Abramson Cancer Center

Some risk factors for cancer, like age and family history, cannot be prevented. Patients who feel they are at risk may benefit from consulting with a risk assessment specialist within one of Penn Medicine’s programs at the Abramson Cancer Center or the Joan Karnell Cancer Center at Pennsylvania Hospital.

Stomach Cancer Risk Factors

Risk factors increase the chance of developing stomach cancer. However, most people with risk factors for stomach cancer never develop the disease. These are some risk factors for stomach cancer:

• Helicobacter pylori (H. pylori) infection. H. pylori is a bacterial infection that can infect the lining of the stomach and chronic infection with H. pylori may increase the risk for stomach cancer.The World Health Organization classifies H. pylori as a class I carcinogen. If found by endoscopic biopsy it should be treated medically.
• Smoking. Smoking, particularly heavy smoking, has been linked to an increased risk of developing stomach cancer. 
• Family history. People who have close relatives with a history of stomach cancer, such as Lynch syndrome, Ménétrier disease, familial adenomatous polyposis (FAP) or diffuse hereditary gastric cancer, may be at an increased risk themselves.
• Pernicious anemia. Pernicious anemia is an autoimmune disease in which the stomach does not produce enough stomach acid.
• Obesity. Those who are obese or overweight may be at an increased risk for cancer in the upper part of the stomach.
• Diet. Studies show people who eat a diet high in salted, smoked or pickled foods and low in vitamins and minerals have an increased risk for stomach cancer.
• Sex. Stomach cancer occurs more often in males than females.
• Race. African-American men are more than twice as likely as caucasian men to die from stomach cancer.

Stomach Cancer Prevention

Most risk factors for stomach cancer such as family history cannot be prevented. However, people can do the following to help decrease their cancer risk.

• Quit smoking. Quitting smoking or chewing tobacco can decrease the risk of developing cancer. Patients can get help to stop smoking through Penn Medicine’s Lung Center or through smoking cessation research programs at the Abramson Cancer Center.
• Control weight. Maintaining a healthy weight with a diet rich in fresh fruits and vegetables, and exercising regularly can help prevent cancer. 

Stomach Cancer Risk Assessment

Penn Medicine offers programs for patients who want to determine their risk of developing gastrointestinal cancer through the Abramson Cancer Center.

These programs offer knowledge about the presence of genetic risk factors for cancer and provide patients with important, sometimes life-saving options.

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• Adenocarcinoma
  • Intestinal
  • Diffuse
• Other types of stomach cancer
  • Lymphoma
  • Leiomyosarcoma

Adenocarcinoma

Cancer is described by the types of cells from which it forms. Most stomach cancers are adenocarcinomas. Adenocarcinoma is cancer that starts in cells that have gland-like properties within the tissues that line the inside of the stomach.

Other Types of Stomach Cancer

Other types of stomach cancer may develop in the stomach, but are very rare. These include:

• Lymphomas Lymphoma is cancer of the lymphatic system. Non-Hodgkin’s lymphoma can develop within the stomach. Helicobacter pylori (H. pylori) is believed to play a role in the development of mucosal-associated lymphoid tissue.
• Leiomyosarcoma: Leiomyosarcoma is cancer of the smooth muscle of the stomach.
• Stromal tumor (GIST): Tumors from the tissue under cells that line the inside of the stomach and between these cells and the smooth muscle of the stomach.

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Stomach cancer is usually not discovered until it becomes more advanced when it causes symptoms. Symptoms of stomach cancer include:

• Pain in the abdomen
• Indigestion and loss of appetite
• Nausea and vomiting
• Fatigue
• Losing weight without dieting
• Feeling full or bloated after a small meal
• Abdominal swelling
• Vomiting blood or having blood in the stool

Staging Stomach Cancer

Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the aggressiveness and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

Staging stomach cancer attempts to discover the following:

• The depth of the tumor involving the stomach
• Whether the cancer has spread to nearby lymph nodes and tissues
• Whether the cancer has spread to other parts of the body

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After being diagnosed with stomach cancer, patients at the Abramson Cancer Center may be evaluated through the Gastrointestinal Cancer Evaluation Center (GICEC). The center provides patients with expert support and evaluation to accurate diagnose with appropriate stage and discuss treatment options and individualized treatment plans.

Patients with gastric cancer are treated by a multidisciplinary team of cancer specialists who see more patients with gastrointestinal (GI) cancers in one year than many doctors see in their careers.

The physicians of Penn Medicine’s GI cancer program are nationally recognized for their expertise in the diagnosis and treatment of cancer.

Penn’s GI cancer treatment team includes:

• Nationally recognized medical experts with years of experience in diagnosing and treating GI cancer [including (not limited) gastroenterologists, surgeons, radiation oncologists, and medical oncologists].
• Nurses with advanced training and experience in caring for patients with GI cancer.
• Oncology Navigation Specialists to help patients navigate the health system.
• Registered dietitians to provide nutrition counseling.
• Cancer counselors to provide individual or family counseling for issues many cancer patients face.
• Rehabilitation therapists who specialize in the diagnosis and treatment of physical effects from cancer and its treatment.

Patients at Penn Medicine can benefit from participating in clinical trials that take place at Penn. Patients interested in learning more about clinical trials should speak with someone on their treatment team.

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Because stomach cancer is relatively uncommon in the United States, there are no general screening tests recommended for stomach cancer like mammograms for breast cancer or colonoscopies for colon cancer. For patients at high risk, GI genetics program at Penn Medicine can help determine if screening tests are needed.

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When physicians suspect stomach cancer, they may order several tests to make a diagnosis and/or stage the disease.

• Medical history and physical exam. The physician feels the abdomen for swelling, fluid or other changes. The physician also checks for swollen lymph nodes.
• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
  • Endoscopy. Endoscopy allows the doctor to see the lining of the upper digestive system with a thin, lighted, flexible tube called an endoscope. The patient is sedated as the tube is inserted through the mouth, down the esophagus, and into the stomach and small bowel. If an abnormality is found, a biopsy is performed.
  • Endoscopic ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. This procedure is often done at the same time as the upper endoscopy. The endoscopic ultrasound can show enlarged lymph nodes, which may indicate a tumor or advanced disease.
  • Computed tomography (CT). A CT scan creates a three-dimensional X-ray of the inside of the chest, abdomen and pelvis. A computer combines the images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (dye) is used to provide better detail.
  •  Laparoscopy. This minimally invasive procedure allows the physician to view the lymph nodes and other organs to see if cancer has spread. Biopsies may be taken of the organ tissue.
  • Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. The tumor absorbs the radioactive substance, and a scanner detects this substance to produce images.
• Biopsy. When other tests find a change that is possibly cancer, a sample of the suspicious area is removed and viewed under a microscope. A biopsy or fine-needle aspiration is the only way to tell if cancer is really present.
• Lab tests. A physician may order lab tests to check levels of carcinoembryonic antigen (CEA), protein and enzyme levels that may indicate cancer.

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Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

The stomach has five layers:

• Inner layer: lining of the stomach
• Submucosa: support tissue for inner layer
• Muscle layer: muscles of the stomach
• Subserosa: support tissue for the outer layer
• Outer layer: outer lining, also called serosa

Staging stomach cancer also involves discovering how many layers of the stomach the cancer has invaded.

• Stage 0. The tumor is found only in the inner layer of the stomach. Stage 0 is also called carcinoma in situ.
• Stage I. One of the following:
  • Tumor has only invaded submucosa, and cancer cells may have spread up to six lymph nodes.
  • Tumor has invaded muscle layer or subserosa. Cancer cells have not spread to lymph nodes.
• Stage II. One of the following:
  • Tumor has only invaded submucosa. Cancer cells have spread to seven to 15 lymph nodes.
  • Tumor has invaded muscle layer or subserosa. Cancer cells have spread to one to six lymph nodes
  • Tumor has penetrated outer layer of stomach with no spread.
• Stage III. One of the following:
  • Tumor has invaded muscle layer or subserosa. Cancer has spread to seven to 15 lymph nodes.
  • Tumor has penetrated the outer layer. Cancer has spread to one to six lymph nodes.
  • Tumor has spread to nearby organs. Cancer has not spread to lymph nodes or distant organs.
• Stage IV. One of the following:
  • Cancer has spread to more than 15 lymph nodes.
  • Tumor has spread to nearby organs and at least one lymph node.
  • Cancer has spread to distant organs.

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Surgery for stomach cancer offers the best possibility for a cure. The surgical expertise and experience of Penn’s gastrointestinal surgery team combined with leading-edge research at Penn offers patients a significant advantage.

Partial Gastrectomy

In a partial or subtotal gastrectomy, the surgeon removes the part of the stomach that contains cancer. The surgeon attaches the remaining part of the stomach to the intestine. Nearby lymph nodes and other tissues may be removed.

Total Gastrectomy

The entire stomach is removed in a total gastrectomy, as well as parts of the esophagus, small intestine, lymph nodes and nearby tissues. The esophagus is then connected to the small intestine. This procedure may be done when the stomach cancer is larger or has spread.

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Radiation oncologists at Penn Medicine are recognized for techniques that target radiation precisely to the disease site while sparing nearby tissue. As national leaders in radiation therapy, they are experts in the use of the latest therapies to treat cancer.

Radiation therapy uses high-energy radiation to kill cancer cells. A radiation therapy schedule usually consists of a specific number of treatments given over an extended period of time. In many cases, radiation therapy is capable of killing all of the cancer cells. Radiation oncologists at Penn Medicine use both internal and external forms of radiation therapy to treat cancer. Radiation therapy is commonly combined with chemotherapy or biologic treatment medications.

3-D Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine helps shape the radiation treatment beam to the shape of the tumor. Conformal radiation therapy gives doctors more control when treating tumors.

Special computers use CT imaging scans to create 3-D maps of the location of the cancer in the body. The system permits the delivery of radiation from several directions, and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Intensity-modulated Radiation Therapy (IMRT)

This advanced type of radiation therapy uses a computer-controlled device, called a linear accelerator, to deliver precise doses of radiation to tumors or specific areas within the tumors. Radiation therapy, including IMRT, stops cancer cells from dividing and growing, thus slowing or stopping tumor growth. In many cases, radiation therapy is capable of killing all of the cancer cells.

Using 3-D computed tomography (CT) images along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the shape of the tumor by controlling, or modulating, the intensity of the radiation beam. The therapy allows higher radiation doses to be delivered to areas within the tumor while minimizing the dose to the surrounding area.

Proton Therapy

Penn Medicine is the only academic medical center in the country that is using proton therapy to treat recurrent cancer in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this precise form of cancer radiation. Patients have access to one of the most sophisticated weapons against cancer, seamlessly integrated with the full range of oncology services available at Penn Medicine. Proton therapy is external beam radiotherapy in which protons are directed at a tumor.

The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.

Proton therapy, like all forms of radiation therapy, works by aiming the energized particles, in this case protons, onto the target tumor. The particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.

Volumetric-modulated Arc Therapy (VMAT)

Volumetric-modulated arc therapy (VMAT) is a type of specialized intensity modulated radiation therapy. VMAT delivers radiation by rotating the radiation machile, through one or more arcs while radiation is continuously delivered.

VMAT allows Penn radiation oncologists to treat complex cancers while minimizing exposure to surrounding healthy tissue. VMAT shortens radiation delivery time, and offers patient more comfort because it does not require patients to lie completely still for long periods of time.

Penn radiation oncologists use RapidArc™ radiotherapy technology to treat hard to reach tumors.

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Cancer specialists at Penn Medicine specialize in a multidisciplinary approach to treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to and after surgery. Medical oncologists, cancer specialists who treat patients with chemotherapy, are part of a multidisciplinary cancer treatment team who approaches cancer care to treat the whole patient with personalized medicine.

Biologic (Targeted) Therapy

Biologic therapy, also called targeted therapy, uses the patients' own immune system to target cancer cells. Substances made by the body or in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer, and are delivered orally by pill or intravenously.  This type of cancer treatment is also called immunotherapy.

Chemoradiotherapy

Chemoradiotherapy is the practice in which chemotherapy and radiation therapy are used simultaneously. 

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is usually delivered intravenously through a catheter, or orally by pill.

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Today, more and more people are surviving cancer. Clinical trials benefit patients by providing access to breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead. Through clinical trials:

• Diagnosing cancer has become more precise.
• Radiation and surgical techniques have advanced.
• Medications are more successful.
• Combinations of medical, surgical and radiation therapy are improving treatment effectiveness and enhancing outcomes.
• Strategies to address the late effects of cancer and its treatment are improving quality of life.

Penn Medicine is the only facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

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In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments, not take their place.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

Cancer specialists at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center’s range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

• Acupuncture
• Diet and nutrition
• Mindfulness-based stress reduction therapy
• Reiki therapy
• Yoga
• Exercise and rehabilitation

The Joan Karnell Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight.

The Supportive Care Clinic helps to manage cancer related symptoms. Integrative support programs include:

• Music therapy
• Art therapy
• Shiatsu massage
• Mindfulness meditation

Support groups and educational programs are available at Pennsylvania Hospital throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, or to improve quality of life when curative therapies are no longer an option.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end-of-life care.

Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.  

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offers a full range of home health care needs by partnering three top-level home health care services under one roof:

• Penn Wissahickon Hospice
• Penn Care at Home
• Penn Home Infusion Therapy

Penn Home Care and Hospice Services offers an array of specialized therapies and medications for patients with cancer and cancer-related conditions.

Oncology Patient Navigators

Every step of cancer treatment, from a cancer diagnosis, to surgery and treatment to forming a survivorship plan, comes with different needs and issues that should be addressed.

Oncology patient navigators are committed to making sure a patient’s experience is as comfortable as possible. They are experts in navigating complex healthcare situations and serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families.

Learn more about Oncology Patient Navigators at the Abramson Cancer Center.

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At the end of treatment, stomach cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Long-term stomach cancer survivors should speak to their oncologist and nurse practitioner about scheduling a one-time survivorship-focused consultation with a nurse practitioner or physician. Annual or more frequent follow-up appointments are also available.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients. 

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including relationships and sexuality.
• Planning follow-up visits.

A survivorship care plan encourages patients to review the information with their health care team and become active participants in their follow-up care.

Penn also offers stomach cancer patients a number of support programs and groups to enhance their survivorship care plans.

Oncology Navigation Specialists

Every step of cancer treatment; from a cancer diagnosis, to surgery and treatment to forming a survivorship plan; comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about patient navigation specialists at the Abramson Cancer Center.

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Penn Medicine’s Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was designated a LIVESTRONG™ Survivorship Center of Excellence Network.  The Abramson Cancer Center is only one of eight LIVESTRONG centers in the United States, and is the only LIVESTRONG Survivorship Center of Excellence in the Philadelphia region. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Joan Karnell Cancer Center at Pennsylvania Hospital, provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

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Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center and Joan Karnell Cancer Center at Pennsylvania Hospital provide materials and host a wide range of activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Gastrointestinal Cancers is a day-long conference that addresses issues for patients with stomach cancer, as well as their loved ones.

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