Stomach cancer

What sets this disease apart is not that it is rare or unusually fearsome, but that for a long time it dresses up as something ordinary. For months a person notices heartburn, heaviness after meals, a lot of burping — precisely what millions of people put down to "gastritis" and treat with tablets bought over the counter. It often seems to work: knock the acid down and the burning stops. That is why the useful thing here is not the list of symptoms but a single rule. Stubborn stomach complaints that do not clear up on treatment, or that come straight back the moment it stops, should not be prescribed for again; they should be looked at once with a camera. A tumour found early in the stomach wall is treated in a completely different way from the same tumour a year later.

Why it starts off looking like ordinary heartburn

The early complaints are non-specific, which means you cannot tell cancer from inflammation or an ulcer by them. Most often they are:

• heartburn and acid reflux that you gradually get used to;
• heaviness and fullness in the upper tummy, feeling full after a few spoonfuls;
• frequent burping, feeling sick and occasionally being sick;
• a dull ache high in the tummy with no clear link to meals;
• loss of appetite, often a particular distaste for meat;
• tiredness and breathlessness on exertion — this is how hidden blood loss shows itself.

What separates this from an ulcer or gastritis is not the sensations themselves but the way they behave. Ulcer pain is usually tied to food: it comes on an empty stomach and eases once you eat, or the other way round, it appears an hour after a meal — and it responds well to treatment, so within two or three weeks there is a clear improvement. Tumour symptoms follow no such logic. They are monotonous, drag on for weeks and creep upwards, and acid-lowering medicines give only partial, temporary relief. If your course has already been extended a second or third time because "it hasn't quite gone", that is a reason for a gastroscopy, not for a fourth course of tablets.

Signs you must not treat blindly

Some symptoms mean the investigation is not postponed, whatever diagnosis is already written in your notes. Book an appointment within the next few days if even one of these appears:

• difficulty swallowing — food goes down badly, sticks, needs washing down;
• weight loss you cannot explain by diet or exercise;
• persistent or repeated vomiting, especially of food eaten the day before;
• a lump you can feel in the upper part of the tummy;
• growing weakness, pallor and dizziness — the signs of anaemia;
• stomach complaints appearing for the first time in later life.

Separately, there are things for which you call an ambulance rather than waiting until morning: vomiting bright red blood or dark material that looks like coffee grounds; black, tarry, strong-smelling stools; sudden severe tummy pain with a board-hard abdomen that hurts even to touch; fainting or cold sweat alongside stomach pain. That is what bleeding and a perforation of the wall look like. Nobody drives in that state: ask someone to take you or call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single European number 112 works for this. Take the list of your medicines with you.

Helicobacter and the other things that shift the risk

The factor that matters most here is the one you can actually do something about: Helicobacter pylori, a bacterium that lives in the mucus lining the stomach surface. It keeps a low-grade inflammation going for years, which in some people thins and rebuilds the lining, and that is the ground on which a tumour can grow. Carrying it is very common and by itself is not a disaster: most infected people will never have a problem. But it is the one cause on this list that a simple test finds and a two-week course of treatment removes. The infection is looked for with a urea breath test, a stool test for the bacterial antigen, or a biopsy taken during gastroscopy; blood antibodies are poor for this purpose, because they stay positive long after the infection has gone.

The rest counts for less individually, but it adds up:

• smoking, which comes straight after the infection in importance;
• a diet heavy in salt, pickles, smoked and cured food and light on fruit and vegetables;
• regular alcohol and a substantial excess of weight;
• atrophic gastritis with intestinal metaplasia, autoimmune gastritis and the vitamin B12 deficiency anaemia that goes with it;
• previous stomach surgery and stomach polyps;
• stomach cancer in a parent, brother or sister, and rarely inherited syndromes in which the tumour appears young, where the family is offered genetic counselling;
• unprotected work with coal dust, rubber and certain chemicals.

Even so, someone with not a single item on this list can still fall ill. Having risk factors or not having them does not change whether symptoms need investigating.

How the stomach is examined

The key test is gastroscopy. A thin flexible tube with a camera is passed through the mouth into the stomach; the doctor inspects the lining and takes small pieces of tissue. It takes about a quarter of an hour, the throat is numbed with a spray, and if you prefer, light sedation lets you sleep through it. The diagnosis is not made by the picture on the screen but in the laboratory: only examining those tissue samples separates inflammation from a tumour and shows what type it is. On the way, the doctor also sees the oesophagus and the start of the duodenum.

If a tumour is confirmed, the next question is how far it reaches, because the treatment depends on that. This usually means a CT scan of chest, abdomen and pelvis, often an endoscopic ultrasound to judge how deeply the tumour has grown into the wall, and sometimes a PET scan. In selected cases a diagnostic laparoscopy is done — a small operation in which a camera is passed into the abdomen through a tiny cut. Ordinary blood tests are taken too, including haemoglobin and iron studies. The tumour tissue is additionally checked for markers that determine whether the newer medicines can be used.

How it is treated

The plan is not made by one doctor but by a team: surgeon, oncologist, radiotherapist, endoscopist and pathologist. Which methods are combined depends on how deep the tumour goes, where it sits, what type it is and on your general health.

• Endoscopic removal. The earliest tumours, still confined to the surface layers, can sometimes be taken out during the gastroscopy itself, without opening the abdomen.
• Surgery. Part of the stomach or the whole organ is removed together with the surrounding lymph nodes and, if needed, parts of neighbouring organs. The digestive route is then reconstructed. Recovery takes months.
• Chemotherapy. It is often given in cycles before surgery to shrink the tumour and repeated afterwards to lower the chance of the disease returning.
• Radiotherapy. Used less often, generally alongside chemotherapy or to relieve particular symptoms.
• Targeted medicines and immunotherapy. These are prescribed when the matching markers are found in the tumour, mostly in advanced disease and combined with chemotherapy.

During and after treatment there are regular check-ups and scans. If new symptoms or heavy side effects turn up between appointments, do not wait for the scheduled date — tell your team straight away.

What changes about eating and weight

Losing weight with this illness is not a cosmetic matter but something that decides how well you will get through treatment. That is why a dietitian belongs on the team as much as the surgeon, and it is worth seeing one from the start rather than once the weight has already dropped.

After part or all of the stomach has been removed, the usual way of eating stops working: meals become small portions six to eight times a day, chewed slowly, with drinks taken separately from food. Many people develop dumping syndrome — weakness, palpitations, sweating and diarrhoea soon after a sweet or large meal — which is managed by adjusting what goes into each portion. Once the whole stomach is gone, vitamin B12 can no longer be absorbed and is given by injection for life; iron, calcium and vitamin D are watched as well. All of this is manageable, but it needs proper guidance rather than diets picked up online.

If the tumour cannot be removed

Sometimes the disease is found already spread and cannot be cured. That does not mean treatment is over. Chemotherapy and modern medicines can hold the tumour back and extend life, and specific procedures relieve specific burdens: when the stomach outlet narrows, a stent is placed or a bypass is created for food; bleeding is stopped endoscopically; pain is controlled with a properly adjusted regimen.

This kind of care is called palliative, and it is not "when nothing more is done" but a separate specialty devoted to making life easier. It is better brought in early, running alongside the main treatment: symptoms are controlled better and there are fewer unplanned hospital admissions. Support extends to the family too, because the weight falls on them as well.

Online consultation

A remote appointment is useful at every stage except the emergency one. Before a diagnosis, the doctor will go through your symptoms, work out whether they fit ordinary heartburn or whether there are warning signs among them, explain why a gastroscopy is needed and how to prepare for it, and arrange testing for Helicobacter. Another real use is making sense of reports you already hold: words like "atrophy", "intestinal metaplasia" or "low-grade dysplasia" all sound equally alarming yet mean very different things and call for very different follow-up. During treatment, an online appointment is a convenient place to discuss side effects, eating, recovery after surgery and the questions that always surface once you have left the room. What does not belong in a message thread is trying to sit out vomiting of blood, black stools or sudden severe tummy pain: that conversation is with an ambulance.

This material is for information only and does not replace medical advice.