Gastrointestinal Cancer Metastatic

Gastrointestinal cancer metastatic occurs when cancer that starts in the digestive system spreads to other parts of the body. The poor prognosis of gastrointestinal cancer is largely due to this spread of cancer cells, which is the biological hallmark of malignant tumors.

Table of contents

• What Is Gastrointestinal Cancer Metastatic?
• Where Gastrointestinal Cancer Spreads
• Symptoms
• Diagnosis
• Treatment Options
• Prognosis and Survival
• Coping with Advanced Cancer

What Is Gastrointestinal Cancer Metastatic?

Metastasis is a process in which cancer cells spread from the original site where they first formed to distant organs in the body^[1]. Gastrointestinal cancer metastatic refers to cancer that begins in the digestive system and then spreads to other body parts. This type of cancer can start in various organs including the stomach, esophagus, liver, pancreas, small intestine, or large intestine^[6].

When cancer spreads to another part of the body, doctors call it metastatic cancer or advanced cancer. It is also called stage 4 cancer^[3][4]. Sometimes cancer is advanced when it is first diagnosed. In other cases, the cancer comes back and spreads after treatment for the original cancer^[3].

Metastasis is considered to be a multistep process. Malignant tumor cells spread in stages from the original site to distant organs. The cancer cells must grow into nearby normal tissue, move through the walls of nearby lymph nodes or blood vessels, travel through the body’s systems, stop in small blood vessels at a distant location, and then grow in that new tissue until a tiny tumor forms^[4].

• Stomach
• Esophagus
• Liver
• Pancreas
• Small intestine
• Large intestine (colon)
• Gallbladder
• Bile ducts

Where Gastrointestinal Cancer Spreads

For cancers of the gastrointestinal tract, the most common places where cancer spreads are the liver, lymph nodes, the lining of the abdominal cavity (called the peritoneum), and then the lungs and other sites of the body^[1]. This spread, whether to a single location or multiple sites, is the major cause of gastrointestinal cancer-related deaths^[1].

Stomach cancer specifically can spread to the liver, lymph nodes, tissue lining the abdominal cavity, and lungs^[3][10]. Advanced stomach cancer means that a cancer that began in the stomach has spread to at least one other part of the body, such as the liver or lungs^[3][6].

When observed under a microscope and tested in other ways, metastatic cancer cells have features like those of the primary cancer and not like the cells in the place where the metastatic cancer is found. This is how doctors can tell that it is cancer that has spread from another part of the body^[4].

Symptoms

Metastatic cancer does not always cause symptoms. When symptoms do occur, what they are like and how often you have them will depend on the size and location of the metastatic tumors^[4].

The symptoms of advanced stomach cancer depend on what part of the body the cancer has spread to^[3]. Some common signs include:

• Indigestion or heartburn
• Abdominal bloating
• Nausea
• Loss of appetite
• Blood in the stool
• Vomiting
• Losing weight without trying
• Abdominal pain
• Jaundice (yellow eyes or skin)
• Ascites (abdominal fluid buildup)
• Problems swallowing^[5]

When cancer spreads to specific organs, it may cause particular symptoms. For example, stomach cancer that has spread to the liver may cause liver problems such as jaundice. Cancer that has spread to the bones may cause bone pain and fractures. Cancer that has spread to the bladder or bowels may cause problems such as blood in the urine, pain during urination or bowel movements, and blood in the stool^[5].

Some common signs of metastatic cancer in general include pain and fractures when cancer has spread to the bone, headache or seizures when cancer has spread to the brain, shortness of breath when cancer has spread to the lung, and jaundice or swelling in the belly when cancer has spread to the liver^[4].

Up to 7 out of 10 people (up to 70% of people) with advanced cancer have nausea and vomiting. Some people may have more than one cause of sickness, and it may not always be linked to the cancer itself^[16].

Diagnosis

A doctor will use a series of tests to diagnose metastatic gastrointestinal cancer. These typically include a physical examination to feel for masses or anything unusual and an examination of a person’s medical history, including family history^[5].

Doctors may order various tests including:

• Blood tests including complete blood count
• Upper endoscopy
• Barium swallow
• CT scan or PET scan
• Biopsy^[5]

The early diagnosis and effective treatment of gastrointestinal cancer metastasis is of vital importance, which may lead to substantial extension of life expectancy of gastrointestinal cancer patients^[1].

Treatment Options

Unfortunately, advanced cancer usually cannot be cured. But treatment might control it, help symptoms, and improve your quality of life for some time^[3]. Treatment for metastatic gastrointestinal cancer focuses on controlling the disease and managing symptoms.

Chemotherapy

Chemotherapy is usually offered for stage 4 or recurrent stomach cancer to help shrink the tumor and control the growth of the cancer. It may be given as a single drug or a combination of drugs^[14]. Palliative chemotherapy including fluoropyrimidine, platin compounds, docetaxel, and epirubicin prolongs survival and improves quality of life to a greater extent than best supportive care^[9].

Systemic chemotherapy is the mainstay treatment for metastatic gastrointestinal cancer, with a median overall survival of approximately 12 months for patients treated with conventional chemotherapy^[12].

Targeted Therapy

Targeted therapy may be given in combination with chemotherapy drugs^[14]. Several targeted agents have been developed and tested:

Trastuzumab (Herceptin and biosimilars) may be used with chemotherapy for stomach cancer that makes too much of the HER2 protein (called HER2-positive stomach cancer)^[14]. Trastuzumab was the first target drug developed, and pivotal phase III trials showed improved survival when trastuzumab was integrated into cisplatin/fluoropyrimidine-based chemotherapy in patients with metastatic gastric cancer^[9].

Trastuzumab deruxtecan (Enhurtu) may be used for HER2-positive stomach cancer after treatment with trastuzumab^[14]. Ramucirumab (Cyramza) may be used with paclitaxel or alone if chemotherapy drugs have stopped working^[14].

Immunotherapy

Nivolumab (Opdivo) may be used with chemotherapy to treat advanced or metastatic stomach cancer. Pembrolizumab (Keytruda) may be used with chemotherapy and trastuzumab to treat advanced or metastatic stomach cancer^[14]. Anti-programmed cell death 1 (PD-1) antibodies have demonstrated impressive efficacy and prolonged survival in untreated patients with microsatellite instability-high or mismatch repair deficient metastatic gastrointestinal cancer^[12].

Surgery

Surgery is sometimes offered for stage 4 or recurrent stomach cancer to relieve the symptoms of advanced cancer such as bleeding, blockage, or pain (called palliative surgery)^[14]. A subtotal gastrectomy may be done to remove the part of the stomach with the tumor. A stent (hollow metal or plastic tube) may be placed during surgery if a tumor is blocking the opening of the stomach. Surgery for a bowel obstruction may be done to remove or bypass the part of the intestine that is blocked^[14].

Radiation Therapy

External radiation therapy may be offered for stage 4 or recurrent stomach cancer. It is used alone or in combination with chemotherapy (called chemoradiation). It may be used to relieve the symptoms caused by advanced stomach cancer such as bleeding, pain, difficulty swallowing, or a blockage^[14].

Prognosis and Survival

The prognosis of patients with gastric cancer is related to tumor extent and includes both nodal involvement and direct tumor extension beyond the gastric wall^[10]. Most patients are unfortunately diagnosed at advanced stages with dismal prognoses due to the lack of distinguishing clinical indications^[12].

In localized distal gastric cancer, more than 50% of patients can be cured. However, early-stage disease accounts for only 10% to 20% of all cases diagnosed in the United States. The remaining patients present with metastatic disease in either regional or distant sites. The 5-year overall survival rate in these patients ranges from almost no survival for patients with disseminated disease to almost 50% survival for patients with localized distal gastric cancers confined to resectable regional disease^[10].

Although palliative chemotherapy has been demonstrated to improve survival and quality of life, the prognosis of patients with metastatic gastric cancer remains poor and responses to first-line chemotherapy are partial and varied^[9].

The evaluation of HER2 status in all patients with metastatic gastrointestinal adenocarcinoma should be considered, as classification based on molecular biomarkers such as programmed cell death ligand 1 (PD-L1), microsatellite instability (MSI), and human epidermal growth factor receptor 2 (HER2) provides an opportunity to differentiate patients who may benefit from immunotherapy or targeted therapy^[12].

Coping with Advanced Cancer

Emotional Impact

Finding out that you cannot be cured is distressing and can be a shock. It is common to feel uncertain and anxious. It is normal to not be able to think about anything else^[3]. Lots of information and support is available to you, your family, and friends^[3].

Some people find it helpful to find out more about their cancer and the treatments they might have. Many people find that knowing more about their situation can make it easier to cope. Talk to your doctor or specialist nurse to understand what your diagnosis means, what is likely to happen, what treatment is available, how treatment can help you, and what the side effects of the treatment are^[3].

You might feel that you do not want to know much information straight away. Tell your doctor or nurse. You will always be able to ask for more information when you are ready. Everyone is different and there is no right way to feel^[3].

Support and Resources

Your friends and relatives might be able to support you and talk to you about your cancer. Sharing can help to increase trust and support between you and make it easier to plan ahead. But some families are scared of the emotions this could bring up, so they may not want to discuss it^[17].

You can help your family and friends by letting them know you would like to discuss what is happening and how you feel. You might find it easier to talk to someone outside your own friends and family. Counseling might help you find ways of coping with your feelings and emotions^[17].

Multidisciplinary Care

The often-rapid progression of unresectable gastrointestinal cancer and the associated malnutrition have a significant impact on the patient’s quality of life and ability to tolerate treatment. A multidisciplinary approach including early access to registered dietitians, personal support networks, and palliative care services is needed to optimize possible outcomes for patients^[18].

Managing Symptoms

It is not always possible to cure advanced cancer, but even if your cancer cannot be cured, treatment is available to control your symptoms, such as sickness^[16]. Community cancer nurses or symptom control nurses can help to support you at home^[17].

If you cannot have or do not want cancer treatment, you may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments do not work anymore, they are not likely to improve your condition, or they may cause side effects that are hard to cope with. Talk to your healthcare team. They can help you^[14].