STOMACH CANCER

( By JASCAP )

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Treatment

Planning treatment for stomach cancer

The usual treatments for stomach cancer are surgery, the main treatment, and chemotherapy which is occasionally used either before or after surgery. Chemotherapy may also be used if surgery is not possible. Radiotherapy is rarely used.

Multidisciplinary team
Treatment choices
Giving your consent
Benefits and disadvantages of treatment

Multidisciplinary team

In most hospitals a team of specialists will decide the treatment that is best for you.

This multidisciplinary team (MDT) will include a surgeon who specialises in gastrointestinal cancers, an oncologist (cancer specialist) and may include a number of other healthcare professionals, such as a:

nurse specialist
dietitian
physiotherapist
occupational therapist
psychologist or counsellor.

Together they will be able to advise you on the best plan of treatment, taking into account a number of factors. These include your age, general health, the type and size of the tumour, and whether it has spread beyond the stomach.

Treatment choices

If two treatments are equally effective for your type and stage of cancer, your doctors may offer you a choice of treatments. Sometimes people find it very hard to make a decision. Make sure that you have enough information about the different treatment options, what is involved and the side effects you might have, so that you can decide which is the right treatment for you.

Remember to ask questions about any aspects that you don't understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your cancer specialist.

If you have any questions about your treatment, don't be afraid to ask your doctor or nurse. It often helps to make a list of questions and to take a close friend or relative with you.

Some people find it reassuring to have another medical opinion to help them decide about their treatment. Most doctors will be pleased to refer you to another specialist for a second opinion if you feel this would be helpful.

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should be given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is very common for people to need to hear explanations more than once. People often feel that the hospital staff are too busy to answer their questions, but it is important for you to understand how the treatment is likely to affect you and the staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment, if you feel that you can't make a decision when it is first explained to you. You are also free to choose not to have the treatment, and the staff can explain what may happen if you do not have it.

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.

Surgery for stomach cancer

Surgery is an important treatment for many stomach cancers. The results of surgery have improved in the last ten years, because nowadays the cancer is often found and treated earlier, and because better surgical methods have been developed.

The operation
Bypass surgery
After your operation

The operation

If the cancer is diagnosed at an early stage, a surgical operation may be all that is needed to cure it. This usually involves removing only a part of the stomach (a partial gastrectomy).

Partial gastrectomy

If all of the stomach is removed this is known as a total gastrectomy (see diagram below).

Often, the lymph nodes close to the stomach are removed at the same time to see if the cancer cells have spread into them. Depending on the extent of the cancer, some other organs in the area of the stomach may be removed during the operation. These may include the lower part of the gullet (oesophagus), the upper part of the small bowel (duodenum), the spleen or part of the pancreas.

Total gastrectomy

If the lower part of the gullet has been removed the gullet is reconnected directly to the small intestine.

Occasionally, before the surgeon decides to operate on your stomach, they may pass a small tube with a light at the end, through a cut in the wall of your abdomen. This is known as a laparoscopy. This is to help decide whether to remove all or part of the stomach. The laparoscopy is done under general anaesthetic and the area will feel sore for a few days afterwards.

Bypass surgery

Sometimes the cancer may block the passage of food from the stomach to the bowel. If this happens, the surgeon may make a connection between the stomach and the small intestine to allow food to bypass the blockage. This is known as bypass surgery and will not cure the cancer, but can relieve symptoms.

After your operation

After your operation you will be encouraged to start moving about as soon as possible. This is an essential part of your recovery. If you have to stay in bed the nurses will encourage you to do regular leg movements and deep breathing exercises. You will be seen by a physiotherapist who can help you to do the exercises.

Drips and drains

A drip (intravenous infusion) will be used to maintain the body's fluids until you are able to eat and drink again.

You will also have a naso-gastric (NG) tube in place. This is a thin tube that passes down your nose into your stomach or small intestine and allows any fluids to be removed so that you don't feel sick. It is usually taken out within 48 hours.

Sometimes a small tube (catheter) is put into the bladder to drain your urine into a collecting bag. You may also have a drainage tube in your wound for a few days to make sure that the wound heals properly.

Drinking and eating

After an anaesthetic, the movement of the bowel slows down, so it is important that you only drink small amounts until it is back to normal. After about 48 hours you will probably be ready to start taking small sips of water. This will be gradually increased after a couple of days until you are able to eat a light diet, usually four or five days after your operation.

Pain

After your operation you may need to take painkilling drugs for a few days. These are usually very effective in controlling any pain. If you still have pain, it is important to let the ward nurses know as soon as possible. Your painkillers can be changed until you find a type and dose that is effective.

Going home

You will probably be ready to go home about two weeks after your operation, once your stitches have been removed. If you think you might have problems when you go home – for example, if you live alone or have several flights of stairs to climb – let the nurses or social worker know when you go into hospital, so that help can be arranged when you go home.

Some people take longer than others to recover from their operation. If you are having any problems you may find it helpful to talk to someone who is not directly involved with your illness.

The nurses at Cancerbackup are always happy to talk with you. They can also give you details of support groups in your area, where you can talk to other people who have had similar problems. You can contact the Cancer Counselling Trust to talk to a counsellor.

Before you leave hospital you will be given an appointment for a post-operative check-up at the outpatient clinic. This is a good time to talk to your doctor about any problems you may have after your operation.

Eating after stomach surgery

When someone has had part of the stomach removed, the stomach cannot hold as much food as before. If all of the stomach has been removed, food is broken down in the small intestine instead of the stomach.

After any type of stomach surgery, eating and drinking can make you feel full quite quickly. So it is a good idea to have several small meals and snacks during the day, rather than a few larger meals. It's also best to have drinks separately from meals (or just drink a small amount with your meals).

You will probably lose some weight before your operation. It is important to go back to a balanced diet as soon as possible. This can help you to gain weight, and recover more quickly. You may not feel much like eating for some time after the operation, so don't be worried if it takes you a couple of months to get back to eating a balanced diet again. You may find that certain foods make you feel sick, or give you indigestion or diarrhoea, and you will begin to know which foods you should avoid. However, it is important to keep trying to build up your strength.

Boosting your weight
Advice about diet
Vitamin B12 injections
Dumping syndrome

Boosting your weight

If you are still losing weight you will need to increase your calorie and protein intake. A good way of doing this is by having nutritious, high-calorie drinks. There are several different types and they are available on prescription from your doctor or you can buy them at most chemists. You could carry 'nibbles' in your pocket or handbag at all times. Another way of improving your appetite is to have a glass of sherry (or another type of alcoholic drink) about half an hour before a meal – but check with your doctor first as some medicines should not be mixed with alcohol.

Advice about diet

It can be very helpful to talk to a dietitian before, or soon after, your operation. They can give advice and information about possible changes to your diet. Most hospitals have a dietitian available and the staff on the ward can arrange for them to visit you. Your GP may also be able to refer you to a community-based dietitian.

Vitamin B12 injections

After your operation your doctor may prescribe an injection of vitamin B12 for you every few months. This is because it is difficult to absorb this vitamin from food once all or part of your stomach has been removed.

You may find it helpful to read our booklets on diet and cancer and dietary problems after surgery.

Dumping syndrome

After an operation on your stomach you may have an effect called dumping syndrome. After meals, your stomach may empty quickly, which leads to a drop in blood sugar and fluid draining into your intestine. If this happens you will feel faint and weak, and you may sweat and look pale. The effect usually lasts between 30 minutes and two hours.

To avoid dumping syndrome that occurs soon after eating, it is helpful to eat foods that are high in starch. These include white bread, potatoes, rice and pasta.

You should avoid foods such as raw sugars, chocolate and sugary drinks, which are full of easily absorbed sugar.

If the dumping syndrome happens a few hours after eating, it can help to eat small, high- protein meals frequently (foods like meat, fish or cheese). Your doctor can also prescribe medicines to help this. In most people the dumping syndrome settles after a while, but let your doctor or dietitian know if it continues to be a problem.

Chemotherapy for stomach cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The drugs work by disrupting the growth and division of these cells.

Even when the tumour itself and the local lymph nodes have been removed by surgery, there is a risk that tiny amounts of the cancer (micro-metastases) have been left behind or have spread. These are too small to be seen on a scan and can make the cancer come back later on.

Early stomach cancer
Locally-advanced stomach cancer
Advanced stomach cancer
How chemotherapy is given
Side effects
Fertility
Early menopause
Contraception

Early stomach cancer

Some research studies have suggested that giving chemotherapy after surgery (known as adjuvant therapy), might lower the risk of the cancer coming back and can help some people to live longer, but this has not been found in other studies. For this reason, chemotherapy is not a standard treatment in this situation.

Chemotherapy may also sometimes be given before the surgery. Giving the chemotherapy in this way may help to reduce the chances of the cancer coming back. A recent research trial (the „MAGIC' study) showed that giving chemotherapy both before and after surgery helped make the surgery more successful and reduced the chance of the cancer coming back.

Locally-advanced stomach cancer

Occasionally, if the cancer has not spread beyond the stomach but it cannot be removed by surgery, doctors may use chemotherapy to try and shrink the cancer. Sometimes this makes it possible for the surgeon to remove the tumour. Chemotherapy given before surgery is called neo-adjuvant therapy.

Advanced stomach cancer

Chemotherapy is also used when the cancer has spread beyond the stomach. In this situation, it can help to shrink and control the cancer for a period of time. This is known as palliative treatment.

How chemotherapy is given

Chemotherapy drugs can be given as tablets, or by injection into a vein (intravenously). Intravenous chemotherapy is given as injections or drips (infusions) into a vein. The drugs can be given through a small tube (cannula) in your arm or through a plastic tube called a central line or PICC line.

The central line can be put into a vein in your chest under a general or local anaesthetic.

Position of a central line

Instead of a central line, a tube may be put into a vein in the bend of your arm: this is known as a PICC line (see below).

Chemotherapy pumps

Some chemotherapy is given by using a small portable pump. This gives a continuous low dose of the chemotherapy drugs over a few weeks or months (known as a continuous infusion). If you are having this type of chemotherapy you will be given detailed information about how to use the pump by your doctors or nurses.

Chemotherapy is sometimes given to you as an outpatient, but at other times it will mean a short stay in hospital.

Side effects

Chemotherapy can cause unpleasant side effects, but these can often be well controlled with medicines. The main side effects are described here, along with some ways of avoiding or reducing them.

Low resistance to infections

While the drugs are acting on the cancer cells in your body, they also temporarily reduce the number of normal cells in your blood. When these cells are reduced, you are more likely to get an infection and you may tire easily.

During chemotherapy your blood will be tested regularly. If necessary, you will be given antibiotics to treat any infection. You may also be given injections of proteins called growth factors to stimulate the production of white blood cells by your bone marrow.

If your temperature goes above 38°C (100.5°F), or you suddenly feel ill, even with a normal temperature, contact your doctor or the hospital straight away.

Feeling sick

Some of the drugs used to treat stomach cancer may make you feel sick (nauseous) and possibly make you vomit. There are now very effective anti-sickness drugs (anti-emetics) to prevent or greatly reduce nausea and vomiting. Your doctor will prescribe these for you.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause small ulcers. Regular mouthwashes are important and your nurse will show you how to do these properly. If you don't feel like eating during your treatment, you could try replacing some meals with nutritious drinks or a soft diet. Our booklet on diet and cancer has some useful tips on coping with eating problems.

Anaemia

If the level of red blood cells (haemoglobin) in your blood is low you will become very tired and lethargic. You may also be breathless. These are all symptoms of anaemia – a low level of haemoglobin in the blood. Anaemia can be very successfully treated by blood transfusions. You will feel more energetic and the breathlessness will be eased.

Bruising and bleeding

Platelets are a type of cell that help to clot the blood. If the number of platelets in your blood is low you will bruise very easily, may develop blood spots in the skin (petechiae) or rashes (purpura), and may bleed heavily from even minor cuts and grazes. If you develop any unexplained bruising or bleeding, contact your doctor or the hospital immediately.

Hair loss

Unfortunately, some of the drugs can make your hair fall out. Ask your doctor if the drugs you are taking are likely to cause hair loss or other specific side effects. You could also ask about the possibility of scalp cooling or cold cap treatment, which is a method of trying to reduce hair loss from chemotherapy. People whose hair falls out often cover up by wearing wigs, hats or scarves. If your hair falls out as a result of chemotherapy, it should grow back over a period of 3–6 months. We have a booklet on hair loss, which you may find helpful.

Tiredness

It is important to remember that chemotherapy affects different people in different ways. Some people find that they are able to lead a fairly normal life during their treatment, but many find that they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it. We have information on coping with cancer-related fatigue.

Diarrhoea

Some of the chemotherapy drugs used to treat stomach cancer can cause diarrhoea. This often starts several days after the treatment. If you are taking chemotherapy tablets or capsules at home, it is important that you let your doctor or nurse know that you have diarrhoea as your treatment may need to be stopped.

Although they may be hard to bear at the time, these side effects will disappear once treatment is over.

Fertility

Your ability to become pregnant or father a child may be affected by taking some of the chemotherapy drugs used to treat stomach cancer. It is important to discuss fertility with your doctor or nurse before starting treatment.

Early menopause

Some women may find that the chemotherapy treatment brings on an early menopause, and they may have signs of the menopause such as hot flushes and sweats. In many women, replacement hormones (HRT) can be given to replace those that are no longer being produced. You may find it helpful to talk this through with your doctor or a support organisation.

Contraception

It is not advisable to become pregnant or father a child while taking any of the chemotherapy drugs used to treat stomach cancer, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for a few months afterwards. You can discuss this with your doctor or nurse.

Condoms should be used during sex within the first 48 hours after chemotherapy to protect your partner from any of the drug that may be present in semen or vaginal fluid.

Radiotherapy for stomach cancer

Radiotherapy is not usually used to treat cancer of the stomach. This is because the stomach is so close to other major organs that it is difficult to give effective treatment without damaging the other organs. The doses that would be necessary to try to cure the cancer would cause many side effects.

In the situation where the cancer has spread beyond the stomach and is causing pain, a small dose of radiotherapy may be very helpful to relieve pain.

In some situations chemotherapy and radiotherapy may be given at the same time. This is known as chemo-radiotherapy and it is sometimes given after surgery. Chemo- radiotherapy in the treatment of stomach cancer is still being researched in clinical trials.

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