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- Stomach cancer is also highly fatal, so delays in diagnosis worsen the outcome. This delay can be attributed to poor awareness regarding this form of cancer.
- As the symptoms that first present point to indigestion, a high index of suspicion is required to diagnose stomach cancer at an early stage, even among high-risk patients.
- Tobacco and alcohol abuse in particular have made India’s northeast one of the world’s most stomach-cancer-dense regions.
- Stomach cancer is more common among males, so it typically affects the breadwinners of families. Together with high out-of-pocket expenses, this pushes families into poverty.
After suffering from heartburn and indigestion for nearly four months, a 52-year-old labourer from West Bengal visited the Christian Medical College (CMC), Vellore, in 2020 for further care. He had seen multiple doctors and all of them had attributed his symptoms to his dietary habits.
Every time he saw a different doctor, he would be prescribed a different antacid.
He had tried everything – tablets, syrups, different diets. But his symptoms kept worsening, and now, at CMC, he was complaining of fatigue and loss of appetite.
Having previously seen a similar presentation of patients, I feared I knew what was going on. I ordered a few tests and confirmed my suspicion: advanced stage stomach cancer.
The incidence of gut-related cancers has progressively increased in India. Stomach cancer is one of the more common cancers in India, and is nearly twice as prevalent in males as in females. With nearly 50,000 new cases every year, stomach cancer is also associated with a high fraction of cancer-related deaths in the country.
The National Cancer Registry Programme reported in 2020 that 1 in 160 Indians (0.6%) is at risk of developing stomach cancer in their lifetimes, with most of them being diagnosed at an advanced stage.
Stomach cancer is also highly fatal, so delays in diagnosis worsen the outcome. This delay can be attributed to poor awareness regarding this form of cancer – among both the general public and among healthcare workers at the primary level, thanks in part to the relatively innocuous nature of the early symptoms.
Specifically, as the symptoms that first present point to indigestion, a high index of suspicion is required to diagnose stomach cancer at an early stage, even among high-risk patients.
The early symptoms are non-specific, and are often attributed to acidity or gas. They typically include heartburn, indigestion, abdominal discomfort, unintentional loss of weight, loss of appetite, fatigue, feeling immediately full after eating and/or nausea. In the advanced stage, more ominous symptoms set in: vomiting with or without blood, black coloured stools and/or jaundice.
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Fewer than 20% of patients in India present with an early-stage disease because the corresponding early symptoms are mostly managed by patients themselves or by the local physician, using over-the-counter medicines.
Once alarming symptoms, like excessive weight loss, blood in stools or vomitus, develop, it is often too late to attempt treatment with a curative intent and the patient’s health declines rapidly – so much so that a significant number are unfit to even start any treatment for the cancer.
The aforementioned symptoms in a patient with risk factors should raise the suspicion of stomach cancer. Tests to look for low haemoglobin count and small amounts of blood in stools constitute the initial steps of evaluation. Doctors must refer patients with an abnormal initial evaluation to higher centres, in timely manner, for further assessment. At these centres, a gastroscopy can be performed to make the diagnosis.
Overall, timeliness is paramount for early diagnosis and subsequent treatment of this disease. Ignoring these subtle findings early can lead to an oft-fatal delay in diagnosis.
In the early 1900s, researchers had identified an infection caused by a bacterium called Helicobacter pylori as a risk factor for stomach cancer. But the prompt treatment of this infection, including with antibiotics, can protect against gastric cancer. Unhealthy lifestyle choices have now taken over as the main risk factor for gastric cancer.
Tobacco and alcohol abuse in particular have made India’s northeast one of the world’s most stomach-cancer-dense regions. Obesity, diets low in fruits and vegetables and high in spices, and the consumption of hot foods have also been identified as independent risk factors for stomach cancer. They are considered to be controllable, and doing so can prevent stomach cancer to some extent.
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Uncontrollable factors – like family history of stomach cancer, blood group type A and certain genetic disorders – also predispose individuals to higher risk.
The high out-of-pocket expenses (non-medical and medical) also impose a heavy financial burden on families of care-seeking persons. Stomach cancer is more common among males, so it typically affects the breadwinners. So families that are barely eking out a living tend to end up with large medical bills, and eventually fall into poverty.
Indeed, medical bills push nearly 55 million Indians below the poverty line every year. So identifying stomach cancer early, and in a potentially curable stage, is paramount.
To make sure that this happens, we need reforms at multiple levels of the healthcare system – from primary care to policymaking. First, healthcare workers at the primary level need adequate training, both in the community and in hospitals, to recognise the early symptoms of stomach cancer.
Second, primary health centre doctors need to be equipped with the skills to perform gastroscopy, which help in the early diagnosis of cancer.
Third, we can use advancements in the field of telemedicine to assess gastroscopic images from remote areas, with the help of a gastroenterologist, to increase diagnostic sensitivity.
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Under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, there is an unmet need for awareness camps that spread knowledge of stomach cancer. This programme is currently limited to free screening for oral and breast cancer. It could be extended to include stomach cancer in high-incidence regions like Northeast India.
Finally, improving cancer care by improving infrastructure and human resources could reduce the financial and geographical inequalities in cancer care. Patients in India frequently travel great distances, even within their own states of origin, for basic cancer treatment.
Inaugurating more tertiary-level regional cancer centres in various states, including in the northeast, is in this regard a step in the right direction. Similarly, with better knowledge and patient-centred care, it will be possible to address this silent epidemic of cancer.
Dr Parth Sharma is a researcher, The Lancet Citizens’ Commission on Reimagining India’s Health System, and an intern, Association for Socially Applicable Research (ASAR), Pune. Dr Anjana Joel is associate professor, Department of Medical Oncology, Christian Medical College, Vellore.