gastric cancer
gastric cancer
Stomach cancer, see there.gastric cancer
From 1930 to the 1990s, the incidence of gastric cancer declined from about 38 cases per 100,000 to about 6 cases per 100,000. In 2010, the ACS estimated there would be 21,000 new cases of gastric cancer in the U.S. and 10,570 deaths from this disease. The prognosis for a particular patient depends on the stage of the disease at the time of diagnosis, but overall the 5-year survival rate is about 19%.
Predisposing Causes
Although the cause of gastric cancer is unknown, predisposing factors include a diet rich in pickled or smoked foods, a history of gastric surgery, and a history of infection by Helicobacter pylori. The disease runs in some families; therefore, there may also be a genetic component.
Complications
Malnutrition occurs as a result of impaired eating, the metabolic demands of the growing tumor, or obstruction of the GI tract. Iron deficiency anemia results as the tumor causes ulceration and bleeding. The tumor can interfere with the production of the intrinsic factor needed for vitamin B12 absorption, resulting in pernicious anemia. As the cancer spreads to regional lymph nodes and nearby structures and metastasizes to other structures, related complications occur.
Signs and Symptoms
In the early stages, the patient may occasionally experience pain in the back or in the epigastric or retrosternal areas that is relieved with nonprescription analgesics. As the tumor grows, the patient may notice a vague feeling of fullness, heaviness, and abdominal distention after meals. Depending on the progression of the cancer, the patient may report weight loss due to disturbance of the appetite; nausea; and vomiting. There may be dysphagia and coffee-ground vomitus if the tumor is located in the cardia and slowly bleeds. Weakness and fatigue are common. Because early symptoms include chronic dyspepsia and epigastric discomfort, patients may self-treat with OTC antacids or histamine blockers, delaying prescribed therapies and allowing the cancer to progress.
Palpation of the abdomen may disclose a mass. A skilled examiner may be able to palpate enlarged lymph nodes, esp. in the supraclavicular and axillary regions.
Diagnostic Studies
Gastric cancer is diagnosed by fiber-optic endoscopy with biopsy. Studies to rule out specific organ metastases include endoscopic ultrasonography, computed tomography scans, chest radiographs, liver and bone scans, and liver biopsy.
Treatment
Radical surgery to remove the tumor is possible in more than one third of patients. Even in the patient whose disease is not considered surgically curable, resection may temporarily ease symptoms and improve the patient’s response to chemotherapy and radiation therapy. The nature and extent of the lesion determine the type of surgery. Surgical procedures include gastroduodenostomy, gastrojejunostomy, partial gastric resection, and total gastrectomy. If metastasis has occurred, the omentum and spleen may have to be removed.
Chemotherapy for GI tumors may help control signs and symptoms and prolong survival. Gastric adenocarcinomas respond to several agents, including fluorouracil, carmustine, doxorubicin, and mitomycin. Tumors that express HER2 antigens respond to treatment with trastuzumab (a monoclonal antibody that targets the human epidermal growth factor). Antispasmodics, antacids, and proton pump inhibitors may help relieve GI acidity and reflux symptoms. Antiemetics can control nausea, which intensifies as the tumor grows. Analgesics, sedatives, and tranquilizers are used to control pain and anxiety.
Patient care
Nutritional intake is monitored, and the patient is weighed periodically. The health care provider initiates comprehensive clinical and laboratory investigations, including serial studies as indicated, if these have not already been done. The patient is prepared physically and emotionally for surgery, chemotherapy, or radiotherapy. During hospitalization, all general patient care concerns apply.
Throughout the course of the illness, a high-protein, high-calorie diet with vitamin supplementation helps the patient avoid or recover from weight loss, malnutrition, and anemia, and promote wound healing. Frequent small meals are offered.
To stimulate a poor appetite, antidepressant or steroid drugs may be administered. The patient is instructed in use of all drugs and the expected adverse effects of treatment, as well as in management strategies for these effects.
Radiation therapy may cause nausea, vomiting, local skin damage, malaise, diarrhea, and fatigue. Chemotherapy may cause bone marrow suppression, infection, nausea, vomiting, mouth ulcers, and hair loss. During radiation or chemotherapy, oral intake is encouraged to remove toxic metabolites. Bland fruit juices, ginger ale, or other fluids, and prescribed antiemetics are provided to minimize nausea and vomiting; comfort and reassurance are offered as needed. The patient is advised to report persistent adverse reactions.
The patient is encouraged to follow a normal routine as much as possible after recovery from surgery and during radiation therapy and chemotherapy. He should stop activities that cause excessive fatigue (at least temporarily) and incorporate rest periods. The patient should avoid crowds and people with known infections. Home-health care is provided as necessary. If curative treatment fails, palliative care and psychological support continues, with questions answered honestly but tactfully. Home or in-patient hospice care referrals are suggested as available.
Synonym: stomach cancer
Gastric Cancer
| DRG Category: | 326 |
| Mean LOS: | 15.4 days |
| Description: | SURGICAL: Stomach, Esophageal, and Duodenal Procedure With Major CC |
| DRG Category: | 375 |
| Mean LOS: | 5.5 days |
| Description: | MEDICAL: Digestive Malignancy With CC |
Gastric cancer is a relatively uncommon malignancy, accounting for approximately 2% of all cancers in the United States. While reports vary, the World Health Organization states that it is the sixth-most common cancer worldwide. Because it is often found in advanced stages both in developed and developing regions of the world, it is difficult to cure. In 2013 in the United States, it was estimated that 21,600 people were diagnosed with gastric cancer and that 10,990 died of the disease. This type of cancer, like lung cancer, is primarily found in the seventh decade of life.
Nearly 95% of gastric neoplasms are classified as adenocarcinomas; these tumors develop from the epithelial cells that form the innermost lining of the stomach’s mucosa. The most common sites for cancer in the stomach include the antrum, the pylorus, and along the area of lesser curvature. According to the Lauren classification, gastric adenocarcinomas are divided into two main histologic types: diffuse and intestinal. The diffuse type is ill defined, infiltrates the gastric wall, and lacks a distinctive mass. The intestinal type, by contrast, is composed of neoplastic cells that cluster together, resembling glands; it is associated with a better prognosis, as are tumors along the area of lesser curvature. A poor prognosis is associated with tumors of the cardia or the fundus.
Metastasis occurs via the lymphatics and the blood vessels by seeding of peritoneal surfaces or by direct extension of the tumor. Sites of metastasis are the liver, lungs, bone, adrenals, brain, ovaries, colon, and pancreas. Intestinal tumors are more likely to spread to the liver, whereas diffuse-type tumors are more likely to spread along peritoneal surfaces. Other complications include malnutrition, gastrointestinal (GI) obstruction, and iron deficiency anemia.
Causes
A probable factor in developing gastric cancer is a Helicobacter pylori infection leading to atrophic gastritis (inflammation and damage to the inner layer of the stomach). Dietary factors linked to gastric cancer are associated with either gastric irritation or exposure to mutagenic or carcinogenic compounds. They include a high intake of smoked foods, salted fish and meat, nitrite-preserved foods, starch, and fat, along with a low intake of fruits, vegetables, and animal proteins. Associated environmental factors include exposure to ionizing radiation and being employed in metal products or chemical industries. Physiological factors are related to a rise in gastric pH or the formation of mutagenic or carcinogenic compounds. Other associated conditions include gastric ulcers, gastric polyps, pernicious anemia, intestinal metaplasia, achlorhydria, hypochlorhydria, gastric atrophy, and chronic peptic ulcers. Similarly, patients who have undergone a partial gastrectomy for benign gastric disease are predisposed to developing gastric cancer.
Genetic considerations
Genetic factors that are linked to an increased incidence of gastric cancer include a family history of stomach cancer and type A blood. There is a familial cancer syndrome with an autosomal dominant pattern of transmission identified as hereditary diffuse gastric cancer. Mutations in the gene E-cadherin/CDH1 are associated with this disease. Family history has also been associated with gastric cancer, with the risk of gastric cancer having a two-fold increase when a first-degree relative is affected.
Gender, ethnic/racial, and life span considerations
Two-thirds of the patients with gastric cancer are older than 65. More men than women die of gastric cancer. Rates for gastric cancer are higher in Asian countries.
Global health considerations
Gastric cancer is the sixth-most common cancer worldwide (after breast, prostate, lung, colorectal, and cervical cancers). It has rates as high as 80 per 100,000 individuals per year in Southeastern Asia, South America, and some Eastern European countries. Developed nations have more than twice the incidence of gastric cancer than developing nations.
Assessment
History
Gastric cancer may not produce symptoms until the disease is very advanced. About one-third of the patients report a long history of dyspepsia (painful digestion). The most common initial symptoms are mild epigastric discomfort, loss of appetite, nausea, and a sense of fullness or gas pains. Patients may also report experiencing unusual tiredness, abdominal pains, constipation, weight loss, and a bad taste in the mouth. Massive GI bleeding is unusual, although chronic bleeding may occur, which results in a positive occult blood test. Patients with advanced gastric cancer report the classic symptoms of anemia, such as fatigue and activity intolerance, as well as vomiting (coffee ground or sometimes containing frank blood), anorexia, abdominal pain, dyspepsia, and dysphagia (difficulty swallowing).
Physical examination
In the early stages of gastric cancer, the patient usually appears healthy. The most common initial symptoms are mild epigastric discomfort, loss of appetite, nausea, and a sense of fullness or gas pains. In later stages, patients may appear weak, pale, dyspneic, and fatigued from anemia; they are thin and seem to be malnourished. Only 37% of patients have a palpable abdominal mass. Observe for abdominal swelling and ascites (poor prognostic sign) and palpate for hepatomegaly secondary to liver or peritoneal metastases. Some patients may have palpable lymph nodes, especially the supraclavicular and axillary nodes. Gastric cancer is frequently staged using the TNM classification system (T: primary tumor, N: lymph node, M: distant metastasis).
Psychosocial
Survival rates after treatment for gastric cancer remain discouraging (the 5-year survival rate is 27% for all gastric cancers), and patients with gastric cancer have special psychosocial concerns. Assess their support systems and their ability to cope with major lifestyle changes. As appropriate, assess their transition through the various stages of death and dying.
Diagnostic highlights
General Comments: The presence of lactic acid and a high lactate dehydrogenase level in the gastric juice are suggestive of cancer. Often, in patients with gastric cancer, plasma tumor markers (carcinoembryonic antigen [CEA], cancer antigent [CA] 19–9) are elevated. Positive fecal occult blood tests are associated with the chronic bleeding that is related to gastric cancer.
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Upper GI series | Normal upper GI tract | Presence of cancer in the stomach | Identifies size and location of tumor |
| Esophagogastroduodenoscopy | Normal stomach | Visualization of cancer in the stomach | Visualizes tumor for biopsy; has a diagnostic accuracy of 95% |
Other Tests: Cytology studies of the specimens obtained, computed tomography scan, abdominal ultrasonography, and laparoscopy; complete blood count, CEA, CA 19–9
Primary nursing diagnosis
Diagnosis
Pain (acute) related to gastric erosionOutcomes
Comfort level; Pain control behavior; Pain level; Symptom severityInterventions
Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management; Patient-controlled analgesia assistancePlanning and implementation
Collaborative
Treatment includes surgery, chemotherapy, and radiation. Of patients with potentially curable gastric cancer, 80% die from a recurrence within 5 years of the initial treatment. If the cancer is resected before it has invaded the stomach wall, the 5-year survival rate is about 90%. The deeper the cancer invades the stomach wall, the poorer the prognosis. A complete en bloc resection of an early, localized tumor is the only cure. Most patients undergo a subtotal gastrectomy, after which GI continuity can be restored by either a Billroth I (gastroduodenostomy) or a Billroth II (gastrojejunostomy) procedure. After such gastric surgery, patients are prone to vitamin B12 deficiency and megaloblastic anemia from lack of intrinsic factor; monthly vitamin B12 replacement is therefore necessary. For patients who undergo a Billroth I procedure, postprandial dumping syndrome is a problem. For patients who undergo a Billroth II procedure, postoperative intestinal obstruction is a concern. In addition, transfusions of packed red blood cells are given to patients to correct anemia.
For patients with advanced disease, palliative subtotal or total gastrectomies may be performed to alleviate gastric symptoms, such as bleeding or obstruction. After surgery, chemotherapy or radiation, or both, may be provided.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Chemotherapeutic agents | Varies with drug | Used as adjuvant (in addition to) or neoadjuvant (before surgery) often in combination: fluorouracil, doxorubicin, methyl-1-(2-Chloroethyl)-3-Cyclohexyl-1-Nitrosourea (CCNU), cisplatin, methotrexate, etoposide; Trastuzumab combined with cisplatin and capecitabine or 5-FU (for people who have not have previous chemotherapy) | Treat cancer that has metastasized to organs beyond stomach; shrink tumors before surgery |
| Vitamins | Tablets come in various sizes | Vitamin B complex | Combat vitamin B12 deficiency and megaloblastic anemia from lack of intrinsic factor |
| Narcotic analgesics | Varies with drug | Manage pain, side effects of treatment drugs such as morphine, meperidine | Increase patient comfort during end-stage disease |
Other Drugs: Antiemetics may be used to control nausea, which increases as the tumor enlarges. In the advanced stages, the physician may prescribe sedatives, narcotics, and tranquilizers to increase the patient’s comfort. Antispasmodics and antacids may also help relieve GI discomfort.
Independent
preoperative.
Explain all preoperative and postoperative procedures. Preoperative needs include nutritional adequacy, intravenous fluids, and prophylactic bowel preparation. Inform the patient about the need for GI decompression via a tube for 1 to 3 weeks postoperatively. Explain the amount of pain that should be anticipated and reassure the patient that analgesia provides relief. Teach coughing and deep-breathing exercises and have the patient practice them.postoperative.
Maintain wound care, provide adequate fluid and nutrition, manage pain, and control symptoms. Monitor the patient for complications such as hemorrhage, intestinal obstruction, and infection. Teach wound care and the signs and symptoms of infection. Teach nonpharmacologic pain management techniques. As indicated, teach the signs and symptoms of “dumping syndrome”: epigastric fullness, nausea, vomiting, abdominal cramping, and diarrhea that occur within 30 minutes of eating. Teach patients that they may also experience sweating, dizziness, pallor, and palpitations related to the dumping syndrome. To relieve the symptoms, teach patients to avoid drinking fluids within a half hour of meals and to eat small meals that are low carbohydrate, high fat, and high protein.Evidence-Based Practice and Health Policy
Ma, J.L., Zhang, L., Brown, L.M., Li, J.Y., Shen, L., Pan, K.F., …Gail, M.H. (2012). Fifteen-year effects of Helicobacter pylori, garlic, and vitamin treatments on gastric cancer incidence and mortality. Journal of the National Cancer Institute, 104(6), 488–492.
- Investigators conducted a randomized controlled trial to determine the effects of a 2-week treatment regimen with amoxicillin and omeprazole and a 7-year vitamin C, E, and selenium supplement regimen on decreasing the risk of gastric cancer among patients who tested positive for H. pylori. Amoxicillin and omeprazole treatments were given to 1,130 patients, and the placebo was given to 1,128 patients. Vitamin treatments were given to 1,677 patients, and the placebo was given to 1,688 patients.
- Over the course of the 14.7 follow-up years, gastric cancer was diagnosed in 3% of the amoxicillin and omeprazole treatment group and 4.6% of the placebo group. Treatment with amoxicillin and omeprazole decreased the risk of gastric cancer by 39% (95% CI, 0.38 to 0.96; p = 0.032).
- Vitamin supplementation did not decrease the risk of gastric cancer, as 2.9% of the vitamin treatment group was diagnosed compared to 3.4% of the vitamin placebo group. However, vitamin treatment was associated with a 49% decreased risk of mortality from gastric cancer (95% CI, 0.30 to 0.87; p = 0.014).
Documentation guidelines
- Physical findings related to gastric cancer: Epigastric discomfort, dyspepsia, anorexia, nausea, sense of fullness, gas pains, unusual tiredness, abdominal pains, constipation, weight loss, vomiting, hematemesis, blood in the stool, dysphagia, jaundice, ascites, bone pain
- GI decompression data: Irrigation and patency of tube, assessment of bowel sounds and passage of gas, complaints of nausea, amount and description of gastric fluid output
- Presence of postoperative complications: Hemorrhage, obstruction, anastomotic leaks, infection, peritonitis
- Presence of postoperative dumping syndrome and associated patient symptoms
Discharge and home healthcare guidelines
Teach the patient the importance of compliance with palliative and follow-up care. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Teach the patient the signs and symptoms of infection and how to care for the incision. Instruct the patient to notify the physician if signs of infection occur. Encourage the patient to seek psychosocial support through local support groups (e.g., I Can Cope), clergy, or counseling services. If appropriate, suggest hospice services. Teach the patient methods to enhance nutritional intake to maintain ideal body weight. Several small meals a day may be tolerated better than three meals a day. Take liquid supplements and vitamins as prescribed. Refer the patient to the dietitian for a consultation. Teach family members and friends prevention strategies. Strategies include increasing the intake of fresh fruits and vegetables that are high in vitamin C; maintaining adequate protein intake; and decreasing intake of salty, starchy, smoked, and nitrite-preserved foods.
Patient discussion about gastric cancer
Q. Do japanese in the US still have high risk of stomach cancer? I was born in the US to parents that emigrated from Japan when they were in their late twenties. I know that people in Japan have a very high risk of stomach cancer. Does that mean that as an individual of Japanese origin I also have high risk, although I never were in Japan?