Stomach Cancer

At a glance

Gastric cancer (stomach cancer) is a malignant tumor that forms in the stomach.
It is the fifth most common cancer in Korea, and the third most common when only men are counted.

Gastric cancer is usually talked about in two broad types.

• Early gastric cancer — the cancer is only in the shallow layers of the stomach wall (the mucosa and submucosa)
• Advanced gastric cancer — the cancer has grown deep into the stomach wall, or has spread elsewhere

This split matters because the treatment is completely different.
Early gastric cancer can sometimes be removed with an endoscope alone, without opening the abdomen,
while for advanced gastric cancer, cutting out part of the stomach in surgery is the basic approach.

Why screening matters

Gastric cancer, too, often causes no particular symptoms in the early stage.
By the time symptoms are felt and people go to hospital, it has quite often already advanced.

Because gastric cancer is common in Korea, the government supports gastroscopy screening.
Even with no symptoms, it is good to have it once you reach the eligible age.

This page is reference information summarised from official sources.
Always talk to a medical professional about diagnosis and treatment.

If changes like the ones below continue, see a doctor.
These are the common symptoms of gastric cancer listed by the National Cancer Information Center (국가암정보센터).

• Heartburn
• Nausea and vomiting
• Abdominal pain (especially discomfort around the pit of the stomach)
• Trouble swallowing food (dysphagia)
• Weight loss
• Tiredness and dizziness
• Diarrhea
• Black, sticky stools (melena)

Signs that need to be seen sooner

• Black stools or vomiting blood — this can mean there is bleeding in the stomach
• A feeling that food gets stuck that keeps getting worse
• Losing weight for no reason

These symptoms also come often from other causes, such as gastritis or a stomach ulcer.
Having symptoms does not mean cancer, and having none is not a reason to feel safe either.
Only tests can tell.

Have a test even without symptoms if this is you

These are the cases the National Cancer Information Center lists as high risk for gastric cancer.

• People with a Helicobacter pylori infection
• People diagnosed with chronic atrophic gastritis or intestinal metaplasia
• People who have had stomach surgery
• People with a family member who has had gastric cancer
• People who often eat salty, burnt or smoked food, or who smoke or drink

Where to go first

If you have symptoms, or a screening test found something, start at gastroenterology (소화기내과).
Anywhere that does gastroscopy can test you, including a local clinic.

After the diagnosis

• Gastroenterology — handles removing early gastric cancer with an endoscope (ESD and the like)
• Gastrointestinal surgery (위장관외과) / general surgery (외과) — when surgery to cut out part of the stomach is needed
• Hematology-oncology (혈액종양내과) — when you have chemotherapy
• Radiation oncology (방사선종양학과) — when radiation therapy is needed (rare in gastric cancer)

Because gastric cancer splits into cases that end with an endoscopy and cases that need surgery,
which department takes the lead is settled only once the biopsy and stage test results are in.

Do I have to go to a large hospital?

If cancer is confirmed or strongly suspected, you will be sent to a general hospital or a tertiary hospital.
A tertiary hospital needs a referral letter (진료의뢰서) for national health insurance (건강보험) to apply,
so it is best to get the referral from the local clinic or hospital where you were tested.

If you take your endoscopy images and biopsy report along with it,
the large hospital can sometimes avoid repeating the same tests.

You can look for local clinics and large hospitals together on the map.

The screening stage

In the national cancer screening program (국가암검진), gastric cancer is checked with gastroscopy.
When endoscopy is difficult, an upper gastrointestinal series (a barium X-ray) is used in selected cases.

The National Cancer Information Center (국가암정보센터) recommends gastroscopy at least every 2 years for men and women aged 40 and over but under 74.
If you have chronic atrophic gastritis or intestinal metaplasia, you may need it more often.

Changes to the eligible ages and test methods of the national cancer screening program are under discussion.
To check whether you are eligible this year and which test you get, see
the National Health Insurance Service (국민건강보험공단).

The diagnosis stage

• Gastroscopy with a biopsy — the inside of the stomach is looked at directly and tissue is taken from any suspicious area. The biopsy is what finally confirms whether it is cancer.
• Endoscopic ultrasound — shows how deep the cancer has grown into the stomach wall. This matters when deciding whether it can be removed with an endoscope.
• Abdominal CT — checks whether it has spread to nearby lymph nodes and other organs.
• Chest CT — checks for spread to the lungs.
• Liver MRI and PET — done in addition when needed.

If the biopsy confirms cancer, the tests above are used to set the stage and decide the treatment.

Treatment for gastric cancer depends on how deep the cancer has grown into the stomach wall, where it is, and whether it has spread.

Endoscopic treatment (early gastric cancer)

Endoscopic submucosal dissection (ESD) cuts the cancer out with an endoscope alone, without opening the abdomen.
The National Cancer Information Center (국가암정보센터) says it can be done when the cancer is 2cm or smaller and the cells are well differentiated.
It needs no general anaesthesia, and the healthy stomach can be kept as it is. The procedure usually takes 30 to 60 minutes.

Whether it can be removed with an endoscope is judged by the medical team from the test results.
Sometimes surgery is needed after all, once the removed tissue has been examined.

Surgery

Part of the stomach is cut out and the nearby lymph nodes are removed with it. How much is removed depends on where the cancer is and how far it reaches.

• Subtotal gastrectomy — for cancer in the lower part of the stomach. The upper stomach is left and joined to the duodenum or the jejunum.
• Total gastrectomy — when cancer has spread through the whole stomach, or sits in the upper stomach. The esophagus is joined to the jejunum.
• Proximal gastrectomy — only the upper part of the stomach is removed.
• Combined resection — when the cancer has invaded nearby organs, those organs are removed as well.

Surgery is chosen from open surgery, laparoscopic surgery and robotic surgery.

Chemotherapy

• Adjuvant chemotherapy — given after surgery to stop the cancer coming back. The National Cancer Information Center explains that it raises the 3-year relapse-free survival rate by about 10~20%.
• Neoadjuvant chemotherapy — given before surgery to shrink the cancer.
• Palliative chemotherapy — given when surgery is difficult, or the cancer has spread. Depending on whether a marker called HER2 shows up, targeted therapy or immunotherapy may be used with it.

Radiation therapy

It is hardly used for gastric cancer in Korea.
It can be given when the cancer has spread to the brain or spine and symptoms need to be eased.

Which treatments you have, and in what order, differs from person to person.
Talk it over fully with your doctor before deciding.

It differs by hospital and by the patient's condition, but the flow is usually like this.

If you have endoscopic treatment (ESD)

1. Fasting before the procedure
2. The procedure (usually 30 to 60 minutes)
3. You often stay in hospital for a few days so they can watch for bleeding or a perforation
4. The removed tissue is examined to check that it was all taken out and whether more treatment is needed

If you have surgery

1. Tests before surgery — blood tests, an ECG, a chest X-ray and so on, to check that you can cope with the operation.
2. The operation
3. Recovery — once the bowel starts moving, you start with water and thin rice porridge, a very little at a time.
4. After discharge — the biopsy result decides whether chemotherapy is needed.

Useful things to bring

• Your referral letter (진료의뢰서), your ID and your national health insurance card (건강보험증)
• Your endoscopy images and biopsy report from the previous hospital, and imaging data (a CD and the like)
• A list of the medicines you take (blood-thinning medicines especially must be reported in advance)

Eating after surgery

When part of the stomach is cut out, you can eat less at one time.
So you change to eating a little at a time, often, and slowly.
Eating in a hurry can bring cold sweats, dizziness or stomach pain, so the hospital gives separate teaching on it.

The length of the stay, how quickly you move on with food, and care after discharge differ by hospital.
Ask the hospital where you have your surgery for the exact details.

The special cost-sharing program

If you are diagnosed with gastric cancer, you can apply for the special cost-sharing program for serious illness (산정특례).
Once you are registered, your out-of-pocket rate for care related to that cancer drops a great deal,
and it applies for a set period.

Usually the hospital that issued your medical certificate applies for you.
If you do it yourself, you submit a registration form to the National Health Insurance Service (국민건강보험공단).

Other support

• If it was found at the national cancer screening program (국가암검진) gastroscopy, you can get support for the screening cost.
• Depending on your income, you may qualify for the medical cost support program for cancer patients.

The rules and the out-of-pocket rates change.
What follows is a summary as of the reference date, so before you apply, always
check the latest rules at the National Health Insurance Service (국민건강보험공단).