Gastric Cancer (Stomach Cancer)

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What is Gastric Cancer (Stomach Cancer)?

About the stomach

The stomach is located in the upper abdomen and plays a central role in digesting food. When food is swallowed, it is pushed down the esophagus (the muscular tube that connects the throat with the stomach) and enters the stomach. The muscles in the stomach mix the food and release gastric juices that help break down and digest the food. The food then moves into the small intestine for further digestion.

Types of stomach cancer

Stomach cancer, also called gastric cancer, begins when cells in the stomach become abnormal and grow uncontrollably. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Cancer can begin in any part of the stomach, and it can spread to nearby lymph nodes and other areas of the body, such as the liver, bones, lungs, and a woman’s ovaries.

Most stomach cancers are a type called adenocarcinoma, which means that the cancer started in the glandular tissue that lines the inside of the stomach. Other types of cancerous tumors that form in the stomach include lymphoma, gastric sarcoma, and carcinoid tumors, but these are rare.

Symptoms and Signs

People with stomach cancer may experience the following symptoms or signs. Sometimes, people with stomach cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor. 

Stomach cancer is usually not found at an early stage because it often does not cause specific symptoms. When symptoms do occur, they may be vague and can include: 

Indigestion or heartburn

Pain or discomfort in the abdomen

Nausea and vomiting, particularly vomiting up of solid food shortly after eating

Diarrhea or constipation

Bloating of the stomach after meals

Loss of appetite

Sensation of food getting stuck in the throat with eating 

Symptoms of advanced stomach cancer may include:

Weakness and fatigue

Vomiting blood or having blood in the stool

Unexplained weight loss

It’s important to remember that these symptoms can also be caused by many other illnesses, such as a stomach virus or an ulcer. People with any of the symptoms listed above should talk with their doctor.

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Risk Factors

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a person’s risk of developing stomach cancer:

Age. Stomach cancer occurs most commonly in people older than age 55. Most people diagnosed with stomach cancer are in their 60s and 70s.

Gender. Men have twice the risk of developing stomach cancer, compared with women.

Family history. People who have a a parent, child, or sibling who has had stomach cancer are at increased risk. 

Race. Black people are more likely than white people to develop stomach cancer.

Diet. Eating foods preserved by drying, smoking, salting, or pickling may increase the risk of stomach cancer. Eating fresh fruits and vegetables may help lower the risk.

Bacteria. A common bacterium called Helicobacter pylori, which causes stomach inflammation and ulcers, may increase the risk of stomach cancer. However, most people who are infected with this bacterium never develop stomach cancer.

Previous surgery or health conditions. People who have had stomach surgery or have pernicious anemia (a severe decrease in red blood cells that occurs when the body does not have enough B12, which is usually due to the stomach’s inability to properly absorb the vitamin) or achlorhydria (the absence of hydrochloric acid in the gastric juices, which help digest food) have an increased risk of stomach cancer.

Occupational exposure. Exposure to certain dusts and fumes may increase the risk of developing stomach cancer.

Tobacco and alcohol. Tobacco use and excessive alcohol consumption may increase the risk of developing stomach cancer.

Genetic mutations. Certain inherited genetic disorders, such as hereditary diffuse gastric cancer, hereditary non-polyposis colorectal cancer (HNPCC or Lynch syndrome), and familial adenomatous polyposis (FAP) may increase the risk of stomach cancer.

Obesity. Excess body weight increases a man’s risk of developing stomach cancer. It is not clear whether obesity increases a woman’s risk of stomach cancer.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose stomach cancer:

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Endoscopy. This test allows the doctor to see the inside of the body. The person may be sedated, and the doctor inserts a thin, lighted, flexible tube called a gastroscope or endoscope through the mouth, down the esophagus, and into the stomach and small bowel. The doctor can remove a sample of tissue during an endoscopy and check it for evidence of cancer.

Endoscopic ultrasound. This test is similar to an endoscopy, but the gastroscope has a small ultrasound probe on the end that produces a detailed image of the stomach wall. An ultrasound uses sound waves to create a picture of the internal organs. The ultrasound image helps doctors determine how far the cancer has spread into the stomach and nearby lymph nodes, tissue, and organs, such as the liver.

X-ray. An x-ray is a way to create a picture of the structures inside of the body using a small amount of radiation.

Barium swallow. In a barium swallow, a person swallows a liquid containing barium, and a series of x-rays are taken. Barium coats the lining of the esophagus, stomach, and intestines, so tumors or other abnormalities are easier to see on the x-ray. 

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Laparoscopy.  A laparoscopy is a minimally invasive surgery in which the surgeon inserts a scope into the abdominal cavity to evaluate spread of the stomach cancer to the lining of the abdominal cavity or liver. This pattern of cancer spread is not detected by CT or PET scan.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

Stages

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery).

There are different stage descriptions for different types of cancer. This section covers staging of adenocarcinoma, the most common type of stomach cancer. Staging is different for gastric lymphoma,sarcoma, and carcinoid tumors.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How far has the primary tumor extended into the stomach?(Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the how far the tumor has extended into the stomach. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below:

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a primary tumor in the stomach.

Tis: This stage describes a condition called carcinoma (cancer) in situ. The cancer is found only in cells on the surface of the epithelium (the inner lining of the stomach) and has not spread to any other layers of the stomach.

T1: The tumor has invaded the lamina propria, muscularis mucosae, or the submucosa (the inner layers of the wall of the stomach).

T1a: The tumor has invaded the lamina propria or muscularis mucosae.

T1b: The tumor has invaded the submucosa.

T2: The tumor has invaded the muscularis propria (the muscle layer of the stomach).

T3: The tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach, but it has not penetrated the peritoneal lining or serosa.

T4: The tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach and has penetrated the peritoneal lining or serosa or the organs surrounding the stomach.

T4a: The tumor has invaded the serosa.

T4b: The tumor has invaded organs surrounding the stomach.

Node. The “N” in the TNM staging system is for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes inside the abdomen are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. The overall prognosis for patients with stomach cancer is based on how many regional lymph nodes show evidence of cancer. If six lymph nodes or fewer are involved, the prognosis is better than if more than 15 lymph nodes contain cancer cells.

NX: Regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread into the regional lymph nodes.

N1: The cancer has spread to one to two regional lymph nodes.

N2: The cancer has spread to three to six regional lymph nodes.

N3: The cancer has spread to seven or more regional lymph nodes.

N3a: The cancer has spread to seven to 15 regional lymph nodes.

N3b: The cancer has spread to more than 16 regional lymph nodes.

Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant metastasis cannot be evaluated.

M0 (M plus zero): The cancer has not metastasized.

M1: The cancer has spread to another part or parts of the body.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: This is also called carcinoma in situ. The cancer is found only on the surface of the epithelium. The cancer has not invaded any other layers of the stomach and is considered an early cancer (Tis, N0, M0).

Stage IA: The cancer has invaded the inner layer of the wall of the stomach, but it has not spread to any lymph nodes or other organs (T1, N0, M0).

Stage IB: Stomach cancer is called stage IB in either of these two conditions:

The cancer has grown into the inner layers of the wall of the stomach and has spread to one to two lymph nodes but not elsewhere (T1, N1, M0).

The cancer has grown into the outer muscular layers of the wall of the stomach, but the cancer has not spread to the lymph nodes or other organs (T2, N0, M0).

Stage IIA: Stomach cancer is called stage IIA for any one of these conditions:

The cancer has invaded the inner layer of the wall of the stomach and has spread to three to six lymph nodes but not elsewhere (T1, N2, M0).

The cancer has invaded the outer muscular layers of the wall of the stomach and has spread to one to two lymph nodes but not elsewhere (T2, N1, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach but has not penetrated the peritoneal lining or serosa. It has not spread to any lymph nodes or surrounding organs (T3, N0, M0).

Stage IIB: Stomach cancer is called stage IIB for any one of these conditions:

The cancer has grown into the inner layers of the wall of the stomach and has spread to seven or more lymph nodes but not elsewhere. (T1, N3, M0).

The cancer has invaded the outer muscular layers of the wall of the stomach and has spread to three to six lymph nodes but not elsewhere (T2, N2, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach but has not penetrated the peritoneal lining or serosa and has spread to one to two lymph nodes but not elsewhere (T3, N1, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach and has penetrated the peritoneal lining or serosa, but it has not spread to any lymph nodes or surrounding organs (T4a, N0, M0).

Stage IIIA: Stomach cancer is called stage IIIA for any one of these conditions:

The cancer has invaded the outer muscular layers of the stomach wall and has spread to seven or more lymph nodes but not to other organs (T2, N3, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach but has not penetrated the peritoneal lining or serosa. It has spread to three to six lymph nodes but not to other organs (T3, N2, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach and has penetrated the peritoneal lining or serosa and has spread to one to two lymph nodes but not to other organs (T4a, N1, M0).

Stage IIIB: Stomach cancer is called stage IIIB for any of these conditions:

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach but has not penetrated the peritoneal lining or serosa. It has spread to seven or more lymph nodes but has not invaded any surrounding organs (T3, N3, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach and has penetrated the peritoneal lining or serosa and has spread to three to six lymph nodes but has not spread elsewhere (T4a, N2, M0).

The cancer has grown through all of the layers of the muscle into the connective tissue outside the stomach and has invaded nearby organs or structures. It may or may not have spread to one to two lymph nodes but not to distant parts of the body (T4b, N0 or N1, M0).

Stage IV: Stage IV stomach cancer describes a cancer of any size that has spread to distant parts of the body besides the area around the stomach (any T, any N, M1).

Recurrent cancer. Recurrent cancer is cancer that comes back after treatment. It may be a localized recurrence (comes back in the place where it started), or it may be a distant metastasis (comes back in another part of the body). If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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