Published on 29 October 2021

    While stomach cancer rates are falling, many cases are being diagnosed at the later stages. A new approach to treatment may be able to improve the outcomes for advanced cancer, with reduced side effects of chemotherapy drugs.

    A new minimally invasive approach to treat advanced stomach cancer is improving the outcomes for stomach – and other abdominal – cancers in a targeted procedure that delivers cancer drugs more effectively and with fewer downsides.

    Current challenges in stomach cancer treatment

    For a long time, chemotherapy has been a mainstay of cancer treatment. While these drugs – typically given via drips or tablets – are largely effective in killing cancer cells, they work in a systemic fashion. That is to say, the treatment is absorbed into the bloodstream and affects the body as a whole. This is why conventional chemotherapy is commonly associated with many toxicity-related side effects, such as nausea, low white blood cell count (neutropenia), fatigue and many other symptoms.

    And while chemotherapy is effective in the treatment of many cancers, it is not always the case for some cancers; such as stomach cancer. Asst Prof Kim Guowei, Consultant, General Surgery (Upper Gastrointestinal Surgery), National University Hospital (NUH) and Surgical Oncology, National University Cancer Institute, Singapore (NCIS), explained that early-stage stomach cancer, where the cancer is limited to the stomach, has a good chance of cure when endoscopy or surgery is performed to remove the cancer.

    Surgery is typically minimally invasive and uses small incisions or 'keyholes’ to access the cancer. “This helps to improve outcomes, minimise complications and hasten recovery,” said Asst Prof Kim. An even newer technique done at NUH is robotic keyhole surgery.

    For late stage stomach cancer that has spread to the peritoneal cavity (the membrane that lines the abdominal cavity and covers the abdominal organs), treatment is more complicated and involves chemotherapy. However, Asst Prof Kim pointed out that “The blood supply to tumour cells on the peritoneum is not great. This results in poor penetration of these systemic chemotherapy drugs into the cancer cells, reducing their efficacy.”

    A more targeted approach

    In a move to improve the efficacy of chemotherapy for stomach cancer, NCIS has introduced the Pressurised Intraperitoneal Aerosol Chemotherapy (PIPAC) method. According to Asst Prof Kim, this method delivers chemotherapy in the form of an aerosol as a mist directly into the peritoneum cavity via a small port made in the abdomen.

    The patient’s own peritoneal cavity thus acts as an 'aerosol chamber', Asst Prof Kim elaborated. “Aerosolised chemotherapy is directed administered into this 'chamber' where cancer cells have metastasised to.” This allows the drug to disperse more evenly and deeply into the cancer cells for greater efficacy. Importantly for patients, this technique means that much less chemotherapy drugs are absorbed into the bloodstream, so there are fewer side effects compared with conventional treatment. The treatment can also be used for other abdominal cancers, such as colorectal and ovarian cancers.

    Asst Prof Kim added that another benefit of PIPAC is that it allows for regular assessments of the peritoneal cavity for response to the treatment. “CT scans and other imaging techniques used to monitor response to conventional treatment are notoriously inaccurate,” he shared. Going forward – and based on promising results from both local and international trials – NCIS hopes to expand the use of PIPAC to more patients.

    This novel new technique adds to the suite of multidisciplinary care programmes at NCIS that are aimed at improving the disease outcomes, including understanding the genomic basis of the cancer and offering patient support.

    Stomach cancer facts

    • Stomach cancer is the 5th and 6th cause of cancer death for males and females respectively, in Singapore

    • Over 50% of stomach cancers are diagnosed late, at Stages III (21.1%) and IV (37.1%), while 28.3% and 13.5% are detected at Stage I and II, respectively

    • Stomach cancer risks include: 

      • Family history of stomach cancer

      • Obesity

      • Gastroesophageal reflux disease

      • A history of Helicobacter Pylori infection 

      • Previous history of stomach lymphoma and stomach polyps

      • Long-term stomach inflammation (chronic gastritis)

      • A diet high in salty and smoked foods

      • A diet low in fruits and vegetables

      • Smoking

    Look out for “red-flag” symptoms such as:

    • Pain or discomfort in the upper abdomen

    • Black stools

    • Vomiting 

    • Loss of weight and/or appetite

    If you experience any more than a few of these symptoms and have risk factors associated with stomach cancer, do speak to your doctor to assess whether gastroscopy is right for you. This is a safe and short procedure uses a flexible tube with a camera to look inside the oesophagus, stomach and part of the small intestine to detect early cancer and pre-cancerous changes. 

    In consultation with Asst Prof Kim Guowei, Consultant, General Surgery (Upper Gastrointestinal Surgery), NUH and Surgical Oncology, NCIS.

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