Nutrition Implications in Gastric Cancer

Running head: NUTRITION IMPLICATIONS IN GASTRIC CANCER 1

Nutrition Implications in Gastric Cancer:

From Causation and Carcinogenesis to Treatment and Recovery

Cooper John Feild

Southern Utah University

Author Note

Cooper J. Feild, Department of Agriculture and Nutrition Science, Southern Utah University

Correspondence concerning this article should be addressed to Cooper Feild, College of Science and Engineering, Southern Utah University, Cedar City, UT 84720.

Contact: [email protected]

NUTRITION IMPLICATIONS IN GASTRIC CANCER 2

Abstract

This paper summarizes recent research about gastric cancer, especially research related to

nutrition during treatment and recovery. Gastric cancer, or cancer of the stomach, is a leading

cause of cancer death worldwide and is still a significant threat in the United States. While its

exact causes remain uncertain, research suggests that a combination of genetic, environmental,

and dietary factors have a strong role in its emergence. Pathogenesis is typical of most other

cancers affecting mucosal layers. It starts from a local malignancy and progresses to metastasis

throughout the body. Surgery, chemotherapy, and radiation therapy are all used in treatment.

Regardless of the location of the cancerous legions, research suggests that adequate nutrition pre-

operatively, post-operatively, and during recovery and adjuvant therapy is important. It can help

improve outcomes and, in some cases, lower morbidity and mortality. This paper examines

specifics in all of these areas, from causation to recovery.


Nutrition Implications in Gastric Cancer: From Causation and Carcinogenesis to Treatment and Recovery

Cancer has been present in the written record for more than 4,000 years, making it one of

the first recorded diseases. Ancient Egyptian and Greek physicians acknowledged what modern

medicine still does today: that cancer is among the most deadly and difficult-to-treat diseases

known to mankind (Mukherjee, 2010). With different variations affecting nearly every part of

human anatomy, it is impossible to take a “one-size-fits-all” approach to treating cancer. Gastric

cancer is a form of cancer that is unique in its epidemiology, occurrence, and treatment. Cancer

itself is the second-leading killer in the United States behind cardiovascular disease. However,

gastric cancer incidence has been steadily decreasing in the United States for the last seventy

years (Crew & Neugut, 2006). Incidence is heavily dependent on region; gastric cancer remains

the most common form of cancer in such countries as Japan, China, and South Korea. According

to US Centers for Disease Control and Prevention data, in 2011 malignant neoplasm of the

stomach accounted for 11,036 deaths in the United States, out of 576,691 total deaths from

malignant neoplasm in general, or 1.9%. Other cancers of the digestive tract, often appearing

side-by-side with gastric cancer in the treatment literature, include esophageal cancer

(accounting for 14,446 deaths in 2011, or 2.5%) and cancer of the colon, rectum, and anus

(accounting for 52,287 deaths in 2011, or 9.1%). Thus, despite a relatively low occurrence

compared to other cancers, gastric cancer and other cancers of the gastro-intestinal tract still

represent a significant threat to the American public.

Epidemiology and Pathophysiology

There are many predisposing factors associated with gastric cancer incidence. Strongly

implicated in the literature is previous infection with Heliobacter Pylori. Environmental factors

and genetics are also associated with incidence, and a history of gastric cancer is documented as


running in some families. Tobacco, obesity, exposure to radiation, and infection with Epstein-

Barr virus also are implicated in causation of gastric cancer. Among all cancers, gastric cancer is

one of the cancers most frequently associated with dietary causes. Research has shown

correlations with gastric cancer and pickled foods, smoked foods, preserved meats, salty foods,

and chemically preserved foods in the diet (Alberts, Cervantes, & de Velde, 2003). In their 2013

article “Molecular Pathogenesis of Gastric Cancer”, Figueredo, Garcia-Gonzalez, and Machado

made the following helpful summary of gastric carcinogenesis:

“Gastric carcinogenesis is a complex and multifactorial process, in which infection with

Helicobacter pylori plays a major role. Additionally, environmental factors as well as

genetic susceptibility factors are significant players in gastric cancer (GC) etiology.

Gastric cancer development results from the accumulation of multiple genetic and

epigenetic changes during the lifetime of the cancer patient that will activate oncogenic

and/or inactivate tumor-suppressor pathways” (2013, p. 28).

As mentioned, many different factors can bring on the genetic changes in gastric cells that result

in cancer. These causes are still being investigated heavily, especially in countries with high

incidences of gastric cancer. As mentioned in the above quote, this accumulation of change can

take time. This is reflected in the age-of-onset of gastric cancer: incidence climbs sharply after

the age of sixty (Venes, 2013). Pathology of gastric cancer is similar to that of most other

cancers. Cellular mitosis restrictions are overcome, resulting in undifferentiated cell growth that

eventually produces a malignant neoplasm in the stomach tissue. These cancerous cells can

eventually invade and disrupt surrounding and distant tissue and organs within the body.

Ninety percent of gastric cancers are adenocarcinomas, or cancers affecting glandular

tissue. In the case of the stomach, this glandular tissue is the mucosa, or the layer of the stomach


exposed to the lumen. While there are other types of carcinoma identified as gastric cancer, the

research (and this article) mostly focus on adenocarcinomas. While the percentages vary

depending on the source, Taber’s Cyclopedic Medical Dictionary states that 50-60% of gastric

cancer occurs in the pylorus, 20% occurs in the lesser curvature, and significant percentages of

the remaining occurrences are in the proximal stomach, especially in the greater curvature

(Venes, 2013). Researchers have noted that rates of cancer occurring in the proximal stomach,

including the cardia and fundus, have increased dramatically in recent years (Alberts et al.,

2003). The National Cancer Institute at the National Institutes of Health divides cancer

progression into various stages from Stage 0, presence of pre-cancerous abnormal cells, to Stage

IV, cancer that has spread beyond the gastric area and into distant parts of the body (2015). For

the exact definitions of all the stages, see Appendix A.

Signs and Symptoms

Signs and symptoms of gastric cancer depend on cancer location, duration, and severity.

For example, dysphagia and acid reflux may be more severe in patients with proximal stomach

cancer. Other signs may reflect cancer-related internal bleeding (as with bloody stools) or the

presence of a tumor (as with feelings of having a full or heavy stomach). In general, signs and

symptoms of gastric cancer can include stomach discomfort, acid reflux (heartburn), nausea, loss

of appetite, fatigue, blood in stools, black tarry stools, bloating or abnormally feeling full after

eating, vomiting after meals, unintended weight loss, and stomach pain (National Cancer

Institute, 2015). Back pain, pain in the epigastric or retrosternal areas, feelings of heaviness or

abdominal distension after meals, dysphagia, and dyspepsia are also possible symptoms (Venes,

2013).

Diagnostic Criteria


For diagnosis, a physician will begin with analyzing a patient’s medical history and

family medical history. Usually this will be followed up with a physical exam. A skilled

examiner can use palpations to possibly detect tumors in the stomach and inflamed lymph nodes

in the gastric region. A complete blood count may also be used to help the physician if he or she

suspects cancer (American Cancer Society, 2013). For exact diagnosis, endoscopy with biopsy

will be used. Endoscopy allows the physician to identify the location of the cancer, and the

biopsy will allow identification of the exact type of cancer. This identification is important in

determining treatment, especially if chemotherapy will be used. For further identification and

staging of the cancer, the physician may request upper gastrointestinal x-ray series (using

barium), carcinoembryonic assay (CEA), endoscopic ultrasound, computerized tomography (CT

scan), magnetic resonance imaging (MRI), positron emission tomography (PET scan), or a chest

x-ray. Diagnostic criteria is made up of two things: First, the cancer staging as shown in

Appendix A. Second, the cancer type as determined by the biopsy (National Cancer Institute,

2015).

Standard Medical Treatments

Surgery is common in gastric cancer treatment, regardless of stage. This can involve

gastrectomy of affected areas (subtotal gastrectomy) or a total gastrectomy. In subtotal

gastrectomy, nearby lymph nodes, the spleen, and parts of other nearby tissues or organs may be

removed. In total gastrectomy, the entire stomach is removed, along with nearby lymph nodes,

and, depending on the case, parts of the esophagus, upper small intestine, spleen, and other

tissues near the stomach (National Cancer Institute, 2015). The optimal invasiveness and amount

of tissue removed during gastric cancer surgery is currently under investigation. Some surgeons

choose radical surgery, removing both cancerous lesions and as much surrounding tissue as


possible (Alberts et al., 2003). Other research is being done into minimally invasive surgery, and

in some countries such as Korea it is now a widespread and accepted practice. In some cases,

tumors of the stomach may not be able to be completely removed despite causing discomfort and

disrupting passage of food and water. In these circumstances stents or laser therapy may be used

to clear passage for nutrients and medications. The added physiological stress of surgery in

gastric cancer patients makes nutrition intervention before, during, and after treatment extremely

important.

Chemotherapy is also employed in gastric cancer. Whether it is used as a first-line

treatment or adjuvant therapy in conjunction with surgery or radiotherapy depends on the cancer

stage, cell type, and mechanism of carcinogenesis. It is more commonly employed in Stage III

and Stage IV patients (Alberts et al., 2003). An oncologist will consider all of this when selecting

a drug, of which there are currently fourteen available for gastric cancer (National Cancer

Institute, 2015). These are sometimes used in combination. Ideally, a drug will be identified that

disrupts the carcinogenesis of the exact form of a patient’s cancer without causing great damage

to healthy tissue. Related to chemotherapy is a newer treatment known as monoclonal antibody

targeted therapy, which is currently showing promise in gastric cancer patients. In this therapy,

modified antibodies are introduced into the affected area. These antibodies are genetically

programmed to only attack cancer cells, while sparing healthy tissue (National Cancer Institute,

2015).

Radiation therapy is often used in combination with surgery or chemotherapy. Research

has shown that adjuvant therapy utilizing radiation in combination with chemotherapy is more

effective than the effects of either therapy used alone (Alberts et al., 2003). Neoadjuvant therapy,

in which a tumor is attacked with radiation before surgery in order to weaken it and prevent its


spread, is also under investigation currently. A patient will often experience surgery,

chemotherapy, and radiation therapy at different times throughout their cancer treatment.

Medical Nutrition Therapy

Nutrition plays a vital role in gastric cancer treatment, and recent research indicates that

this role deserves more emphasis than previously expected. Because surgery is such a vital part

of gastric cancer treatment, here medical nutrition therapy will be divided up into the following

categories: pre-surgery, immediate post-surgery, and during recovery and adjuvant therapy.

Pre-surgery

Once diagnosed with operable gastric cancer, measures to improve nutrition should be

taken. Ideally, nutrition screening and assessment will take place according to the guidelines of

the American Academy of Nutrition and Dietetics to identify the nutrition status of patients

before surgery. Knowledge of nutrition status helps in identifying those that need nutrition

support before treatment begins. It also prepares staff to be ready to provide customized support

at any stage of treatment (Senesee et al., 2001). Because gastric cancer affects appetite and

digestion, it is common for patients to have compromised nutrition status and/or malnutrition.

One study showed malnutrition rates in 31% and 43% of patients, depending on the type of

assessment used (Ryu & Kim, 2010). Patients in another study (n=60) had malnutrition at a rate

of 21% (Farreras et al., 2005). Esophageal cancer patients are often comparable to gastric cancer

patients in terms of malnutrition and under nutrition, and in one study over 80% of esophageal

cancer patients were reported to have either moderate or severe nutrition risk going into

treatment. Another showed that 30.5% of patients had weight loss of greater than 10% (the

normal criteria for malnutrition) upon entering treatment. Some sources estimate the prevalence


of malnutrition in gastrointestinal cancer patients in general to be as high at 80% (Ravasco,

Grillo, & Camilo, 2007).

For such patients with compromised nutrition, nutrition support should be used in the

days leading up to surgery. This should be done with the aim of establishing stable nutrition

status prior to surgery, and studies have shown that positive baseline nutritional status is

predictive of response to treatment and survival in some cancers. Senesse et al. (2001) suggest at

least 10 days of nutritional support in severely malnourished patients prior to surgery to reduce

surgical morbidity and mortality. They also noted that in both severely and non-severely

malnourished patients preoperative oral immunonutrition was associated with a 50% decrease in

postoperative complications. This immunonutrition usually contained arginine, omega-3 fatty

acids, and nucleotides in addition to macronutrients. In providing this nutrition support, the

overwhelming consensus is that enteral nutrition is superior to parenteral nutrition both pre-

operatively and post-operatively.

Immediate Post-Surgery

After surgery, nutrition support has been shown to be beneficial in many ways. A

supplemented formula administered immediately after surgery by way of enteral nutrition has

been shown to significantly increase healing and collagen synthesis, decrease morbidity and

wound complications, and more quickly restore patients to favorable levels of prealbumin and

lymphocytes. It contained protein (in the form of casein, L-arginine, and RNA), fat (including

linoleic acid, omega-3 fatty acids, and MCTs), carbohydrates (in the form of maltodextrin and

sacarose), and a wide range of minerals, trace elements, and vitamins (Farreras et al., 2005).

Another study investigated the importance of the type of post-operative nutrition provided. It

found that total parenteral nutrition, enteral nutrition, and immunoenhanced enteral nutrition


decreasing risk of complications by 26%, 42%, 54% respectively when compared to standard

intravenous fluids. The authors noted that this reduction in complications was more pronounced

in reducing infectious complications than non-infectious ones, and that nutritional support is

actually “the only variable that can easily be modified by the surgeon to prevent postoperative

complications” (Bozzetti et al., 2007, p. 708). In a 2011 review of the literature, Baker, Wooten,

and Malloy suggested that enteral nutrition in post-operative patients is superior in that it

provides all necessary micronutrients and macronutrients in a more intact form, is cheaper, helps

maintain gut mucosal integrity, inhibits cytokine response, has a lower risk of complications,

reduces stress hormone secretion, and inhibits bacterial translocation. They showed that there is

ample evidence that early enteral nutrition (started 6-24 hours post-operatively) reduces ICU and

total hospital days, offers a significantly faster return of bowel function, prevents GI atrophy,

maintains immunocompetence, and preserves normal gut flora. This is in contrast with

conventions at many hospitals that withhold food until several days post-surgery.

During Recovery and Adjuvant Therapy

Cancer cachexia represents a difficult obstacle for a patient recovering from surgery or

undergoing radiation or chemotherapy. Symptoms include loss of desire to eat, weight loss, and

progressive wasting of lean body mass and adipose tissue. Supplemental nutrition may be needed

in these patients. Two other important interventions to consider include specific and intense

nutrition counseling and the use of appetite-boosting medications and hormones. Several studies

have shown that nutrition counseling has been shown to slow the deterioration of nutritional

status and accelerate recovery of physical function and global quality of life (Laviano et al.,

2005, and Ravasco et al., 2007). In terms of drug and hormone therapy, progestogens such as

megestrol acetate have been shown in multiple studies to relieve symptoms of cachexia by


improving food intake and body weight (Laviano et al., 2005). Grehlin has been shown in

multiple studies to improve appetite, and is predicted to have a much greater role in combating

anorexia and cancer cachexia in the future. Steroids such as prednisolone or dexamethasone have

been shown to increase appetite and well-being. Anabolic steroids are being investigated for

potential to increase muscle mass in patients suffering from cachexia (Fearon, 2008).

Alternative Treatments

Nutrition is also a focus of many forms of alternative treatments for cancer. While it is

true that a well-balanced diet with high amounts of fiber, vitamins, and antioxidants can help

lower risk for cancer and help with recovery, little empirical evidence exists that shows nutrition

itself can treat gastric cancer. Other alternative treatments include alternative medical systems

(such as acupuncture), mind-body methods that are based on the idea that the mind itself can

affect the body’s response to cancer, and use of vaccines, hormones, and botanicals not typically

used in cancer treatment. Patients must take care to carefully research alternative treatments and

inform their physician of any plans to use these methods (National Cancer Institute, 2012). At

best, alternative treatments can promote healing and recovery in those undergoing traditional

treatments. However, the potential for interactions with chemotherapy and potential to shirk

standard medical advice often make pursuing alternative treatments for cancer dangerous.

Long-Term Impact on Quality of Life and Life Span

In gastric cancer, quality of life and life span are highly dependent on the stage of cancer,

the outcome of treatment, and measures taken by the patient to recover and increase quality of

life (such as a balanced diet, exercise, and meditation). If treatment can cause cancer to go into

remission, quality of life and life span can be similar to that of someone free from cancer.


Without treatment, cancer progresses through the stages already mentioned. This sometimes

occurs even with treatment. Unfortunately, many patients do not receive a diagnosis of gastric

cancer until they have reached stage III or stage IV. In stage IV, the estimated survival rate of

patients treated at Cancer Treatment Centers of America at six months was 64%. This dropped to

31% after a year, 14% after a year and a half, 7% at two years, and continued falling until four

and five years, when the survival rate was 2% (Cancer Treatment Centers of America, 2015).

Survival is also a function of which area of the stomach is affected by cancer, with

tumors located in the cardia having a poorer prognosis, lower 5-year survival, and higher

operative mortality than those located in the distal stomach. Screening, location of cancer

treatment, and even genetics have been shown to affect survival. In Japan, early and effective

screening has led to 5- year survival rates of 95% when the disease is confined to the inner lining

of the stomach. In the United States and Europe, detection is much lower, leading to 5-year

survival rates between 10-20% (Crew & Neugut, 2006). Quality of life is more greatly affected

at each progressively higher stage of cancer. Because gastric cancer by definition affects the

gastrointestinal tract, fatigue, indigestion, and abdominal pain are often constant or at least

intermittent.

Conclusion

Nutrition is intrinsically tied to gastric cancer. Many sources credit diet as one of the

main factors in developing gastric cancer. Once gastric cancer is developed, food intake and

absorption can be severely affected. Even cancer treatments can negatively affect food intake and

absorption, at least in the short-term. As with many other forms of cancer, our knowledge of its

causes, predisposing factors, and epidemiology is increasing rapidly. A skilled physician now

has many resources and tools to help make a correct diagnosis, and research is helping improve


the efficacy of the three main treatment modalities: surgery, chemotherapy, and radiation

therapy. With incidence rates decreasing in the United States and treatments improving, gastric

cancer is no longer among the leading killers found under the umbrella of cancer. Research into

the effects of nutrition intervention before surgery, after surgery, and during recovery and

adjuvant therapy are extremely promising. Recently, early enteral nutrition, with

immunoenhanced constituents, has shown to have beneficial effects in many areas of recovery.

With further research and investigation, a future in which gastric cancer is at least

partially prevented through adequate nutrition is possible. Expanding knowledge into the role of

nutrition during recovery, and advances in understanding its role in combating cancer cachexia,

will help patients recover from cancer faster and attain a high quality of life. Gastric cancer still

remains a viable threat, and cancer treatment has still not reached a level that makes gastric

cancer diagnosis easy to cope with. However, if advances in the last several decades are any

indication, gastric cancer should become increasingly more rare and treatable, especially when

nutrition status is made a priority.


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Appendix A

Gastric Cancer Stages-The National Cancer Institute

Stage 0 (Carcinoma in Situ)- In stage 0, abnormal cells are found in the inside lining of the mucosa (innermost layer) of the stomach wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I- In stage I, cancer has formed in the inside lining of the mucosa (innermost layer) of the stomach wall. Stage I is divided into stage IA and stage IB, depending on where the cancer has spread.

Stage IA: Cancer may have spread into the submucosa (layer of tissue next to the mucosa) of the stomach wall.

Stage IB: Cancer may have spread into the submucosa (layer of tissue next to the mucosa) of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or has spread to the muscle layer of the stomach wall.

Stage II- Stage II gastric cancer is divided into stage IIA and stage IIB, depending on where the cancer has spread.

Stage IIA: Cancer has spread to the subserosa (layer of tissue next to the serosa) of the stomach wall; or has spread to the muscle layer of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or may have spread to the submucosa (layer of tissue next to the mucosa) of the stomach wall and is found in 3 to 6 lymph nodes near the tumor.

Stage IIB: Cancer has spread to the serosa (outermost layer) of the stomach wall; or has spread to the subserosa (layer of tissue next to the serosa) of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or has spread to the muscle layer of the stomach wall and is found in 3 to 6 lymph nodes near the tumor; or may have spread to the submucosa (layer of tissue next to the mucosa) of the stomach wall and is found in 7 or more lymph nodes near the tumor.

Stage III- Stage III gastric cancer is divided into stage IIIA, stage IIIB, and stage IIIC, depending on where the cancer has spread.

Stage IIIA: Cancer has spread to the serosa (outermost) layer of the stomach wall and is found in 1 or 2 lymph nodes near the tumor; or the subserosa (layer of tissue next to the serosa) of the stomach wall and is found in 3 to 6 lymph nodes near the tumor; or the muscle layer of the stomach wall and is found in 7 or more lymph nodes near the tumor.

Stage IIIB: Cancer has spread to nearby organs such as the spleen, transverse colon, liver, diaphragm, pancreas, kidney, adrenal gland, or small intestine, and may be found in 1 or 2 lymph nodes near the tumor; or the serosa (outermost layer) of the stomach wall and is found in 3 to 6 lymph nodes near the tumor; or the subserosa (layer of tissue next to the serosa) of the stomach wall and is found in 7 or more lymph nodes near the tumor.

Stage IIIC: Cancer has spread to nearby organs such as the spleen, transverse colon, liver, diaphragm, pancreas, kidney, adrenal gland, or small intestine, and may be found in 3 or more lymph nodes near the tumor; or the serosa (outermost layer) of the stomach wall and is found in 7 or more lymph nodes near the tumor.

Stage IV- In stage IV, cancer has spread to distant parts of the body.

Nutrition Implications in Gastric Cancer

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