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02.14 Stomach Cancer (Gastric Cancer)

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Overview

  1. Stomach Anatomy
    1. Proximal stomach (top)
      1. Cardia
      2. fundus
      3. bomdy
      4. Makes gastric juices to digest food and intrinsic factor (B-12)
        1. Pepsinogen –> Pepsin
        2. HCL-hydrochloric acid
    2. Distal stomach (bottom)
      1. Antrum
      2. Pylorus
      3. Holds broken down food and releases to the small intestine
    3. Layers of stomach
      1. Mucosa (innermost)
      2. Submucosa
      3. Muscle
      4. Serosa (outermost)
    4. Close to other organs
      1. Colon   
      2. Liver
      3. Spleen
      4. Pancreas
      5. Small intestine

Nursing Points

General

  1. Treatment varies
    1. Stage (TNM)
      1. Tumor size
      2. Lymph node involvement
      3. Metastasis
    2. Location of disease
    3. Type of cell involved
    4. Adenocarcinomas- 90-95%
  2. Stomach (gastric) cancer is 4th most common cancer worldwide
    1. Usually diagnosed between ages 55-80, rare <30
    2. A rare disease in the United States
      1. More common in Asia, Europe, and Central America than the US
      2. Screening available in Asia, not in the US unless high risk
    3. Cases have decreased since 1930
      1. Improved food storage
      2. Less sodium intake
    4. Often diagnosed in late stages
      1. No symptoms in the early stages
      2. Vague symptoms in later stage
      3. 2/3 of patients diagnoses with advanced disease
        1. With advanced disease, no cure
  3. Several risk factors
    1. Environmental/ lifestyle
    2. Diet
      1. Smoked foods
      2. Nitrates
      3. High sodium intake
      4. Tobacco
      5. Alcohol
    3. Infection/ disease- Chronic inflammation leads to cellular changes
      1. H-Pylori infections
        1. Correa’s cascade: Gastritis → metaplasia → dysplasia
      2.   Epstein Barr
      3. Chronic gastric atrophy
      4. Pernicious anemia (↓ B-12)
    4.  Familial
      1. FAP- Familial Adenomatous polyposis
      2. HNPCC- Hereditary nonpolyposis colon cancer

Assessment

  1. No symptoms initially
    1. Vague digestion changes (Often treated for other things first)
    2. Heartburn
    3. Bloating
    4. Appetite loss
    5. Abdominal pain
  2. More advanced
    1. Cellular changes
      1. Anemia
      2. Weight loss
    2. Large tumor burden
      1. Melena
      2. Hematemesis
      3. Palpable mass
      4. Dysphagia
    3. Metastasis
      1. Jaundice
      2. Enlarged lymph nodes
      3. Ascites- peritoneal effusion
      4. Shortness of breath- pleural effusion

Therapeutic Management

                        I.         Diagnosis

A.    EDG- endoscopy

1.    Biopsies 

B.    MRI

C.   Barium Swallow

D.   CT

1.    Chest

2.    Abdomen

3.    Pelvis

E.    Tumor markers- ↑ blood levels in some cases  

1.    CEA and CA 19-9- ↑ proteins produced by tumors

2.    Not specific to gastric cancer, not always elevated

                      II.         Treatment

A.    Surgery

1.    Total gastrectomy

2.    Esophagogastrectomy- proximal stomach cancer

3.    Subtotal gastrectomy- distal stomach cancer 

B.    Systemic chemotherapy or targeted biotherapy 

1.    Neoadjuvant prior to surgery

2.    Adjuvant after surgery

3.    Side effects

a.    Nausea and vomiting

b.    Fatigue

c.     Neuropathy

d.    Heart damage

C.   Radiation

1.    High energy rays to kill cells

2.    Side effects

a.    Skin problems

b.    Fatigue 

D.   Palliative goals 

Nursing Concepts

  1. Nutrition
    1. Directly linked to stomach cancer
  2. Cellular regulation
    1. Chronic inflammation leading to cellular changes and cancer
  3. Gastrointestinal/ Liver Metabolism Impaired metabolism with cancer and post gastrectomy

Patient Education

                        I.         Diet/Lifestyle

A.    Increased fruits and vegetables

B.    Limit smoke meats and nitrates

C.   No smoking

D.   Decreased alcohol consumption

                      II.         Recurrence rate

A.    Follow up care important

B.    40-65% recurrence 

                     III.         Treatment specific

A.    Side effect management

B.    Surgery precautions 

            

Reference Links

Study Tools

Video Transcript

All right, we’re going to be talking about stomach or gastric cancer, and we’ll do a real brief A &P review just to remember what the stomach does and the parts. So the stomach can be divided into two parts. We’re talking about the top or the proximal and the bottom or the distal, and then the top is divided in three different areas, the cardia, the fundus, and the body. What does the stomach do? It produces gastric acid, right? That’s a big one. Hydrochloric acid and pepsinogens. It also helps us with processing B12 with the intrinsic factor. 

And the stomach does have three layers. So it has the mucosa, which is the innermost layer. And this is where cancer forms most is in this mucosa here. So it starts from here and usually spreads outwards through the submucosa, the muscles, and the serosa. Okay. And some facts about stomach cancer. It is usually found in older adults, between the ages of 55 and 80 rarely, rarely found in someone under 30. It is a rare disease in the United States, but it’s more common in other countries. So, Asia, Europe, Central America also, not exactly known why, but it’s treated differently in these areas. There’s no screening in the U.S. but in Asia, they do a regular screening for it because it’s more prevalent. So that’s why that’s important, but we do not do routine screening for gastric cancer. In the United States cases have decreased since the 1930s. 

And this has happened because of the development of the refrigerator. It’s so cool to think about how history relates to these diseases. So we used to process food even more heavily than we process it now to store it because we didn’t have refrigeration or a way to store food so things were stored with so much salt which was leading to gastric cancer. So they’ve decreased since 1930, because we can have fresher foods because of our refrigerator.

Gastric cancer is often diagnosed in late stages. So this is very, very unfortunate, but important to note, we’re talking about symptoms, but they’re pretty vague or absent at the beginning. So we usually find it in late stages and it is difficult to treat in those late stages. Risk factors, there are quite a few lifestyle or modifiable risk factors, which is good. We know ways that we can prevent this cancer- people don’t like to always hear this, but a huge one is diet. So this has been linked directly to diet, and that includes smoked foods and nitrates and high sodium intake. People do not like to hear that their bacon and their lunch meat is linked to gastric cancer, but it is. And then with that also tobacco use and alcohol are linked to it. Also, infection and chronic disease are huge risk factors. So chronic inflammation leads to cellular changes, which is why this is linked to different diseases. So infection with H pylori is a big one that causes those stomach ulcers to be formed. And that’s discovered often, and it’s treated with antibiotics, but if you have this in the past, you’re at risk of gastric cancer. Also, Epstein Barr is another infection related to chronic inflammation leading to gastric cancer. 

And there is a familial or a genetic component also. So initially I mentioned, there are no symptoms, right? It’s not caught in early stages often because we don’t see a lot of symptoms initially. And then when, even when we do start seeing symptoms, they’re pretty vague. So we’re talking about a tumor growing in the stomach. We’re kind of used to changes to our stomach, right? I mean, who doesn’t have abdominal pain every once in a while, or a little bit of cramping or heartburn, those are symptoms of early symptoms of gastric cancer. So it’s not caught unitl these more advanced symptoms later when we have cellular changes or that sort of thing. So these late symptoms, we’re talking about are bleeding, vomiting blood, blood in the stool, and that’s from these tumors causing things to rupture, right? Other late symptoms that we see would be from spreading to the peritoneal cavity, or, ascites, or fluid in the pleural cavity if it spread up to the lungs, we’ll have inflammation in the pleural space. So those are more advanced symptoms that we can see.

Diagnosis. This is diagnosed often with an EGD. So something’s going on with his stomach. And we’re like, why don’t you get a colonoscopy and an EGD? So this is found on the EGD, and this is the one that goes in through the mouth, the camera that goes through the mouth. And we can take biopsies. If something looks suspicious, they’ll take a biopsy. And a lot of times that’s how gastric cancer is found. They’ll also look at lesions or tumors on the MRI and the CT scan or the barium swallow. And that’s when you swallow that white powder and then x-rays examine how it’s processed in your body. And then there are blood tests that are related to gastric cancer, although not a direct relation, but some cancer markers, tumor markers are CEA and CA-19-9. And these are proteins that are released from tumors, and they’re not specific to gastric cancer, but sometimes at the time of diagnosis, there’ll be elevated. And then throughout treatment, we can trend them to see if they’re decreasing. And that can kind of point us in the right direction if the treatment we’re doing is working.

And speaking of treatment, we’ll move on to talk about that. Like most cancers, the treatment depends on several different risk factors, right? So this is staged by the tumor lymph node and metastasis. So that’s gonna guide our treatment. Likewise, the type of cell that’s involved with guide treatment. So we have several ways to treat it, especially with different chemotherapies. It is often also treated with surgery. So if the cancer is up here, we can take out just part of the stomach in a esophagogastrectomy.  If it’s down here in the distal area, we can just do a subtotal gastrectomy to remove this portion. Or sometimes people have the whole stomach removed in a total gastrectomy. And that would be removing this whole stomach here. Um, and of course that would come with a lot of nutrition education after  the surgery. 

Chemotherapy often is used. A lot of times this cancer has spread. We need to use something systemic to treat it, to treat all the places that it has spread. There are different many different types of chemotherapy that can be used. And the side effects are generic for all chemotherapy, then nausea, vomiting, fatigue. It can be given pre or post-surgery. The same with radiation, it can be pre or post-surgery. And just remember with radiation, we’re targeting this organ right here in the abdominal cavity, but there’s a lot of other organs around here, right? We have the liver, we have the esophagus, and a lot of other organs are around here. So radiation is kind of difficult, but it is sometimes used.

Education for our patients is important because we want to educate about diet and lifestyle, right? Those are modifiable risk factors, very important, increase those fruits and vegetables, also follow-up care.

This cancer likes to come back. Unfortunately, even if we do treat it with surgery and we think that it’s gone, it comes back in 40 to 65% of people. So that’s a pretty large amount. So follow up is very important, and then treatment specific education. This depends on if we’re talking about chemotherapy, radiation, or surgery, all right.

Nursing concepts. I’ll mention again, nutrition because this is so hard for people to hear. A lot of times they don’t want to, they do not want to hear that the foods that they’re eating could be contributing to their cancer, but it’s important to educate, even educate your families about this, these foods have been linked to gastric cancer. Cellular regulation is an important concept in any cancer, right? something has gone wrong. And the way that our body responds to abnormal cell growth and then GI and liver metabolism. So this is important in cancer. And then also post-surgery the way that we metabolize foods is obviously going to be different if we’ve removed the stomach. All right, That’s all I have today about gastric cancer. You guys go out and be your best self today, and as always happy nursing.

 

 

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