1.What is the incidence of gastric cancer in China and what is its level compared to the world?
Gastric cancer, including malignant tumors of epithelial origin occurring in the lower esophagogastric junction and the stomach, is still one of the most common malignant tumors in the global population, ranking fourth. According to statistics, about 900,000 new cases are added globally each year, while 700,000 people die from gastric cancer. Although there is a slight decrease in the incidence of gastric cancer worldwide, the overall treatment effect is still unsatisfactory, and the mortality rate remains high. Gastric cancer is typically geographically dense, occurring in Asian countries such as Japan, Korea and China.
According to the 2005 survey data of National Cancer Control Office, gastric cancer is the third most common tumor in China, with more than 400,000 new cases and 300,000 deaths per year, and the incidence rates of men and women are 37.1/100,000 and 17.4/100,000 respectively. 100,000 (ranked second) and 8.71/100,000 (ranked third) for women in the developed city of Shanghai. Although there was a slight decrease in the overall incidence and mortality of gastric cancer in China between 2000 and 2005, this trend was caused by males, in contrast to a significant increase in incidence and mortality among females. This trend is due to the increase in the proportion of protein in the diet due to the improvement of living standard.
2.Where does gastric cancer tend to occur? What are the main causes of the disease?
Adenocarcinoma is the most common form of gastric cancer, and its incidence site has certain regional differences. In developed countries such as Europe and America, the incidence of proximal gastric cancer, including gastric body cancer and esophagogastric junction cancer, is gradually increasing, but distal gastric cancer still dominates in Asian countries such as Japan and China. In fact, the incidence of gastric cancer in China alone varies somewhat from region to region, which may be related to the different causes of the disease.
In poor areas, due to malnutrition, large intake of unclean and pickled foods, and widespread infection with Helicobacter pylori, gastric cancer is predominantly a distal lesion; while in relatively developed port cities, the incidence of esophagogastric cancer shows a rising trend similar to that of developed countries in Europe and the United States due to the intake of high-fat diet, the increase of lower esophageal reflux disease, and the excessive intake of tobacco and alcohol. In areas with high salt intake, esophagogastric junction cancer occupies the major part of gastric malignant tumors. In addition, about 1-3% of gastric cancer patients, a very small number of them, also show familial heredity. Familial diffuse gastric cancer families, HNPCC families (hereditary non-polyposis colorectal cancer, gastric cancer can be the second accompanying cancer in China) of gastric cancer patients can be found with certain genetic level mutation defects.
3.What are the symptoms that should be alerted to gastric cancer? How to prevent it in daily life?
Most of the gastric cancers have no specific symptoms in early stage, but there are symptoms similar to gastritis, such as fullness and vague pain in upper and middle abdomen, increase of acid reflux and belching, decrease of appetite, feeling of obstruction in eating, etc. These symptoms are often ignored by patients; with the development of the disease, there will be bleeding and nausea, vomiting, weakness, emaciation and other consumption symptoms, and when the tumor is bleeding, there will also be vomiting blood and black stool. When the tumor invades the retroperitoneal nerve tissue, back pain may appear; and in the middle and late stage, systemic symptoms such as ascites, tumor intestinal obstruction and malignant fluid will appear.
The best way to prevent stomach cancer is to ensure the regularity and healthiness of daily diet, avoid long-term intake of unhealthy foods such as pickled, high-salt, spicy, fermented and moldy foods, reduce the intake of tobacco and alcohol, and improve the diet structure and habits. And more importantly, after the age of more than 40 years, once there is no obvious acute irritation factors resulting in upper abdominal discomfort or gastrointestinal symptoms, you should actively seek medical advice and perform gastroscopy; patients with long-term atrophic gastritis, gastric mucosal erosion, atypical hyperplasia of gastric mucosal glands or intestinalization, especially those with a family history of suspected gastric cancer, should regularly review gastroscopy every year; patients with H. pylori, severe Patients with H. pylori, severe infection or symptoms should be actively treated with bactericidal therapy. In countries such as Japan and Korea, regular gastroscopy screening of high-risk groups has greatly improved the detection rate of early gastric cancer. In China, due to the lack of the habit of regular medical check-ups and medical treatment in many underdeveloped areas, most of the gastric cancer cases in China are already in the middle and late stages when first diagnosed, and the best time for treatment is lost.
4.What are the treatment means of gastric cancer?
At present, the treatment of gastric cancer advocates surgery as the center and focus of multidisciplinary comprehensive treatment.
For early-stage gastric cancer, after assessing and excluding local lymph nodes or distant metastases, local lesion resection (EMR, ESD) can be performed under gastroscopy, and the next treatment plan can be decided after pathological evaluation; laparoscopic surgery can also be chosen for minimally invasive treatment.
For locally progressive gastric cancer, the patient’s systemic condition should be fully evaluated before surgery. If the lesion can be resected, surgery can be performed directly, or neoadjuvant chemotherapy can be administered followed by surgery plus postoperative adjuvant chemotherapy. This perioperative combined chemotherapy treatment model has been proven to be beneficial in extending the overall survival time of patients in clinical studies abroad, while its effectiveness in China is still under study; if the local lesion cannot be resected, preoperative chemotherapy can be administered and surgery can be obtained again after the lesion regresses.
In our department, D2 radical surgery, including resection of local gastric lesions and clearance of the first and second perigastric lymph nodes, is actively performed as long as the general condition of the patient allows, in strict accordance with the treatment standard, to ensure the adequacy and radicality of the surgery. Currently, more than 800 cases of gastric cancer are treated each year, with an overall survival rate of about 50-60% at 5 years, an overall complication rate of less than 5%, and a surgery-related mortality rate of less than 1%, making the overall medical level among the best in Shanghai and even in China. The accumulation of a large number of cases also illustrates the skillfulness and mastery of our surgeons in gastric cancer surgery, and at the same time, such surgery has been proven to be safe and effective.
After surgery, patients should further undergo chemotherapy or radiotherapy to prevent the recurrence of the disease.
For advanced gastric cancer that cannot be resected by surgery or cannot be completely resected, or has distant metastases that cannot be operated on at the time of consultation, palliative systemic treatment is performed. Some advanced patients may have a chance to get another chance of surgical resection if their disease is in remission.
5.What is the multidisciplinary comprehensive treatment for gastric cancer?
As a specialized oncology hospital, Fudan University Cancer Hospital has been actively carrying out multidisciplinary comprehensive treatment in various common tumor diseases in recent years, which reflects the professional profile of considering tumor diseases as systemic diseases.
Multidisciplinary comprehensive treatment means that for the same case, the case should be evaluated in detail from multidisciplinary perspectives such as oncology surgery, medical oncology (radiotherapy and chemotherapy), oncology diagnostic radiology and pathology to give the patient the best treatment means and treatment sequence to improve the patient’s treatment effect. For example, in a case of locally advanced gastric cancer, if direct surgery may not achieve radical resection, preoperative chemotherapy should be given first, and then radical surgery should be performed after local tumor regression, followed by postoperative supplemental chemotherapy or radiotherapy, which greatly improves the effectiveness of treatment.
The multidisciplinary integrated treatment team for gastric cancer established in our hospital involves important departments such as abdominal surgery, chemotherapy, radiotherapy, diagnostic radiology and pathology, etc. The team discusses difficult cases every week, and doctors from various departments give their opinions and views to each other to draw up the best treatment plan for patients.
6.What are the methods of surgical treatment for gastric cancer? Why some patients can preserve the stomach body and some patients need total gastrectomy?
According to the different parts and stages of gastric cancer, the surgical methods are different.
Surgery for gastric cancer includes two parts of tissues, one is resection of the lesion, which generally requires removal of the tumor and the normal gastric body within 5cm of the side; the other part is lymph node dissection around the stomach, including the first and second stations; when the tumor involves the surrounding important organs, combined resection may be required, commonly including resection of the tail of the pancreas and the spleen, resection of the transverse colon, and resection of the left lobe of the liver.
For general distal gastric cancer, a major distal gastrectomy with postoperative residual gastroduodenal anastomosis, or residual gastrojejunostomy, or residual gastrojejunostomy Roux-Y is performed; when the tumor occurs in the gastric cardia or fundus, a major proximal gastrectomy (with a sufficiently long residual stomach (>20 cm) preserved to reduce reflux), an esophageal residual gastric anastomosis, or a total gastrectomy is usually performed; when the lesion is located in the body of the stomach, a total gastrectomy is usually required total gastrectomy is performed, and the postoperative GI reconstruction is more complicated.
Reconstruction of the digestive tract after total gastric surgery requires maximizing the residence time of food in the digestive tract, increasing the absorption of nutrients, while reducing symptoms such as reflux and dumping, and improving the patient’s nutritional status. Currently, in our abdominal surgery department, Roux-Y anastomosis of the esophagus and jejunum after total gastric surgery or Roux-Y single storage pouch reconstruction of the esophagus and jejunum is routinely performed, the latter of which can better slow down the emptying of food and improve the absorption of nutrients.
When gastric cancer cannot be removed surgically, only dissection or biopsy can be performed. For patients with obstruction, gastrointestinal shortcut surgery or jejunostomy can be performed.
7.Does cardia tumor belong to esophageal cancer or gastric cancer? Should thoracic surgery or abdominal surgery be performed? What is the treatment effect?
Cardia cancer, or combined esophagogastric cancer, is a tumor that occurs at the junction of esophagus and stomach. Depending on the pathological type, it can be divided into squamous carcinoma of esophageal origin and adenocarcinoma of gastric origin, and a few of them are adenosquamous carcinoma and hypofractionated carcinoma. According to current research, pancreatic tumors have characteristics of both esophageal and gastric cancers, but as the most common adenocarcinoma of the esophagogastric junction, it should be treated according to the standard of care for gastric cancer, which is more prone to lymph node metastasis in the abdominal cavity.
The surgical management of adenocarcinoma of the esophagogastric junction is complicated, and the decision to combine thoracic surgery should be based on the extent of tumor invasion of the lower esophagus. For patients with more invasion of the lower esophagus, combined thoracoabdominal surgery is required to ensure adequate resection of the esophagus and possible metastasis of mediastinal lymph nodes in the thoracic cavity; whereas for adenocarcinoma mainly confined to the cardia and the high gastric body and fundus, simple laparotomy is possible, provided that a 5-cm esophageal margin is ensured. It should be noted that for pancreatic adenocarcinoma, a purely thoracic operation is definitely not advisable because it is impossible to adequately remove the abdominal lymph nodes.
If the tumor is too large and involves the middle and low gastric body, a total gastrectomy should be performed if sufficient margins cannot be guaranteed.
The overall treatment effect of pancreatic cancer is not as good as distal gastric cancer, and the 5-year survival rate in our hospital is about 45%, which may be due to the fact that pancreatic adenocarcinoma has more complicated lymphatic metastasis pathways than distal gastric cancer. This is because the chance of postoperative surgical complications and sequelae such as anastomotic fistula, abdominal infection and reflux are also relatively higher for pancreatic cancer.
8.How to follow up after gastric cancer surgery?
Once every 3-6 months for 1-3 years; once every 6 months for 3-5 years afterwards; and once a year afterwards.
Blood biochemical examination and tumor index examination should be performed in each follow-up, and imaging examinations such as chest X-ray, liver ultrasound or CT should be recommended, and it is generally recommended to review gastroscopy once a year.
9.What can I eat after gastric cancer surgery? How to eat? Why do some patients lose weight severely after surgery?
Nutritional support for gastric cancer is getting more and more attention, because the nutritional status of patients is directly linked to their tolerance of systemic medical adjuvant treatment, which affects their prognosis.
For cases with gastrointestinal obstruction or malnutrition before treatment, nutritional support should be actively performed to correct the malnutrition and increase the patient’s tolerance of treatment.
Generally, during gastric cancer surgery, the surgeon will establish a short-term nutritional channel through a nasogastric tube or jejunostomy. After 48 hours postoperatively, nutritional support in the intestine can be given, mainly in the form of fluids, including rice soup, nutritional soup, juice, etc. Currently, there are also specially formulated enteral nutritional preparations and elemental diets (Ensure, etc.), and the nutrients and energy supply of these formulated preparations should be encouraged due to the general families preparing their own liquid diet; from 5-7 days postoperatively, patients start to gradually resume transoral diet, from fluid to After eating semi-liquid and feeling normal, patients can be discharged from the hospital.
After discharge, patients with gastric cancer should still focus on easily digestible semi-liquid and soft food, emphasize the principle of eating less and more meals, eat well-cooked food with less dregs, and no obvious restrictions on the types of food, avoid fresh and spicy food, etc. If the general family diet is not tolerated, enteral nutrition preparation can still be used for support to ensure the daily energy supply. In addition, if patients have severe reactions during radiotherapy and cannot eat, intravenous nutritional support should be considered.
It should be reminded that in early postoperative recovery of gastric cancer, if the eating status is poor, oral intake of non-essential antitumor drugs, such as proprietary Chinese medicines and health products, should be delayed to avoid aggravating the loss of appetite and increasing the discomfort of digestive tract.