Visibility of gastric cancer awareness programs

International Journal of Community Medicine and Public Health Hange N et al. Int J Community Med Public Health. 2021 Sep;8(9):4605-4610 http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20213573

Review Article

Visibility of gastric cancer awareness programs

Namrata Hange1*, Manoj Reddy Somagutta2, Sai Harsha Bobba3, Narayana Reddy Bathula2,

Erkan Batti3, Obumneme Jude Iloeje4, Klodin Ghazarian5, Gouthami Sajjanagandla6,

Ulhas Vasave1, Bernard Emuze7

1Eurasian Cancer Research Council (ECRC), Chembur, Mumbai, Maharashtra, India 2Department of Medicine, Avalon University School of Medicine, Willemstad, Curacao 3Department of Medicine, Washington University of health and science, Jade Street, San Pedro Belize 4Department of Medicine, University of Health Sciences, Antigua 5Department of Medicine, Avalon University School of Medicine, Churchill Hubbard Road, Youngstown, OH, United States 6China Medical School, Shenbei, Shenyang, Liaoning, China 7Department of Medicine, St. James School of Medicine, Park Ridge, U.S.A Received: 24 June 2021 Revised: 20 July 2021 Accepted: 03 August 2021 *Correspondence: Dr. Namrata Hange, E-mail: namratah3@yahoo.co.in Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT Gastric cancer is one of the most common and deadliest cancers known globally. Due to historically low survival rates and available few treatment modalities, especially in developing nations with high burden incidence of gastric cancers, reducing incidence seems to be the key to reducing mortality. This article has emphasized the planning and visibility of the gastric cancer awareness program. The gastric cancer awareness programs shall help people approach health care facilities if reported to be symptomatic and help to reduce the mortality burden through early detection and access to treatment. Stomach cancer awareness programs involve sensitization of the population regarding symptom recognition, screening, identification of vulnerable people, and preventive measures focused on disease control. Recognition of people at risk, symptom screening protocol along with prevention, and management of gastric cancer is meant to achieve this Gastric cancer control strategy. Gastric cancer awareness campaign, along with identification of risk factors, shall include prevention, early detection, and potential gastric cancer treatments through appropriate programs and activities. Targeting high-risk populations including males, aged more than 40 years, smokers, obese, alcoholic, red-meat eaters, population with low socioeconomic status, and people with a positive family history of gastric cancer along for health education shall be directed towards the annual gastric cancer screening programme either free or subsidized rate. Holistic gastric cancer awareness programs encompass the integrated lifestyle modification approach-addressing a healthy balanced diet; de-addiction for smoking and alcohol and stress-free life. Specific local, country-specific strategies tailored to each country's risk factor profile shall be considered while planning a gastric cancer awareness program. Keywords: Stomach cancer, Awareness, Programs, Treatment, Gastric cancer

International Journal of Community Medicine and Public Health | September 2021 | Vol 8 | Issue 9 Page 4605

Hange N et al. Int J Community Med Public Health. 2021 Sep;8(9):4605-4610

INTRODUCTION

Globally, gastric cancer is a silent public health calamity with poor survival, possibly because of late diagnosis making it tough to get cured.1,2 It is one of the death- dealing cancers, the fourth leading cause of cancer death worldwide despite progress in medical and surgical treatments of gastric cancers.3,4 Related incidence and mortality of stomach cancer are remarkably fluctuating, mostly secondary to dietary changes and a history of Helicobacter pylori infection.2,3,5 Radical gastrectomy is the only curative treatment of gastric cancer, specifically at early stages with common recurrences.4,5-8 Early diagnosis of gastric cancer may be achievable through screening of the high-risk population.6 This is possible in Japan and Korea, where gastric cancer screening has been conducted regularly.6-8 For these patients, systemic chemotherapy is the mainstay of treatment when diagnosed in later phases. Considering limited treatment options for a curve in advanced stages of gastric cancer leading to poor prognosis; a decline in incident cases through early detection seems a total solution to tackle the burden of mortality.4-6 Still, awareness of gastric cancer is horrifyingly flat. Thus, this review tries to address the planning and visibility of stomach cancer awareness programs.

DISCUSSION

Epidemiology of gastric cancer

Despite declining incidence globally, gastric cancer is one of the sixth most common cancers, with 1.09 million incident cases globally (5.6% amongst all cancers).9 About 1 in 13 of all cancer-related deaths is attributable to gastric cancers.9 It has proved to be the most lethal cancer with 769 000 deaths with 7.7% cancer deaths.9-10 These cancers are more generally diagnosed in developed nations. About 70% of cancer cases occur in the least developed countries, with more than half in East Asia particularly, Mongolia, Japan, South Korea, and China.8,10-11 Despite gastric cancer frequently diagnosed in developed nations, this has been reported as the leading cause of cancer death in several South-Central Asian countries, including Iran, Afghanistan, Turkmenistan, and Kyrgyzstan.8-11 Gastric cancer is more prevalent in males. The male to female ratio of stomach cancer is 2.2 in developed countries, while 1.83 in developing countries.11-13 Even the mortality from gastric cancer is higher among males.4-6,9 The average five-year survival rate for gastric cancer varies from 19% (United Kingdom)-31% (United States).13,14 These survival rates have gradually heightened over the past few decades, with medication innovations contributing to earlier detection and better treatment options. This has been translated from the five-year survival rate ranging from 18% for stage IIIC tumours treated with surgery while 94% and 88% for stage IA and IB tumours treated with surgery, respectively.5,9,10

Gastric cancer cinico-pathology

Out of all cancers of the stomach, 95% are adenocarcinoma, followed by primary gastric lymphoma. Gastric cancer refers to tumours of the stomach that arise from the gastric mucosa (adenocarcinoma), the connective tissue of the gastric wall (gastrointestinal stromal tumours), neuroendocrine tissue (carcinoid tumours), or lymphoid tissue (lymphomas). This adenocarcinoma can be classified according to two topographical sub-sites, the cardia (upper stomach) and non-cardiac (lower stomach). Histologically, well- differentiated noted to have the highest incidence in older adults and better prognosis while undifferentiated noted to have in young populations.10,15,16 Gastric cancer is an inflammation-associated malignancy triggered when cells in the stomach lining start to develop uncontrollably. This infection, directly and indirectly, causes progressive genetic damage to the gastric epithelium that may eventually lead to gastric adenocarcinoma. Deregulation of proliferation/stem cells, NF-kappaβ, and Wnt/beta- catenin pathways have been identified as oncogenic pathways in most gastric cancers.17 Gastric cancers evolve the combined effect of existing genetic susceptibility, H. pylori infection, lifestyle changes inclusive of diet and addiction and few environmental factors.18 Often patients present with late reporting of signs and symptoms when the disease is already in advanced stages.12,19 In the early stages, stomach cancer with possibly few or nil symptoms makes early detection difficult. One tricky diagnosis, most of the people, retrospectively felt symptoms, but these vague symptoms can be confused with many other benign gastrointestinal disorders. An unexpected loss of weight, appetite plummets, exhaustion, bloating, altered bowel habit, gastrointestinal (GI) bleeding (Melena, hematochezia, hematemesis), gastroesophageal reflux and Prolonged nausea, abdominal discomfort are presenting symptoms of stomach cancer in most stomach cancer cases.6,11,18,20,21 Overall, symptoms of new-onset dyspepsia (in patients aged >55 years), family history of upper gastrointestinal cancer, unintended weight loss, upper or lower gastrointestinal bleeding, progressive dysphagia, odynophagia, unexplained iron deficiency anaemia, persistent vomiting, palpable mass or lymphadenopathy, jaundice has been reported red flags for suggestive of gastric cancer.4,11,21-22

Vulnerabilities and risk of gastric cancer

Identifying risk factors and high-risk groups is of utmost importance for creating awareness and screening programs. The epidemiological triad of stomach cancer causation has been explained in Figure 1 below to specify risk and vulnerabilities. Gastric cancer is known to be prevalent in males. Despite these can occur in the young population, most people get diagnosed in the 60-70s, with increased incidence after 40s.6,12,19-22 Long-term infection with Helicobacter pylori (H. pylori) bacteria has been reported as a major cause of gastric cancer, especially in

International Journal of Community Medicine and Public Health | September 2021 | Vol 8 | Issue 9 Page 4606

Hange N et al. Int J Community Med Public Health. 2021 Sep;8(9):4605-4610

the lower (distal) part of the stomach. Family history is one of the risk factors for stomach cancer. The risk of stomach cancer is increased at least 1.5 times in first- degree relatives, including siblings or offspring of patients with stomach cancer.22A global attributable fraction of more than 85% for H. pylori in gastric cancer directly translates to the need to eliminate H. pylori for the prevention of gastric cancer.4,5,10,23,24 Epstein-Barr virus (EBV) is found in the cancer cells of about 5% to 10% of people with stomach cancer, although nil direct association has been established with stomach cancer.10,25,26 The high-risk population for gastric cancer involves patients above age 50 or above, atrophic gastritis patients, patients with pernicious anaemia, ethnic populations with a high incidence rate of gastric carcinoma and patients with a condition such as sporadic gastric adenomas, menetrier disease, familial adenomatous polyposis, or hereditary non-polyposis colon cancer.2,3,6,10,18,19,26,27

Figure 1: Epidemiological triad of gastric cancer.

There is strong evidence of association of stomach cancer with greater body fatness, smoking, and consumption of alcoholic drinks. There is some evidence that consumption of preserved food by salting; processed, grilled, or charcoaled meats and low consumption of fruit might increase the risk of stomach cancer. Consumption of citrus fruit and raw vegetables appears to protect against the risk of stomach cancers.2,6,10,12,16,18,19 These entities differ in terms of risk factors, carcinogenesis, and geographical, ethnic, and socioeconomic differences in distribution. Improved socioeconomic status, hygienic practices, and widespread antibiotics leading to a decrease in infection rates have helped reduce the incidence of gastric cancer.28 A positive correlation was found between increased stomach cancer risk and several occupations with exposure to dusty and high-temperature

environments, including cooking, wood processing, coal industry, mining, farming, refining, and fishing, as well as in workers processing rubber, timber, and asbestos.30,31

Screening of gastric cancer

People with these symptoms suggestive of stomach cancer shall be considered for further workup. Despite nil standard or routine screening tests for stomach cancer, several screening tests have been studied to find stomach cancer at an early stage. Along with non-invasive tests, including H-pylori serology, Serum-pepsinogen test, Gastrin-17 helps predict gastric-cancer development and can be used as the first level of screening.31,32 Invasive tests such as contrast radiography such as photofluorography, upper-gastrointestinal endoscopy, and upper gastrointestinal (UGI) series are recommended for screening gastric cancer in high risk or symptomatic patients.33,34 In most high-risk countries, Japan and Korea, gastric cancer screening is conducted annually for all residents aged 40 and older with upper gastrointestinal (UGI) series.34-36 Gastroscopy possible with biopsy will be helpful in confirmation of gastric cancer diagnosis.33,34,36 British consensus guidelines recommended diagnostics of stomach cancer involving endoscopic visualization of a mass followed by histological confirmation with biopsy.5,36-38

Prevention and management of gastric cancer

GC is a malignant disease with a generally poor long- term prognosis.5,38 Surgical resection, including subtotal or total gastrectomy enhanced by standardized lymphadenectomy, remains the gold standard in gastric cancer therapy.39-41 Subtotal or total gastrectomy with radical lymph node dissection, adjuvant chemo- radiotherapy or perioperative chemotherapy, Neoadjuvant therapy represents potentially curative treatment options for gastric cancer.41,42 Due to historically low survival rates and few treatment options, especially in developing nations, reducing incidence seems to be the key to reducing mortality. Gastric cancer is one of the major preventable cancers and is influenced by lifestyle changes and behaviour. Gastric cancer is treatable and potentially curable if diagnosed in early phases.2,3,6,11,12,27,43 The steady decline in gastric cancer Incidence globally over half a century preceded the significant decrease of H. pylori infection and possibly attributable alternation in food and meat processing and preservation.4,5,44 Eradication of H. pylori reduces the risk of gastric cancer in infected subjects and reduces the risk of metachronous gastric cancer after resection of early gastric cancer.23,24,31,42-44 The level of prevention for gastric cancer discussed in the following Table 1.

International Journal of Community Medicine and Public Health | September 2021 | Vol 8 | Issue 9 Page 4607

Hange N et al. Int J Community Med Public Health. 2021 Sep;8(9):4605-4610

Table 1: Level of prevention in gastric cancer.2,6,45-47

Outline Gastric Cancer Awareness Campaign

4. Screening of

1.Sym

Unexpecte plummets, altered bo (GI) bleedi hematoche gastroesop Prolonged discomfort

ng for

2. Identific population

Population infection, obese, smoker, red meat eater, alcoholic, and low socioeconomic status

Consume more fresh fruits & vegetables Reduce intake of salted & smoked foods Tobacco Control

Figure 2: Gastric cancer awareness programme.

Awareness campaign

November is gastric cancer awareness month. A soft, powdery-blue ribbon is a sign of support for those living with stomach or gastric cancer. This awareness campaign focuses on motivating populations with concerns to visit their doctor as early as possible. This awareness month and raising awareness shall support efforts to educate people about stomach cancer, including risk factors, prevention, early detection, and potential stomach cancer treatments through appropriate programs and activities.2,3,5,6,10 This outline of awareness campaign has been described in Figure 2. Main target audience for awareness includes the general population with particular emphasis on high-risk patients, patients with a family history of gastric cancer, patients with precancerous

lesions. These shall flag off high-risk populations such as males, aged more than 40 years, smokers, obese, alcoholic, red-meat eater, population with low socioeconomic status, and people with a positive family history of gastric cancer.2,3,5,7-12,46 Gastric Cancer awareness campaign focuses on imparting knowledge regarding symptoms identification, screening of suspects/symptomatic, vulnerable population and recommendation for prevention of gastric cancers.47-49 Risk modification involves consuming fresh vegetables and fruits, reducing salted and smoked foods, avoiding preservative life; addiction focused on smoking cessation and quitting liquor/ alcohol 3, 6,8,10,12.

CONCLUSION

Due to the increased incidence and lethality of stomach cancer, the population shall be cognizant of gastric cancer symptoms, especially in high prevalence countries like East Asian countries. Cancer awareness programs emphasize the integrated lifestyle modification approach, addressing a healthy diet, de-addiction and stress-free life. Several elements like symptom sensitization, recognizing the population at risk, and screening for symptomatic and preventive measures to the awareness programs have added benefits. All East-Asian governments shall consider promoting awareness and targeted screening programs a priority. Locality and specific strategies tailored to each country's risk factor profile shall be deemed while planning a stomach cancer awareness program.

Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required

International Journal of Community Medicine and Public Health | September 2021 | Vol 8 | Issue 9 Page 4608

Hange N et al. Int J Community Med Public Health. 2021 Sep;8(9):4605-4610

REFERENCES

1. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64:9-29. 2. World Cancer Research Fund International/American Institute for Cancer Research. Continuous Update Project Report: Diet, Nutrition, Physical Activity and Stomach Cancer. 2016. 3. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M et al. Global cancer observatory: International Agency for Research on Cancer. 2020. 4. Balakrishnan M, George R, Sharma A, Graham DY. Changing trends in stomach cancer throughout the world. Current gastroenterology reports. 2017;19(8):1-0. 5. Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of oncology. 2016;27:v38-49. 6. Lin JT. Screening of gastric cancer: who, when, and how. Clin Gastroenterol Hepatol. 2014;12(1):135-8. 7. Suh YS, Lee J, Woo H, Shin D, Kong SH, Lee HJ et al. National cancer screening program for gastric cancer in Korea: Nationwide treatment benefit and cost. Cancer. 2020;126(9):1929-39. 8. Leung WK, Wu MS, Kakugawa Y, Kim JJ, Yeoh KG, Goh KL et al. Screening for gastric cancer in Asia: current evidence and practice. Lancet oncol. 2008;9(3):279-87. 9. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer. J clin. 2021;71(3):209-49. 10. World Cancer Research Fund International/American Institute for Cancer Research. Continuous Update Project Report: Diet, Nutrition, Physical Activity and Stomach Cancer. 2016. 11. Karimi P, Islami F, Anandasabapathy S, Freedman ND, Kamangar F. Gastric cancer: descriptive epidemiology, risk factors, screening, and prevention. Cancer Epidemiol Prevention Biomarkers. 20141;23(5):700-13. 12. Rawla P, Barsouk A. Epidemiology of gastric cancer: global trends, risk factors and prevention. Prz Gastroenterol. 2019;14(1):26-38. 13. Howlader NN, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF et al. SEER cancer statistics review, 1975-2012. National Cancer Institute. 2014. 14. Cancer Research UK, Stomach Cancer Survival in UK compared to US Available at: https://www.cancerresearchuk.org/health- professional/cancer-statistics/statistics-by-cancer- type/stomach-cancer/survival#heading-Four. Accessed on 13 June 2021. 15. Mukaisho K, Nakayama T, Hagiwara T, Hattori T, Sugihara H. Two distinct aetiologies of gastric cardia adenocarcinoma: interactions among pH, Helicobacter pylori, and bile acids. Front Microbiol. 2015;6:412.

16. Chon HJ, Hyung WJ, Kim C, Park S, Kim JH, Park CH et al. Differential Prognostic Implications of Gastric Signet Ring Cell Carcinoma: Stage Adjusted Analysis from a Single High-volume Center in Asia. Ann Surg. 2017;265(5):946-53. 17. Ooi CH, Ivanova T, Wu J, Lee M, Tan IB, Tao J et al. Oncogenic pathway combinations predict clinical prognosis in gastric cancer. PLoS genetics. 2009;5(10):e1000676. 18. Berger H, Marques MS, Zietlow R, Meyer TF, Machado JC, Figueiredo C. Gastric cancer pathogenesis. Helicobacter. 2016;21:34-8. 19. Mohandas KM, Jagannath P. Epidemiology of digestive tract cancers in India. VI. Projected burden in the new millennium and the need for primary prevention. Indian J Gastroenterol. 2000;19(2):74-8. 20. Yufen Lín MS, Bailey Jr DE. Common and co- occurring symptoms experienced by patients with gastric cancer. In Oncology nursing forum. 2020;47(2):187-202. 21. Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129:1756-80. 22. La Vecchia C, Negri E, Franceschi S, Gentile A. Family history and the risk of stomach and colorectal cancer. Cancer 1992;70:50-55. 23. Eslick GD. Helicobacter pylori infection causes gastric cancer A? review of the epidemiological, meta-analytic, and experimental evidence. World j gastroenterol. 2006;12(19):2991. 24. Take S, Mizuno M, Ishiki K, Nagahara Y, Yoshida T, Yokota K et al. The effect of eradicating Helicobacter pylori on the development of gastric cancer in patients with peptic ulcer disease. Am J Gastroenterol. 2005;100(5):1037-42. 25. Lee JH, Kim SH, Han SH, An JS, Lee ES, Kim YS. Clinicopathological and molecular characteristics of Epstein–Barr virus‐associated gastric carcinoma: A meta‐analysis. J gastroenterol hepatol. 2009;24(3):354-65. 26. Quach DT, Hiyama T, Gotoda T. Identifying high- risk individuals for gastric cancer surveillance from western and eastern perspectives: Lessons to learn and possibility to develop an integrated approach for daily practice. World j gastroenterol. 2019;25(27):3546-62. 27. Moss SF, Shirin HA. Epidemiology and molecular epidemiology of gastric cancer. Gastrointestinal oncolo. 2004. 28. Etemadi A, Safiri S, Sepanlou SG, Ikuta K, Bisignano C, Shakeri R et al. The global, regional, and national burden of stomach cancer in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease study 2017. Lancet Gastroenterol Hepatol. 2020;5(1):42-54. 29. Santibañez M, Alguacil J, de la Hera MG, Navarrete- Muñoz EM, Llorca J, Aragonés N et al. Occupational exposures and risk of stomach cancer by histological