What is Stomach Cancer?

On Feb. 5, Oklahoma lost a favorite son and icon, Toby Keith, to stomach cancer and Oklahomans are in mourning. As an oncologist, a cancer specialist, I wanted to talk a bit more about stomach cancer as it’s not very common and can be devastating.

The Facts:

• Every year in the United States about 26,000 new cases of stomach cancer are diagnosed, and over 10,000 people die from stomach cancer. 
• Stomach cancer can be difficult to diagnose and only half the patients diagnosed have early stage disease which is amenable to curative surgery. 
• Screening for gastric cancers is not widely performed outside of certain Asian countries such as Japan and Korea where the incidence is much higher. 

The Symptoms:

• Weight loss and abdominal discomfort (stomach aches) tend to be the most common presenting complaints. About a quarter of patients with gastric cancer have a history of a stomach ulcer. 
• Weight loss tends to be from a decreased appetite or difficulty eating due to pain in the stomach or while swallowing. Some people can have cancer in the upper stomach causing a feeling of food getting stuck which can also cause weight loss.
• Nausea and low appetite are other presenting symptoms. In some patients, they may have a stomach bleed which can be caught on annual blood tests as low iron content or anemia. 
• Sometimes patients can present with symptoms that may seem unrelated to stomach cancer such as the development of multiple old spots (sebbhoreic keratoses) or hyperpigmentation at the back of the neck (acanthosis Nigricqns). These findings are not specific for stomach cancer but if present stomach cancer should be ruled out. 

The Diagnosis:

• Diagnosing stomach cancer takes a high level of suspicion as these presenting symptoms can be very vague and patients can also often dismiss them as not too worrying. 
• Once stomach cancer is on the differential we start with getting an esophagogastroduodenoscopy (EGD). An EGD is done by advancing a small camera from the mouth, down the food pipe, to the stomach and up to the first part of the intestines (the duodenum) at each point biopsies are taken and if there is any area that looks injured or bruised they take extra biopsies around that area. 
• If the biopsies from the EGD show cancer, we get a CT scan of the chest, abdomen and pelvis to see if the disease has spread. Almost half of all patients with stomach cancer present with advanced disease so it’s essential to evaluate for this at the get-go. Depending on the extent of the disease a treatment plan is made. 

The Treatment:

For patients with disease confined to the stomach, we recommend a staggered approach of chemo, then surgery, followed by more chemo. In recent years we have also added immunotherapy to our treatment repertoire. Immunotherapy is different from chemotherapy. Our bodies are designed to find cancer and fight it when it’s in early stages but sometimes our bodies fail to do so. This failure can be from a weakened immune system or cancer cells camouflaging themselves as regular cells.

Immunotherapy works in two ways, firstly by finding cancer cells and undoing the camouflage making it easier for our immune cells to find them, and secondly by ramping up our immune system making it more aggressive and able to fight cancer cells. I like to explain chemo and immunotherapy by using the old give a man a fish versus teach a man to fish adage. 

Chemotherapy acts fast and immediately helps us kill cancer cells but even with great success if any cancer cells are left behind they will start growing once chemo stops. Meanwhile, immunotherapy works slower and does not work for everyone, but for those in whom it works, it works for a longer time and can work even after the treatment has stopped. 

For patients who have advanced disease, treatment entails chemotherapy with the possibility of immunotherapy, and in a small percentage of patients targeted therapy, particularly anti HER2 therapy.

Targeted therapy can only be used in patients who have HER2 mutation working as a molecular driver of disease. We test all patients for these molecular drivers to help us tailor therapy to each individual. 

Even with all these new therapies gastric cancer remains very deadly. Patients who have cancer confined to the stomach and lymph nodes have a five year survival rate of 33%. If the disease has spread beyond the stomach the five year survival falls to 6%. Stomach cancer is a deadly disease with a vague presentation making it difficult to diagnose and even with modern advancements in treatment, survival is abysmal. I send all my love, thoughts, prayers and well wishes to the friends, family and admirers of Toby Keith and hope this small explainer of stomach cancer helps people understand this devastating disease and encourage everyone to take any of the above-mentioned symptoms seriously and see their physician if they feel out of sorts.

Laila Babar, M.D., is an oncologist with the INTEGRIS Health Cancer Institute at Southwest Medical Center in Oklahoma City. She is accepting new patients. Click here to schedule an appointment.