn
  • Severe indigestion that is always present
  • Unexplained, persistent nausea
  • Stomach pain
  • Persistent vomiting
  • Unintentional weight loss

When to see a doctor

If you have signs and symptoms that worry you, make an appointment with your doctor. Your doctor will likely investigate more common causes of these signs and symptoms first.

Stomach and pyloric valve

Your stomach is a muscular sac about the size of a small melon that expands when you eat or drink to hold as much as a gallon of food or liquid. Once your stomach pulverizes the food, strong muscular contractions (peristaltic waves) push the food toward the pyloric valve, which leads to the upper portion of your small intestine (duodenum).

Stomach and pyloric valve

Your stomach is a muscular sac about the size of a small melon that expands when you eat or drink to hold as much as a gallon of food or liquid. Once your stomach pulverizes the food, strong muscular contractions (peristaltic waves) push the food toward the pyloric valve, which leads to the upper portion of your small intestine (duodenum).

Stomach cancer

Stomach cancer most commonly begins in the cells that line the inside of the stomach.

Causes

In general, cancer begins when an error (mutation) occurs in a cell's DNA. The mutation causes the cell to grow and divide at a rapid rate and to continue living when a normal cell would die. The accumulating cancerous cells form a tumor that can invade nearby structures. And cancer cells can break off from the tumor to spread throughout the body.

Gastroesophageal junction cancer is associated with having gastrointestinal reflux disease (GERD) and, less strongly, with obesity and smoking. GERD is a condition caused by frequent backflow of stomach acid into the esophagus.

There is a strong correlation between a diet high in smoked and salted foods and stomach cancer located in the main part of the stomach. As the use of refrigeration for preserving foods has increased around the world, the rates of stomach cancer have declined.

Risk factors

The main risk factors for gastroesophageal junction cancer are a history of GERD and obesity.

Factors that increase your risk of stomach cancer located in the stomach body include:

  • A diet high in salty and smoked foods
  • A diet low in fruits and vegetables
  • Eating foods contaminated with a fungus called aflatoxin
  • Family history of stomach cancer
  • Infection with Helicobacter pylori
  • Long-term stomach inflammation
  • Pernicious anemia
  • Smoking
  • Stomach polyps

Diagnosis

Tests and procedures used to diagnose gastroesophageal junction cancer and stomach cancer include

  • A tiny camera to see inside your stomach (upper endoscopy). A thin tube containing a tiny camera is passed down your throat and into your stomach. Your doctor can look for signs of cancer. If any suspicious areas are found, a piece of tissue can be collected for analysis (biopsy).
  • Imaging tests. Imaging tests used to look for stomach cancer include computerized tomography (CT) scans and a special type of X-ray exam sometimes called a barium swallow.

Determining the extent (stage) of gastroesophageal or stomach cancer

The stage of your stomach cancer helps your doctor decide which treatments may be best for you. Tests and procedures used to determine the stage of cancer include:

  • Imaging tests. Tests may include CT and positron emission tomography (PET).
  • Exploratory surgery. Your doctor may recommend surgery to look for signs that your cancer has spread beyond your esophagus or stomach, within your chest or abdomen. Exploratory surgery is usually done laparoscopically. This means the surgeon makes several small incisions in your abdomen and inserts a special camera that transmits images to a monitor in the operating room.

Other staging tests may be used, depending on your situation.

Stages of stomach cancer

The stages of adenocarcinoma of the stomach or esophagus include:

  • Stage I. At this stage, the tumor is limited to the top layer of tissue that lines the inside of the esophagus or stomach. Cancer cells also may have spread to a limited number of nearby lymph nodes.
  • Stage II. The cancer at this stage has spread deeper, growing into a deeper muscle layer of the esophagus or stomach wall. Cancer may also have spread to more of the lymph nodes.
  • Stage III. At this stage, the cancer may have grown through all the layers of the esophagus or stomach and spread to nearby structures. Or it may be a smaller cancer that has spread more extensively to the lymph nodes.
  • Stage IV. This stage indicates that the cancer has spread to distant areas of the body.
Endoscopy

An endoscopy procedure involves inserting a long, flexible tube (endoscope) down your throat and into your esophagus. A tiny camera on the end of the endoscope lets your doctor examine your esophagus, stomach and the beginning of your small intestine (duodenum).

Endoscopy

An endoscopy procedure involves inserting a long, flexible tube (endoscope) down your throat and into your esophagus. A tiny camera on the end of the endoscope lets your doctor examine your esophagus, stomach and the beginning of your small intestine (duodenum).

Endoscopy

An endoscopy procedure involves inserting a long, flexible tube (endoscope) down your throat and into your esophagus. A tiny camera on the end of the endoscope lets your doctor examine your esophagus, stomach and the beginning of your small intestine (duodenum).

Treatment

Your treatment options for gastroesophageal junction cancer or stomach cancer depend on the stage of your cancer, your overall health and your preferences.

Surgery

Gastroesophageal junction cancer that has not spread requires surgery to remove the part of the esophagus or stomach where the tumor is located. The goal of surgery is to remove all of the cancer and a margin of healthy tissue, when possible. Nearby lymph nodes are typically removed as well.

The goal of surgery for cancer in the body of the stomach is also to remove all of the stomach cancer and a margin of healthy tissue, when possible. Options include:

  • Removing early-stage tumors from the stomach lining. Very small cancers limited to the inside lining of the stomach may be removed using endoscopy in a procedure called endoscopic mucosal resection. The endoscope is a lighted tube with a camera that's passed down your throat into your stomach. The doctor uses special tools to remove the cancer and a margin of healthy tissue from the stomach lining.
  • Removing a portion of the stomach (subtotal gastrectomy). During subtotal gastrectomy, the surgeon removes only the portion of the stomach affected by cancer.
  • Removing the entire stomach (total gastrectomy). Total gastrectomy involves removing the entire stomach and some surrounding tissue. The esophagus is then connected directly to the small intestine to allow food to move through your digestive system.
  • Removing lymph nodes to look for cancer. The surgeon examines and removes lymph nodes in your abdomen to look for cancer cells.
  • Surgery to relieve signs and symptoms. Removing part of the stomach may relieve signs and symptoms of a growing tumor in people with advanced stomach cancer. In this case, surgery can't cure advanced stomach cancer, but it can make you more comfortable.

    Surgery carries a risk of bleeding and infection. If all or part of your stomach is removed, you may experience digestive problems.

Radiation therapy

Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells. The energy beams come from a machine that moves around you as you lie on a table.

In gastroesophageal junction cancer, as well as in cancer of the stomach body, radiation therapy can be used before surgery (neoadjuvant radiation) to shrink a tumor so that it's more easily removed. Radiation therapy can also be used after surgery (adjuvant radiation) to kill any cancer cells that might remain in the area around your esophagus or stomach.

In gastroesophageal junction cancer, radiation and chemotherapy are typically administered at the same time (chemoradiotherapy), most often before surgery.

Radiation therapy to your stomach can cause diarrhea, indigestion, nausea and vomiting. Radiation therapy to your esophagus can cause pain on swallowing and difficulty swallowing. To avoid this side effect, you may be advised to have a feeding tube placed in your stomach through a small incision in your abdomen until your esophagus heals.

In cases of advanced cancer, radiation therapy may be used to relieve side effects caused by a large tumor.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs travel throughout your body, killing cancer cells that may have spread beyond the stomach.

Chemotherapy can be given before surgery (neoadjuvant chemotherapy) to help shrink a tumor so that it can be more easily removed. Chemotherapy is also used after surgery (adjuvant chemotherapy) to kill any cancer cells that might remain in the body. Chemotherapy is often combined with radiation therapy. Chemotherapy may be used alone in people with advanced stomach cancer to help relieve signs and symptoms.

Chemotherapy side effects depend on which drugs are used.

Targeted drugs

Targeted therapy uses drugs that attack specific abnormalities within cancer cells or that direct your immune system to kill cancer cells (immunotherapy). Targeted drugs used to treat stomach cancer include:

  • Trastuzumab (Herceptin) for stomach cancer cells that produce too much HER2
  • Ramucirumab (Cyramza) for advanced stomach cancer that hasn't responded to other treatments
  • Imatinib (Gleevec) for a rare form of stomach cancer called gastrointestinal stromal tumor
  • Sunitinib (Sutent) for gastrointestinal stromal tumors
  • Regorafenib (Stivarga) for gastrointestinal stromal tumors

Several targeted drugs are being studied for treatment of gastroesophageal junction cancer, but only two of these drugs — ramucirumab and trastuzumab — have been approved for this use.

Targeted drugs are often used in combination with standard chemotherapy drugs. Tests of your cancer cells can tell your doctor whether these treatments are likely to work for you.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing aggressive treatments, such as surgery, chemotherapy or radiation therapy.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

Potential future treatments

Researchers around the world are studying a number of new medications that harness the power of the immune system to eradicate cancer — an approach called immunotherapy. These medications work in complex ways to make the immune system respond to cancer cells as if they were foreign invaders, such as bacteria.

Preparing for an appointment

Start by seeing your family doctor if you have signs or symptoms that worry you. If your doctor suspects you may have a stomach problem, you may be referred to a doctor who specializes in gastrointestinal diseases (gastroenterologist). Once gastroesophageal junction cancer or stomach cancer is diagnosed, you may be referred to a cancer specialist (oncologist) or a surgeon who specializes in operating on the digestive tract.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
  • Note down any symptoms you're experiencing, even if they seem unrelated to the reason you have scheduled the appointment.
  • Make a note of key personal information, including things like recent life changes, or major stresses.
  • List all of the drugs, vitamins or supplements that you're currently taking or have taken recently.
  • Note what seems to improve or worsen your signs and symptoms. Keep track of which foods, medications or other factors influence your signs and symptoms.
  • Consider taking a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down a list of questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you cover all your concerns. List your questions from most important to least important in case time runs out. For stomach cancer, some basic questions to ask your doctor include:

  • What type of stomach cancer do I have?
  • How advanced is my stomach cancer?
  • What other kinds of tests do I need?
  • What are my treatment options?
  • How successful are the treatments?
  • What are the benefits and risks of each option?
  • Is there one option you feel is best for me?
  • How will treatment affect my life? Can I continue to work?
  • Should I seek a second opinion? What will that cost, and will my insurance cover it?
  • Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time later to cover other points you want to address. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Coping and support

A cancer diagnosis can be overwhelming and frightening. Once you start to adjust after the initial shock of your diagnosis, you may find it helps to stay focused on tasks that help you cope. For example, try to:

  • Learn enough to make decisions about your care. Ask your doctor to write down the details of your cancer — the type, stage and your treatment options. Use those details to find more information about stomach cancer and the benefits and risks of each treatment option.
  • Connect with other cancer survivors. Ask your doctor about support groups in your area. Or go online and connect with cancer survivors on message boards, such as those run by the American Cancer Society.
  • Stay active. Being diagnosed with cancer doesn't mean you have to stop doing the things you enjoy or normally do. For the most part, if you feel well enough to do something, go ahead and do it.

Prevention

It's not clear what causes gastroesophageal junction or stomach cancer, so there's no way to prevent it. But you can take steps to reduce your risk of gastroesophageal junction cancer and stomach cancer by making small changes to your everyday life. For instance, try to:

  • Exercise. Regular exercise is associated with a reduced risk of stomach cancer. Try to fit physical activity into your day most days of the week.
  • Eat more fruits and vegetables. Try to incorporate more fruits and vegetables into your diet each day. Choose a wide variety of colorful fruits and vegetables.
  • Reduce the amount of salty and smoked foods you eat. Protect your stomach by limiting these foods.
  • Stop smoking. If you smoke, quit. If you don't smoke, don't start. Smoking increases your risk of stomach cancer, as well as many other types of cancer. Quitting smoking can be very difficult, so ask your doctor for help.
  • Ask your doctor about your risk of gastroesophageal junction or stomach cancer. Talk with your doctor if you have an increased risk of gastroesophageal junction cancer or stomach cancer. Together you may consider periodic endoscopy to look for signs of stomach cancer.

Last updated: August 29th, 2017

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