Comprehensive Clinical Approach to Managing Gastric Cancer

Summary:
Gastric Cancer in India shows strong regional variation, with higher incidence in southern and north-eastern states, particularly Mizoram, and is often diagnosed at an advanced stage, making early detection crucial. Risk factors are largely linked to diet, tobacco and alcohol use, along with infections such as Helicobacter pylori and peptic ulcer disease, which are frequently underdiagnosed. The disease presents with vague symptoms, complicating early diagnosis, and requires comprehensive evaluation through endoscopy, imaging, and molecular testing. Treatment depends on disease stage, ranging from surgery in resectable cases to systemic therapies like chemotherapy, targeted drugs, and immunotherapy, while palliative care plays a key role in advanced stages. Experts emphasise the importance of early screening, genetic assessment in high-risk individuals, and a holistic, long-term care approach to improve outcomes. 

While Gastric Cancer remains a leading cause of cancer-related deaths in countries like Japan, its pattern in India shows distinct regional variation. Higher incidence rates are observed in South India and the North-Eastern states, particularly in Mizoram, where the burden is significantly elevated. Given that the disease is often diagnosed at an advanced stage, understanding these regional trends is critical for enabling earlier detection and intervention.

The Indian Risk Landscape

Dietary habits and infections play a major role in shaping risk. Common factors include consumption of rice, chilies, alcohol, and tobacco use. Importantly, infection with H. pylori and the presence of peptic ulcer disease substantially increase susceptibility, yet these conditions are frequently underdiagnosed in primary care. Persistent dyspepsia or chronic ulcer symptoms should therefore raise clinical suspicion.

Recognising the Disease

Gastric cancer often presents with non-specific symptoms such as loss of appetite, unexplained weight loss, abdominal discomfort, nausea, vomiting, bowel changes, and fatigue, making early detection challenging. Symptoms like difficulty swallowing or signs of spread usually indicate advanced disease. The cancer can extend locally, spread via lymphatics, or disseminate through the bloodstream, including to the lungs. While adenocarcinoma is the most common type, clinicians should also consider other forms such as gastrointestinal stromal tumors, lymphomas, and connective tissue tumors.

Diagnostic Approach

Accurate diagnosis requires more than basic tests. Initial investigations include blood work such as CBC, liver and renal function tests, along with cardiac and viral markers. Upper gastrointestinal endoscopy with biopsy is essential for confirmation, staging, and management. Imaging with contrast-enhanced CT scans of the chest, abdomen, and pelvis is standard, while PET scans and endoscopic ultrasound provide additional detail for early-stage disease. In metastatic cases, further evaluation includes HER2 status, PD-L1 expression, microsatellite instability, mismatch repair status, and advanced genetic profiling, often supported by biopsy of metastatic lesions.

Genetic Considerations

Inherited syndromes contribute to risk but are often overlooked. Conditions such as Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis, and familial adenomatous polyposis require proactive screening. Less common syndromes like Bloom’s, Li-Fraumeni, hereditary breast and ovarian cancer, and Cowden syndrome also play a role. Genetic testing decisions are guided by age, family history, and known mutations in genes such as CDH1, APC, STK11, SMAD4, MLH1, MSH2, MSH6, and EPCAM.

Surgical Management

Treatment decisions depend on whether the disease is resectable. Advanced local spread, major vascular involvement, distant metastases, or peritoneal disease typically make surgery unfeasible. For operable cases, options include endoscopic removal for small lesions, partial or total gastrectomy, and more extensive resections when required. Minimally invasive techniques such as laparoscopic and robotic surgery are increasingly used, and splenectomy may be necessary in select cases. When curative treatment is not possible, palliative procedures like bypass surgery, stenting, or feeding support are essential for maintaining quality of life.

Systemic Therapy

Medical treatment continues to evolve rapidly. First-line therapy may include targeted agents such as trastuzumab for HER2-positive cases, alongside chemotherapy regimens tailored to patient fitness. Newer approaches incorporate perioperative and neoadjuvant immunotherapy, as well as adjuvant chemotherapy and chemoradiation for advanced disease.

Beyond Treatment

Ongoing monitoring and structured follow-up are critical components of care. Equally important is patient counseling and the early inclusion of palliative care services. Given the frequency of late-stage diagnosis, a comprehensive, patient-centred approach remains essential for improving outcomes and quality of life.