FACTSHEET

What is the stomach?

The stomach is in the upper abdomen. It is part of the (the gut). It lies in the upper part of the abdomen, just below the ribs. When we eat, food passes down the oesophagus (gullet) into the stomach. The stomach makes acid which is not essential, but helps to digest food. The muscles in the wall of the stomach contract to mix up the food with the acid. Food then passes into the duodenum (the first part of the small intestine). Here food mixes with enzymes (chemicals) which come from the and lining of the gut. The enzymes break down (digest) the food. Digested food is then absorbed into the body from the small intestine. Source: www.patient.co.uk

What is ?

Stomach cancer is sometimes called gastric cancer. World-wide it is one of the most common . For example, it is common in Japan and China. It is less common in the UK. Stomach cancer is more common in men than women and tends to occur mainly in older people. Most cases are in people over the age of 45.

Adenocarcinoma of the stomach In most cases, stomach cancer begins from a cell which is on the inside lining of the stomach (the mucosa). This type of stomach cancer is called of the stomach. As the cancer cells multiply:

• The tumour may invade deeper into the wall of the stomach. In time it may pass through the wall of the stomach and invade nearby organs such as the pancreas or . • The tumour may spread up or down the stomach into the oesophagus (gullet) or small intestine. • Some cells may break off into the lymph channels or bloodstream. The cancer may then spread to nearby lymph nodes or spread to other areas of the body (metastasise).

Other types of stomach cancer There are some less common and rare types of stomach cancer which include: • . These are cancers which arise from lymphatic tissue within the wall of the stomach. • Sarcomas. These are cancers which arise from muscle or connective tissue within the wall of the stomach • cancers. These are cancers which arise from cells in the stomach lining which make hormones.

Source: www.patient.co.uk

What causes stomach cancer (adenocarcinoma of the stomach)?

A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain in the cell. This makes the cell abnormal and multiply 'out of control'.

Many people develop stomach cancer for no apparent reason. However, certain 'risk factors' increase the chance that stomach cancer may develop. These include: Ageing. Stomach cancer is more common in older people. Most cases are in people over the age of 45. If a close relative has had stomach cancer. Stomach cancer is also more common in people with blood group A. (So, there is probably some genetic factor.) Diet is probably a factor: Countries such as Japan where people eat a lot of salt, pickled and smoked foods have a high rate of stomach cancer. Eating a lot of fruit and green vegetables is thought to reduce the risk. Long term infection of the stomach lining with a bacterium called H pylori . (This infection is very common in the UK, and most people with H pylori infection do not develop stomach cancer. But it does have some small risk at causing stomach cancer.) If you have pernicious anaemia there is a small increased risk. Gender. Stomach cancer is twice as common in men than women. If you have had part of your stomach removed in the past for any reason. For example, if you had part of your stomach removed to treat a stomach ulcer or some other condition. Source: www.patient.co.uk

People with concerns about their own health should contact their GP or cancer team

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT www.wcisu.wales.nhs.uk STOMACH CANCER FACTSHEET

Symptoms of stomach cancer

The symptoms of stomach cancer can be quite vague. Symptoms can include:

• , acidity and • Feeling full • Pain • Feeling or being sick • Difficulty in swallowing • or tiredness and breathlessness because you have lost blood • Blood clots • (usually a symptom of a more advanced cancer)

Indigestion and burping The earliest symptoms are often acidity and burping. Many people diagnosed with stomach cancer have had symptoms like these for years. But these are symptoms of other stomach problems too. Most people who have chronic indigestion and wind never develop cancer. About 1 in every 50 people going to the doctor for the first time with indigestion and burping will have stomach cancer.

Feeling full

Another early symptom can be feeling full up sooner when eating your meals. If this leads to eating less over a period of time, you will start to lose weight.

Pain, sickness and difficulty swallowing

These are common symptoms. More than half of those diagnosed with stomach cancer have either pain, sickness or some difficulty swallowing. You may feel sick or actually be sick. The exact site of the pain can vary. It is most usually in the upper abdomen. Or you may have pain just under your breastbone (sternum) or slightly lower down.

Bleeding

Even early stomach cancers can bleed. Bleeding over a period of time can make you anaemic. This means your red blood cell count is too low. Anaemia will make you look pale and feel tired. If you are very anaemic you may feel breathless. blood is not a common early symptom, but it can happen. If it does, the blood may not be clearly seen. The blood you bring up may be bright red, which means it is fresh bleeding. Or it may look like used grounds because the blood has been in the stomach for a while.

Blood clots

People with stomach cancer are more likely to get blood clots. If you have pain or swelling in a leg, or sudden chest pain and breathlessness, you could have a blood clot in your leg or . You should contact your doctor straight away because you will need immediate anti-clotting medication.

Advanced stomach cancer

Symptoms of a more advanced stomach cancer can include:

• Loss of appetite • Weight loss • Fluid in the abdomen • Blood in the stool • Anaemia

Losing your appetite and losing weight are often later symptoms and can be a sign that the cancer is more advanced. (Although some people with early stomach cancer lose their appetite too).

With an advanced cancer it may be possible for your doctor to feel a lump in your tummy (abdomen). Some people with advanced stomach cancer develop fluid in the abdomen. This is called ascites.

Some stomach cancers bleed but don't cause you to vomit. The blood goes through your digestive system. This can cause your bowel movements to look black, like tar. Source: www.cancerhelp.org.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT www.wcisu.wales.nhs.uk STOMACH CANCER FACTSHEET

Tests for stomach cancer Usually you begin by seeing your family doctor who will examine you and ask about your general health. Your doctor will ask you about your symptoms. This will include what they are, when you get them and whether anything you do makes them better or worse. Your doctor will ask you to lie down for a physical examination. The doctor will feel your tummy (abdomen). It may feel tender, or it may be possible to feel a lump. After your examination, your doctor will need to refer you to hospital for tests and X-rays. You may see a specialist next. Or your GP may send you to hospital for some tests first.

At the hospital If you see a specialist, they will ask about your medical history and symptoms. The specialist will then examine you by feeling your abdomen. You may have blood tests and a chest X-ray to check your general health. Then other tests will be arranged for you in the out patients department. You may have:

• • Barium meal • Blood tests Endoscopy An endoscope is a long tube with a light and camera inside. The endoscope tube can be swallowed. This allows the doctor to look at the inside of the gullet (oesophagus), stomach and the first part of the small bowel (the duodenum). The doctor will take of any abnormal looking areas. You can have this test as an outpatient. But you should take someone with you to take you home. You will have a sedative before the test and will not be able to drive for the rest of the day. You won't be able to eat or drink for about 8 hours before the test so that your stomach and duodenum are empty. When you get to the clinic, the nurse will ask you to change into a hospital gown. When you are lying comfortably you will have an injection to make you very drowsy. Once you are drowsy and relaxed, the doctor will pass the endoscope tube down your throat into your stomach. The doctor will examine the lining of the stomach for any abnormal looking areas. This examination can show whether you have a stomach ulcer as well as helping to diagnose stomach cancer. If there are any abnormalities, the doctor will take biopsies to send to the laboratory. A is a piece of body tissue removed from a suspicious area and checked under the microscope for cancer cells. Once the test is over you will need to rest for a while. Because of the sedative, you may not remember anything about the test once it is over. You should be able to go home the same day.

Barium meal A barium meal is a type of X-ray investigation. You can have this test as an outpatient. You won't be able to eat or drink anything for six hours before you have your test. When you get to the X-ray department, the nurse will ask you to change into a hospital gown. When the test is about to begin, you will have:

• An injection to relax the muscles of your digestive system • A white liquid to drink

The white liquid is the barium meal. It is this chalky liquid that shows up on the X-rays. After you've drunk the barium, you lie down on the X-ray couch. Your doctor will watch on an X-ray screen as the barium passes through your stomach and duodenum. Any growths or ulcers will show up on the screen. The couch will be tipped into different positions during the test to make the barium flow where the doctor wants it to go. The whole test takes about an hour. You should be able to go home straight after the test. You can eat and drink normally as soon as the test is over. But some people feel sick for a while afterwards. You may find the barium makes you constipated. Your bowel motions will be white for a day or so as your body gets rid of the barium.

Blood tests

As well as blood tests to investigate your general health, your doctor may test for cancer markers. Markers are chemical substances that can show up in the blood stream in some types of cancer. The marker CEA () sometimes shows up in stomach cancer, as well as other cancers. But half the people with stomach cancer do not have a raised CEA level in their blood. If your tests show you have stomach cancer, you may have further tests to see if the cancer has spread. These tests help your doctor work out the stage of your cancer. And to decide on the best treatment. You may have:

• CT scan of the abdomen • Liver ultrasound • Blood tests and chest X-ray • Laparoscopy • • MRI scan

You may have had some of these tests already while your cancer was being diagnosed. If so, you won't have to have them again. Source: www.cancerhelp.org.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT www.wcisu.wales.nhs.uk STOMACH CANCER FACTSHEET

Staging and grading of stomach cancer

Staging The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment.

A commonly used staging system is described below.

Stage 1A The cancer is contained within the inner lining of the stomach (mucosa) only.

Stage 1B The cancer has spread through the mucosal layer of the stomach either to the muscle layer, OR it is affecting up to six of the nearby lymph nodes.

Stage 2 The cancer has spread through the mucosa and is affecting between seven and 15 lymph nodes nearby, OR it is affecting the muscle layer and up to six lymph nodes, OR it has spread to the outer layer of the stomach (serosa).

Stage 3A The cancer has spread to the muscle layer of the stomach and also to between seven and 15 lymph nodes nearby, OR it has spread to the outer layer of the stomach and is affecting up to six lymph nodes, OR it has spread to structures close to the stomach but not to any lymph nodes or any other parts of the body.

Stage 3B The cancer has spread to the serosa and it is also affecting between seven and 15 lymph nodes.

Stage 4 The cancer has spread to organs close to the stomach and to at least one , OR to more than 15 lymph nodes, OR it has spread to other parts of the body such as the . This is known as secondary cancer (or metastatic cancer).

If the cancer comes back after initial treatment it is known as recurrent stomach cancer .

Grading

The grade of a cancer gives an idea of how quickly it may develop. To find the grade of your cancer, your doctors will look at a sample of the cancer (a biopsy) under the microscope. The cancer will be graded as:

• Grade 1 (low grade) – the cancer cells tend to be slow growing, look quite similar to normal cells (are 'well differentiated') and are less likely to spread. • Grade 2 (moderate grade) – the cells look more abnormal. • Grade 3 (high grade) – the cancer cells tend to be more quickly growing, look very abnormal (are 'poorly differentiated') and are more likely to spread than low-grade cancers. Source: www.cancerbacup.org.uk

What are the treatment options for stomach cancer?

Treatment options which may be considered include , (and sometimes radiotherapy). The treatment advised for each case depends on various factors such as the stage of the cancer (how large the cancer is and whether it has spread), and your general health. You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side-effects, and other details about the various possible treatment options for your type of cancer. Surgery Removing the tumour may be curative if the cancer is in an early stage. The common operation is to cut out the affected part of the stomach. Sometimes the whole of the stomach is removed. This is a major operation and carries some risk. Even if the cancer is advanced and a cure is not possible, some surgical techniques may still have a place to ease symptoms. For example, a blockage may be eased by removing part of the stomach, or by using , or by a bypass operation. Chemotherapy Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stops them from multiplying. When chemotherapy is used in addition to surgery it is known as 'adjuvent chemotherapy'. For example, following surgery you may be given a course of chemotherapy. This aims to kill any cancer cells which may have spread away from the primary tumour. Sometimes, adjuvant chemotherapy is given before surgery to shrink a large tumour so that surgery is easier. Radiotherapy Radiotherapy is a treatment which uses high energy beams of radiation which are focussed on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. Radiotherapy is not commonly used to treat stomach cancer. It is sometimes used to reduce the size of a particular part of the cancer which is causing symptoms.

Source: www.patient.co.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT www.wcisu.wales.nhs.uk STOMACH CANCER FACTSHEET

Benefits and disadvantages of treatment

Many people are frightened at the thought of having cancer treatments, because of the potential side effects. Some people ask what would happen if they do not have any treatment.

Although the treatments can cause side effects, these can often be well controlled with medicines.

Treatment can be given for different reasons and the potential benefits will vary for each person.

Early-stage stomach cancer

In people with early-stage stomach cancer, surgery is often done with the aim of curing the cancer. Occasionally, additional treatments are given to help reduce the risks of the cancer coming back.

Advanced stomach cancer

If the cancer is at a more advanced stage, treatment may only be able to control it, giving an improvement in symptoms and a better quality of life. However, for some people the treatment will have no effect upon the cancer and they will get the side effects without any of the benefit.

If you have been offered treatment that is intended to cure your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide what to do.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.

Source: www.cancerbacup.org.uk

What is the (outlook)?

Without treatment, a stomach cancer is likely to get larger, and spread to other parts of the body. If it is diagnosed and treated at an early stage (before growing through the wall of the stomach or spreading to lymph nodes or other areas of the body) then there is a good chance of a cure with surgery. Unfortunately, most cases in the UK are not diagnosed at an early stage.

If the cancer is diagnosed when it has grown through the wall of the stomach, or spread to other parts of the body, a cure is less likely. However, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment. Source: www.patient.co.uk

FollowFollow----upup after treatment for stomach cancer

After your treatment has finished, you will be asked to go back to the hospital for regular check-ups. To begin with, these may be every three months or so and will include a physical examination and possibly scans or x-rays. Over time the appointments will gradually become less frequent but will probably continue for several years. If you have any problems, or notice any new symptoms in between these times, let your doctor know as soon as possible. Source: www.cancerbacup.org.uk

How can I prevent getting stomach cancer?

Experts believe that diet could play a major part in most stomach cancers. Smoking tobacco and drinking alcohol will slightly increase the risk of stomach and other cancers developing. Try to maintain a healthy balanced diet as this offers some protection to all types of cancer. Source: www.homehealth-uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT www.wcisu.wales.nhs.uk STOMACH CANCER FACTSHEET

* Please note the following information is for Wales only *

Summary

For the fifteen year period 1992-2006 the average number of registrations per annum were 400 for males and 236 for females. Stomach cancer is ranked 6th and 8th in males and females respectively. Incidence has fallen significantly since 1992 with a fall in EASR of 4.2% per annum in males and a fall of 3.5% per annum in females, both statistically significant at the 1% level.

Males Females Average registrations per annum (1992-2006) 400 236 Relative Frequency 5.1% 3.1% Rank 6th 8th Mean age at diagnosis (years) 70.8 75.2 * Significant at 5% level Cumulative Rate (0-64 years) 0.6% 0.2% ** Significant at 1% level Cumulative Rate (0-74 years) 1.7% 0.6% Percentage Annual Change in EASR (incidence) -4.2%** -3.5%** Percentage Annual Change in EASR (mortality) -5.2%** -4.6%** Percentage Death Certificate Only 6.3% 9.4% Average deaths per annum (1992-2006) 277 172 Mortality:Incidence Ratio (1992-2006) 69.3% 73.1%

Number of incident cases and age-specific rates, 1992-2006

1400 240

1200 200

1000 160

800

120

600 Number Number of cases

80 400 Age Age Specific rate 100,000 per population

40 200

0 0 Under 5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age Group

Male Cases Female Cases Male ASR Female ASR

Prevalence Statistics (at 31st December 2006) in Wales

Males Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year 199 13.77 0.01 12.62 >1 to 5 years 401 27.76 0.03 25.43 >5 to 10 years 433 29.97 0.03 27.46 >10 to 20 years 544 37.65 0.04 34.50 Total up to 20 years 1577 109.15 0.11 100.00

Females Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year 112 7.36 0.01 11.44 >1 to 5 years 269 17.68 0.02 27.48 >5 to 10 years 260 17.09 0.02 26.56 >10 to 20 years 338 22.22 0.02 34.53 Total up to 20 years 979 64.36 0.06 100.00

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Trends in Incidence 1992-2006

Males

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0-4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5-9 000000000000000 10-14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15-19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20-24 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 25-29 2 0 1 1 1 0 2 0 1 1 0 0 0 0 0 30-34 1 2 1 1 0 1 1 4 2 1 0 0 0 0 1 35-39 3 0 2 0 1 6 0 1 3 2 3 1 5 2 5 40-44 4 3 5 4 2 3 8 9 0 3 1 8 0 4 3 45-49 7 6 21 17 8 14 10 9 7 10 8 6 8 6 7 50-54 21 16 18 19 11 20 8 17 9 18 10 16 17 10 11 55-59 27 24 40 27 20 30 25 26 22 28 27 25 25 27 19 60-64 58 41 55 62 49 51 34 41 33 39 29 33 33 36 36 65-69 88 82 65 86 59 73 55 62 52 60 50 60 41 39 49 70-74 91 91 117 93 82 88 89 89 77 57 60 58 47 64 51 75-79 89 65 89 88 87 84 94 76 90 67 73 71 41 61 53 80-84 53 41 75 59 59 44 53 60 45 47 51 63 53 36 44 85+ 43 28 30 35 36 35 23 43 32 37 35 33 38 31 34 Total 487 400 520 492 416 449 402 437 373 370 347 374 308 316 313 Crude Rate 34.97 28.65 37.18 35.14 29.69 31.98 28.57 31.05 26.49 26.27 24.54 26.23 21.47 21.98 21.66 EASR 29.76 23.80 30.62 28.92 23.75 26.11 22.20 24.63 20.28 20.59 18.43 19.58 16.20 16.31 15.93 WASR 19.32 15.61 20.01 19.06 15.27 17.26 14.41 16.02 13.01 13.53 11.80 12.67 10.55 10.62 10.48

Females

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0-4 000000000000000 5-9 000000000000000 10-14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15-19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20-24 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 25-29 1 0 0 0 0 0 0 1 0 0 0 2 0 0 0 30-34 0 0 1 1 1 0 2 0 0 0 0 1 0 0 0 35-39 1 1 1 0 2 1 1 1 2 2 1 0 0 1 1 40-44 0 1 0 4 3 1 3 0 2 2 0 4 1 2 3 45-49 1 2 5 2 3 1 2 7 2 3 5 0 6 4 3 50-54 6 9 7 7 4 10 3 8 7 5 8 3 6 3 2 55-59 17 14 9 14 11 12 10 8 6 7 7 6 7 7 7 60-64 26 15 23 15 13 21 14 13 14 15 15 15 11 7 11 65-69 36 20 32 25 28 26 20 26 25 27 20 21 18 14 13 70-74 36 44 47 56 55 48 42 25 42 30 31 40 35 28 23 75-79 56 35 55 38 48 57 43 44 51 35 41 43 38 31 39 80-84 43 47 61 59 40 49 35 55 43 38 36 44 57 38 36 85+ 60 49 53 56 48 47 59 50 43 55 38 35 38 42 38 Total 283 237 294 277 256 273 234 238 237 219 202 214 217 178 176 Crude Rate 19.05 15.93 19.75 18.61 17.18 18.31 15.68 15.94 15.81 14.58 13.38 14.15 14.29 11.70 11.57 EASR 11.45 9.39 11.37 10.62 9.97 10.64 8.80 8.92 8.95 8.26 7.78 8.02 7.78 6.31 6.21 WASR 7.33 5.96 7.25 6.77 6.41 6.80 5.60 5.72 5.71 5.34 5.02 5.21 4.92 4.00 3.89

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