NCLEX Review Guide: Gastric Cancer

Gastric Cancer Development

• Gastric cancer typically develops from the mucosal lining of the stomach, most commonly in the pyloric antrum and along the lesser curvature. The disease progression follows a sequence from chronic gastritis to atrophy, intestinal metaplasia, dysplasia, and finally adenocarcinoma.
• Malignant cells invade the gastric wall layers progressively (mucosa → submucosa → muscularis → serosa) before potentially metastasizing to regional lymph nodes, liver, peritoneum, and other distant sites.

Risk Factors

• Helicobacter pylori infection is the most significant risk factor, increasing risk 3-6 fold. H. pylori causes chronic inflammation that can lead to precancerous changes in the gastric mucosa over decades.
• Other significant risk factors include chronic atrophic gastritis, intestinal metaplasia, pernicious anemia, previous gastric surgery, family history (especially in first-degree relatives), dietary factors (high salt, smoked foods, nitrates/nitrites), and smoking.

Early Signs & Symptoms

• Early gastric cancer is often asymptomatic, which contributes to delayed diagnosis and poor prognosis. When present, early symptoms are typically vague and nonspecific, including mild epigastric discomfort, early satiety, indigestion, or heartburn that may be dismissed as benign dyspepsia.
• Weight loss without trying may be one of the first noticeable signs, often accompanied by fatigue due to developing anemia from chronic, slow blood loss that may not be visibly evident.

Advanced Disease Manifestations

• Advanced gastric cancer presents with more pronounced symptoms including persistent epigastric pain, nausea, vomiting (particularly with pyloric obstruction), anorexia, and significant weight loss. Hematemesis or melena may occur due to tumor erosion into blood vessels.
• Physical examination may reveal a palpable epigastric mass, enlarged liver (suggesting metastasis), periumbilical (Sister Mary Joseph) nodule, left supraclavicular lymphadenopathy (Virchow's node), or ascites in cases with peritoneal spread.

Diagnostic Procedures

• Upper endoscopy (EGD) with biopsy is the gold standard for diagnosis, allowing direct visualization of suspicious lesions and tissue sampling. Multiple biopsies (6-8 samples) should be obtained from any suspicious areas to minimize sampling error.
• Endoscopic ultrasound (EUS) provides information about tumor depth and regional lymph node involvement, which is crucial for staging. CT scans of chest, abdomen, and pelvis assess for metastatic disease, while PET/CT may detect occult metastases not visible on conventional imaging.

Laboratory Findings

• Laboratory tests may reveal microcytic, hypochromic anemia due to chronic blood loss, elevated liver enzymes in cases with hepatic metastases, and hypoalbuminemia reflecting malnutrition. Fecal occult blood testing may be positive due to intermittent bleeding.
• Tumor markers including carcinoembryonic antigen (CEA) and CA 19-9 may be elevated but lack specificity for diagnosis. They are more useful for monitoring treatment response and surveillance for recurrence after treatment.

Staging & Classification

• The TNM staging system (Tumor, Node, Metastasis) is used to classify gastric cancer. T stage describes the depth of tumor invasion through gastric wall layers, N stage indicates the number of involved regional lymph nodes, and M stage denotes the presence or absence of distant metastases.
• Accurate staging is critical for treatment planning and prognosis. The 5-year survival rate varies dramatically by stage: Stage I (>90%), Stage II (70-80%), Stage III (30-50%), and Stage IV (<5%).

Surgical Interventions

• Surgical resection is the only potentially curative treatment for gastric cancer. The extent of surgery depends on tumor location, size, and stage. Distal subtotal gastrectomy is preferred for distal tumors, while total gastrectomy is performed for proximal tumors or diffuse disease.
• D2 lymphadenectomy (removal of perigastric and regional lymph nodes) is the standard of care in specialized centers. Minimally invasive approaches (laparoscopic or robotic) may be used for early-stage disease with comparable oncologic outcomes and faster recovery.

Preoperative Nursing Care

1. Assess nutritional status and implement interventions to optimize nutritional status before surgery.
2. Provide thorough education about the surgical procedure, expected postoperative course, and potential changes in eating patterns.
3. Explain potential need for feeding tubes, dietary modifications, and vitamin supplementation after gastrectomy.
4. Initiate VTE prophylaxis and antibiotic prophylaxis as ordered.
5. Ensure completion of preoperative testing including cardiac clearance for high-risk patients.

Chemotherapy & Radiation

• Perioperative chemotherapy (before and after surgery) is standard for locally advanced gastric cancer (≥Stage II) in many countries. Common regimens include FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel), FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin), or ECF/ECX (epirubicin, cisplatin, and 5-fluorouracil/capecitabine).
• Chemoradiation may be used in the adjuvant setting, particularly for patients with positive margins or inadequate lymph node dissection. For metastatic disease, systemic therapy is the mainstay of treatment, with regimens selected based on performance status, comorbidities, and molecular profiling.

Postoperative & Supportive Care

• Postgastrectomy syndrome management is a critical aspect of nursing care. This includes dumping syndrome (early and late), vitamin B12 deficiency, iron deficiency anemia, malabsorption, and weight loss. Nutritional counseling should focus on small, frequent meals, limiting simple carbohydrates, and consuming liquids between rather than with meals.
• Pain management, early mobilization, respiratory care, and wound management are essential components of postoperative care. Monitor for complications including anastomotic leak, intra-abdominal abscess, pneumonia, and thromboembolic events.

Gastric Cancer vs. Peptic Ulcer Disease

Early vs. Late Dumping Syndrome

Intestinal vs. Diffuse Type Gastric Cancer

Key Assessment Priorities

• Focus on recognizing red flag symptoms that warrant urgent investigation: unintentional weight loss, progressive dysphagia, persistent vomiting, early satiety, palpable abdominal mass, iron-deficiency anemia without obvious source, and melena or hematemesis.
• Understand the importance of comprehensive health history, including family history of gastric cancer, dietary habits (high salt, smoked foods), H. pylori infection history, and occupational exposures that increase risk.

Critical Nursing Interventions

• Understand nutritional support strategies for patients after gastrectomy, including dietary modifications, supplement requirements, and monitoring for deficiencies. This includes recognizing the signs and symptoms of vitamin B12, iron, folate, calcium, and fat-soluble vitamin deficiencies.
• Know the nursing management of chemotherapy-related side effects, particularly for common regimens used in gastric cancer. This includes appropriate antiemetic protocols, neutropenia precautions, and peripheral neuropathy assessment and management.

Common Pitfalls in NCLEX Questions

• Misunderstanding staging terminology and its implications for treatment options. Remember that treatment approaches vary significantly based on stage: early-stage disease (Stages I-II) may be treated with surgery alone or with perioperative therapy, while advanced disease (Stages III-IV) requires multimodality treatment or palliative care.
• Confusing the management of different postgastrectomy complications. Know the specific interventions for dumping syndrome (dietary modifications), vitamin B12 deficiency (monthly injections), and anastomotic strictures (endoscopic dilation).

• Pathophysiology: Gastric cancer typically develops from the mucosal lining, with adenocarcinoma accounting for 95% of cases. H. pylori infection is the most significant risk factor, increasing risk 3-6 fold.
• Clinical Presentation: Early disease is often asymptomatic or presents with vague symptoms. Advanced disease manifests with persistent epigastric pain, weight loss, early satiety, nausea/vomiting, and potential GI bleeding.
• Diagnosis: Upper endoscopy with biopsy is the gold standard. Staging requires endoscopic ultrasound, CT scans, and possibly PET/CT or diagnostic laparoscopy.
• Treatment: Surgical resection is the only potentially curative treatment, often combined with perioperative chemotherapy for locally advanced disease. Targeted therapies include trastuzumab for HER2-positive disease.
• Nursing Management: Focus on nutritional support, management of postgastrectomy syndromes, chemotherapy side effect management, and psychosocial support. Patient education regarding dietary modifications is essential.
• Complications: Key complications include dumping syndrome, vitamin deficiencies (especially B12), malnutrition, anemia, and chemotherapy-related toxicities.