“Unfortunately, the diagnosis is often made at an advanced or metastatic stage”

– Why Doctor: What does the term “digestive cancer” include?

Professor Jean-Baptiste Bechet: Digestive cancer represents all cancers that can occur in the digestive tract, starting in the esophagus and ending in the stomach, duodenum, and small intestine, along with the anus. , colon and rectum. So, we can get cancer that affects these different areas, but also all the organs connected to the digestive system: pancreas, liver, gall bladder.

Esophageal cancer: “Lifestyle changes” increase cases of “so-called proximal cancer”.

What are the risk factors for stomach cancer?

Stomach cancer is one of the most common cancers worldwide. It has many features. First, in France and in Western countries, the incidence has decreased in recent years: we had about 8,500 cases per year in France in the 1980s and today we have about 6,500 cases per year. So there is a reduction in risk that can be explained epidemically by the evolution of risk factors. In fact, historically, we have a bacteria called Helicobacter pylori: it is a bacteria that is a carcinogen that can cause stomach cancer. Its presence in the stomach is completely linked to changes in lifestyle and hygiene. So improvements in sanitation in France and in Western countries have meant that we are fewer carriers of this bacteria and, as a result, we have fewer stomach cancers associated with it. This mainly gives rise to the so-called distant stomach cancer, that is, which affects the distant part, the antrum and the body of the stomach.
At the same time, there has been an increase in other types of stomach cancer which this time is linked to lifestyle changes, especially overweight and obesity, and which will promote the occurrence of gastroesophageal reflux. Over time, this can lead to gastroesophageal reflux abnormalities and inflammation. So we have an increase in so-called proximal cancer cases that will affect the lower esophagus or the cardia.

Lynch syndrome increases the risk of developing certain types of cancer

Besides poor lifestyle, do we know the genetic causes of stomach cancer?

About 3% of cases have rare genetic causes. There are mainly two genetic syndromes that are responsible for stomach cancer of genetic origin. There is Lynch syndrome, a syndrome that will give rise to a whole spectrum of different cancers, including colorectal cancer. And then, we have a very specific syndrome, called hereditary diffuse gastric cancer syndrome. It is linked to mutations in genes that will promote the occurrence of cancer at a younger age.

What symptoms may lead to the diagnosis?

Since there is no screening in France, diagnosis is often based on symptoms. You may have symptoms associated with the presence of a primary tumor in the abdomen, hence pain in the epigastric cavity. We can have complications like hemorrhage, so bleeding that can reveal the presence of these tumors. If the tumors are high enough, we can also have an obstruction, which we call dysphagia, meaning difficulty in getting food, a feeling of obstruction with possible regurgitation. And then we may also have symptoms that are non-specific to the primary tumor, but which correspond to the evolution of the disease, because unfortunately, the diagnosis is often made at an advanced or metastatic stage. At this time, you may experience fatigue, slightly more diffuse pain, and a change in your general condition, which will lead to examinations and a cancer diagnosis.

“For very small tumors, we can treat surgically or endoscopically alone”

What are the possible treatments?

In terms of treatment, we distinguish two things. First, tumors that are localized, the goal of which is cure. For very small tumors, surgical or endoscopic treatment may be performed alone. As soon as the tumors get a little bigger, pretreatment will be done in France, essentially based on chemotherapy for two months before the operation. Then we operate and do more chemotherapy. Or, we may perform radiochemotherapy for tumors proximal to the esophagus or cardia. Therefore, in all cases, we treat preoperatively because the tumor is slightly advanced.
For tumors that are not immediately operable, those that are said to be locally advanced, for which surgery is a contraindication, or tumors that are metastatic, treatment is based on chemotherapy in combination with a variety of treatments.
In recent years, there have been many new treatments: we have developed immunotherapies specifically for subgroups of stomach cancers that we know will respond better, allowing a good percentage of stomach cancers to benefit from them. This immunotherapy is combined with chemotherapy. Or, we have other types of treatments that are under development that are targeted therapies, which we will also use with chemotherapy. In the future, we will have to see if we can combine these targeted therapies in the double change setting. Or to find out if patients who have double mutations are better off starting with one therapy than the other… So there’s a lot of work in perspective, a lot of new treatments coming out, and hope for our patients!

How is support provided to patients?

Many things are done to support families in France. The National Cancer Institute provides a lot of information, as does the League Against Cancer, which also provides support to patients. There are also associations that are created for genetic syndromes, associations for particular types of cancer… So there are a lot of things that are done, that vary by region, depending on the center we’re in. And also for post-cancer, that is once we have completed the entire therapeutic sequence. The goal is to heal patients after this treatment, so we also have a whole set of aids to enable them to live with the possible after effects of various surgeries, help with vocational reintegration, etc.
Physical activity is important too! We now have a lot of evidence showing that physical activity helps to better tolerate treatment with fewer complications for both drugs and surgery, and that it also helps strengthen the immune system. This activity is important at all times during treatment and is convenient for our patients.

You can see the interview in images by Scientific Editor Juliette de Noiron (PhD) with Professor Jean-Baptiste Bechet:

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