Gastrointestinal cancer-5

GASTROINTESTINAL CANCER PART-5

Welcome to the fifth part of educational series on GastroIntestinal Cancers. We completed discussion about evaluation and treatment of Esophageal Cancer.

Question: Now Dr. Chiragbhai, what about cancer of Stomach, the next subsite?

Answer: Stomach cancer is very common in India, once again with significant regional variation as in other GI subsites. Also, for unknown reasons, it has declined significantly in West and now represents a much smaller proportion of all cancers there, also proximal tumors are more common in West. In rest of the world, however, it remains one of the most common cancer, including number 1 in Japan.

Que: What are the known risk factors?

Ans: Known risk factors include:

1. Helicobacter pylori infection
2. Smoking
3. High salt intake
4. Hereditary – only 1-3% patients

Que: Why is the mortality so high in stomach cancer?

Ans: Once again, it is more because of late diagnosis. In Japan, where earlier diagnosis is done because of aggressive screening, mortality is much lower than in other countries. Since symptoms are nonspecific i.e. early satiety, nausea, vomiting, anemia, and sometimes bleeding, patients are not investigated till late.

Que: What should our readers keep in mind to make an early diagnosis?

Ans: There is a tendency for empiric treatment without diagnosis, for many of the above noted symptoms. Also, patients frequently change doctors when invasive or expensive tests are advised.

Frequent counseling and awareness among both doctors and patients, and wider availability of tests, will help to change this situation. For example, chest pain is now more thoroughly investigated with non invasive and invasive tests to detect heart disease. Even though there is a potential for excessive work up, over diagnosis, and sometimes test related complications, it has certainly helped many patients with early detection of heart disease. In spite of all these limitations, most educated patients, including most doctors themselves, prefer to undergo these tests rather than miss a heart disease. Similar change of mindset is required for cancer related tests, including endoscopy, CT scans and biopsy.

It is important to highlight the fact that a significant proportion of almost all cancers are now curable if detected early. This is the reason why we should be doing evaluation. And this is not a wishful thinking, as one can see published literature in the era of internet, and data from various patient support groups. There are a few million people with cancer in USA alone who were treated several years ago, and hence are now considered cured. Such patients, many of them celebrities or leaders, have also helped to change mindset in USA. Even with such late diagnoses in India, if you ask around, you are very likely to find at least one person who has been cancer free for many years. We can increase this number of cured patients substantially if we make more early diagnoses.

Even today some doctors and many educated people ask me this question, if cancer can ever be cured. This question is a reflection of our poor job in highlighting the fact that many patients have already been cured. The question should be “how many more can be cured?”

Que: Chiragbhai, can you give some detailed recommendations for our readers?

Ans: Let us start with one of the above noted symptom of stomach cancer i.e. anemia, which happens to be an important symptom for many GI cancers.

Anemia in an adult over 40 (more so in men) should be thoroughly investigated, as it may be first sign of many serious diseases e.g. cancer of upper or lower GI tract, myeloma as well as non malignant diseases like early kidney failure, hypothyroidism etc. Stool for occult blood should be tested for 3 consecutive days, and GI endoscopy must be done if even one day is positive. GI endoscopy should also be done if there is no other obvious reason (such as clear cut poor nutrition history), even if stool for occult blood is negative, as blood loss from tumor may be intermittent.

Treatment of iron deficiency anemia with Iron supplement is only half treatment, without finding out the reason for developing iron deficiency. This is very important since iron deficiency anemia related to chronic blood loss from a cancer will also respond to iron supplement, for few months. However if not picked up at that time, it will present at a late stage in few months.

Severe anemia (Hb less than 8 g/dl) without very obvious cause should also be evaluated thoroughly. Blood transfusion or other empiric treatment without finding out the underlying reason should be considered completely inadequate and poor medical care. In most of the western countries, if a cancer is missed because of such empiric treatment, patient may go to court and will almost certainly win the case.

Yes, there are many women and young people in India, for whom diagnosis is mostly nutritional or menorrhagia even with severe anemia. But as mentioned above, it should be obvious stated cause, and not a presumption.

Importantly remember to investigate following subsets: all of them will not have an underlying cancer, but some will do, and many others will have another significant underlying disease. Just like we investigate almost every pain in chest or nearby region not to miss one case of heart disease, following should be evaluated not to miss a cancer in potentially curative stage (especially when there is no obvious cause like poor nutrition or menorrhagia).

1. Men with anemia, especially over 35-40.
2. Women with anemia over age 35-40.
3. Any one with new anemia i.e. documented normal Hb within last two years.
4. Iron deficiency anemia, in an adult, even with negative stool for occult blood.
5. Positive stool for occult blood, even if only one of 3 days.
6. Bleeding from upper or lower GI tract, even if only once (in absence of very obvious cause like piles)
7. Non specific GI symptoms persisting for more than 4 weeks (not evaluated in last two years), or change in pattern of old chronic symptoms, or increasing in severity, or associated with significant weight loss.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496

Diplomate American Board of Oncology and Hematology. Ahmedabad.

Shyam Hem-Onc Clinic. 402 Galaxy, Near Nehrunagar Circle, Ahmedabad.

98243 12144; 98988 31496,drchiragashah@gmail.com