Stomach cancer is changing: An expert explains surgical approaches
· Medical Xpressby Travis Grotz, Mayo Clinic
edited by Sadie Harley, reviewed by Andrew Zinin
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Sometimes innovation in cancer care means developing something entirely new. Other times, it means returning to an old idea with the knowledge and tools to make it work better. Both are happening in stomach cancer surgery, says Travis Grotz, M.D., a Mayo Clinic surgical oncologist who specializes in treating stomach cancer.
From adapting a surgical pouch used in colorectal surgery to revisiting an operation largely abandoned decades ago, surgeons are finding new ways to treat stomach cancer while focusing on how patients will eat, recover and live after surgery.
At the same time, Grotz says the disease itself is changing. Stomach cancers in the U.S. are increasingly being diagnosed in younger people and in different parts of the stomach than they were decades ago.
Here are several changes Grotz says patients should know about.
An old stomach cancer operation is getting a second look
For cancers in the upper portion of the stomach, surgeons once commonly performed a proximal gastrectomy, removing the upper portion of the stomach and reconnecting the remaining stomach directly to the esophagus.
The operation could effectively treat the cancer, but there was a significant problem: Patients often experienced severe bile reflux after surgery.
"The patients' quality of life was negatively impacted," Grotz says.
Eventually, surgeons in the U.S. largely moved away from the procedure and instead removed the entire stomach.
Now, surgeons are performing a technique called double-tract reconstruction, and Mayo Clinic surgeons are using it to change how the remaining stomach, esophagus and intestine are connected, helping preserve part of the stomach while reducing reflux. Mayo Clinic surgeons have adapted that approach for the more advanced stomach cancers typically seen in the U.S.
The result is an approach that allows surgeons, for appropriate patients, to remove enough tissue to treat the cancer while preserving part of the stomach. Grotz says the incidence of reflux with the reconstruction can be around 5%.
A lesson from colorectal surgery may help patients eat more normally
Removing the entire stomach can treat cancer, but it also eliminates the body's reservoir for food. Without a stomach, patients typically need to eat five or six small meals throughout the day and can experience "dumping syndrome," in which food moves too rapidly into the small intestine.
Surgeons are adopting a concept familiar in colorectal surgery: modifying the small intestine to create a J-pouch, a new reservoir that helps do the job the stomach did.
"The pouch holds on to the food for about 90 minutes, and then it slowly releases it," Grotz says.
That can make a substantial difference in everyday life. Grotz estimates more than 80% of patients with a pouch can return to eating roughly three normal-sized meals a day.
"You really wouldn't even know they have it when you're eating," he says. "They may eat a little slowly but definitely still within the realm of normal."
The goal goes beyond successful surgery. It is to help patients return to a full and meaningful life afterward.
Stomach cancer found early may not require traditional surgery
Most stomach cancers in the U.S. are discovered after they have advanced, but patients whose cancers are found early may have another option.
Some can be treated through an endoscope rather than conventional surgery. The procedure requires specialized expertise and allows physicians to remove the cancer through an endoscope without removing the stomach.
That expertise can matter when patients are considering where to seek care, Grotz says. A patient who might be offered a larger operation elsewhere could, after careful evaluation, be eligible for endoscopic treatment at a center with the necessary experience.
For patients who need surgery, minimally invasive and robotic approaches can also reduce the physical burden of treatment.
For most patients with locally advanced stomach cancer, treatment involves more than an operation. Chemotherapy, immunotherapy and surgery increasingly work together, with the sequence tailored to the individual patient.
Even some patients whose cancer has spread beyond the stomach may be considered for surgery after responding well to systemic treatment.
"Surgery is a great consolidative therapy," Grotz says. "If you've had a great induction response to therapy, then it's very effective to consolidate with surgery and get rid of the rest of the cancer."
Stomach cancer is increasingly affecting younger people
The profile of stomach cancer in the U.S. also has changed.
Decades ago, Grotz says, stomach cancer more often occurred in the lower portion of the stomach and in older patients. Today, physicians are seeing more proximal and diffuse stomach cancers, including cancers in younger adults.
Researchers are trying to understand why.
One area Grotz and colleagues are studying is whether greater consumption of ultraprocessed foods could be contributing to the increase in early-onset stomach cancer. Grotz cautions that current evidence shows an association, not proof that these foods cause stomach cancer. Researchers are using large data sets and artificial intelligence to investigate those relationships further.
Grotz says the question deserves particular attention because today's younger adults have been exposed to ultraprocessed foods much earlier in life than previous generations were.
"What we eat is going to affect our stomach; it's the first place it goes," he says.
Innovation can mean doing more ... and sometimes doing less
Taken together, the advances reflect a broader change in how surgeons approach stomach cancer treatment.
The goal is not simply to perform the largest possible operation. Depending on the cancer and its stage, treatment may mean removing a tumor endoscopically, preserving part of the stomach, creating a new reservoir after the stomach is removed, or combining surgery with increasingly sophisticated systemic and regional treatments.
Sometimes progress also comes from looking backward.
The return of proximal gastrectomy is one example: an operation surgeons knew could treat cancer but largely abandoned because of its side effects. Surgeons are now revisiting it with an approach designed to address the problem that led them to move away from the procedure.
For patients, Grotz says, those advances can translate into something deceptively simple: treating the cancer while preserving as much normal life as possible.
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OncologyGeneral surgeryCommon illnesses & Prevention Provided by Mayo Clinic Who's behind this story?
Sadie Harley
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