Complications of Gastric Cancer in Older People

Introduction

The stomach has three portions, the cardia, which is the upper part and connects with the food pipe known as the esophagus; the fundus is the middle part of the body of the stomach; the antrum and pylorus are the lower parts of the stomach. Cancer can arise from any of these parts. Most stomach cancers occur in the esophageal junction. Stomach cancer mostly affects older individuals. The average age is 68 years for those diagnosed with stomach cancer. Around 60 % of cases occur in older individuals aged more than 65 years, and men have a slightly higher lifetime risk of stomach cancer. Stomach cancer can develop slowly over time. Small changes occur in the stomach cells' DNA (deoxyribonucleic acid), making them multiply and accumulating abnormal growth called tumors.

What Are the Types of Gastric Cancer?

There are numerous types of gastric cancer, but the most common is adenocarcinoma, which accounts for 90 to 95 % of people with stomach cancer. Other types are-

• Primary gastric lymphoma.

• Gastrointestinal stromal tumor.

• Neuroendocrine tumors.

What Are the Risk Factors of Gastric Cancer?

Gastric cancer comes with various risk factors, some of which are mentioned below-

• Older age with a median age of 70 years.

• It occurs twice as frequently in men as in women.

• Infection with Helicobacter pylori is involved in 60 % of cases.

• Smoking.

• Alcohol consumption.

• Obesity.

• A diet rich in pickled food and processed meat.

• Family history is associated with 10% of cases, with one percent having a genetic syndrome causing cancer, such as autosomal dominant hereditary diffuse gastric cancer.

• Pernicious anemia.

What Are the Signs and Symptoms of Gastric Cancer?

Some of the signs and symptoms of gastric cancer are as follows-

• Weight loss.

• Dyspepsia (difficulty in digestion).

• Indigestion.

• Heartburn.

• Fatigue.

• Bloating.

• Nausea and vomiting.

• Hematemesis (vomiting of blood).

• Melena (dark stool containing partly digested food).

• Anemia.

• Dysphagia (difficulty in swallowing).

How Is It Diagnosed?

To determine stomach cancer, the doctor may proceed with an upper endoscopy, where a tiny camera is passed through the throat into the stomach. If there are some findings, a small amount of tissue is removed for biopsy, where the tissue is sent to a laboratory for analysis. Some imaging tests, like computed tomography (CT scan) or a special X-ray called the barium swallow, can be performed. Identifying the extent of cancer can help a doctor determine the best treatment. More tests can be run to determine the stage, like blood tests, endoscopic ultrasounds, or positron emission tomography (PET scan).

How Is Gastric Cancer Treated?

Cancer prevention is encouraged by maintaining a diet rich in fruits and vegetables and avoiding modifiable risk factors. There are some treatment methods that can be followed, such as-

• Helicobacter pylori eradication is also believed to reduce the risk of developing gastric cancer.

• Endoscopic mucosal resection can be done in the early stages when the cancer is still limited to the most superficial layers, while in later stages, more advanced surgery is required, which involves total or partial gastrectomy.

• Chemotherapy may be done adjunctively after surgery or neo-adjunctively before surgery to help shrink the tumor.

• Trastuzumab is a her-2 inhibitor which is a growth-promoting protein, and this treatment has been found to increase survival in patients with her-2 positive gastric cancer, which is seen in nearly 25 % of cases.

• Nivolumab is a monoclonal antibody that targets the programmed death receptor-1 blocking the interaction between it and its elements. The binding of this receptor usually leads to a decreased anti-tumor response; therefore, blocking the interaction leads to increased anti-tumor activity.

What Are the Complications of Gastric Cancer in Older People?

Old age plays a significant factor for patients with gastric cancer and comprises more serious complication in elderly patients, which includes-

• Older people have a functional decline of reserve capacity, and they show a high incidence of comorbidity, which leads to reduced ability of older people to tolerate surgical stress, including gastric cancer surgery.

• The other feature of older people is that they get less social and economic support as they pose a greater burden for additional fees associated with postoperative complications of gastric surgery.

• Comorbidity is a high-risk factor for elderly patients.

• Post-operative pneumonia in elderly patients has also been identified and is potentially a result of interaction between various immunologic, hormonal, and microbiological factors.

• Malnutrition is a risk factor for complications in elderly patients after major abdominal surgery.

How to Manage Gastric Cancer in Older People?

With the option of chemotherapy and surgery available for gastric cancer, treatment of elderly patients may vary in comparison with younger patients due to their functional loss and comorbidities that come with age, therefore following are a few points that can be considered-

• Gastric cancer surgery is a significant abdominal operation; hence older patients must be carefully evaluated before the surgery as they have an increased risk of mortality and morbidity with surgery.

• A minimally invasive approach should be considered in elderly patients for gastric cancer surgery.

• The comprehensive geriatric assessment (CGA) should be established, which gives a validated score of functional status in both the geriatric and oncological settings and helps to identify frail, vulnerable patients at risk of morbidity or mortality. It also considers comorbidities, cognitive impairment, functional difficulties, and social circumstances and helps to risk stratify patients when making clinical decisions.

• Neoadjuvant chemotherapy is a reasonable treatment option for elderly patients with locally advanced resectable gastric cancer.

• Generally, adjuvant chemotherapy is less tolerated than neoadjuvant chemotherapy, certainly, in older patients with resectable gastric cancer. Hence, perioperative chemotherapy may be a preferential option for those who have not received preoperative chemotherapy.

• Elderly patients should be encouraged and also considered for inclusion in clinical trials for gastric cancer.

• A well-maintained diet is important in elderly patients with gastric cancer.

Conclusion

An individualized approach is needed for the treatment decisions in elderly patients to improve the outcome and survival rate. Both the surgical and chemotherapy option should be considered. Even though older patients have a high risk of complications with gastric cancer along with their comorbidities, it is a curable condition, and the treatment options should not be disregarded because of old age.