If your general practitioner (GP) suspects that you have stomach or oesophageal cancer, they will examine you and refer you for further tests. The main tests for diagnosing stomach and oesophageal cancers are endoscopy and the removal of a tissue sample (biopsy).
Endoscopy and biopsy
An endoscopy (also called a gastroscopy, oesophagoscopy or upper endoscopy) allows your doctor to see inside your digestive tract to examine the lining. This test is usually performed as day surgery.
You will be asked not to eat or drink (fast) for about 4–6 hours before an endoscopy. Before the procedure, your throat will be sprayed with a local anaesthetic and you will probably be given a sedative to help you relax. A flexible tube with a light and small camera on the end (endoscope) will then be passed into your mouth, down your throat and oesophagus, and into your stomach.
If the doctor sees any suspicious-looking areas, they may remove a small amount of tissue from the stomach or oesophageal lining. This is known as a biopsy. A pathologist will examine the tissue under a microscope to check for signs of disease. Biopsy results are usually available within a few days. This waiting period can be an anxious time and it may help to talk to a supportive friend, relative or health professional about how you are feeling.
An endoscopy takes about 15 minutes. You may have a sore throat afterwards and feel a little bloated. Endoscopies have some risks, such as bleeding or getting a small tear or hole in the stomach or oesophagus (perforation). Your doctor should explain all the risks before asking you to consent to the procedure.
Endoscopic ultrasound (EUS)
You may have this test at the same time as a standard endoscopy. The doctor will insert an endoscope with an ultrasound probe on the end. The probe releases soundwaves, which echo when they bounce off anything solid, such as an organ or tumour. This procedure helps determine whether the cancer has spread into the oesophageal wall, nearby tissues or lymph nodes, and whether you are a suitable candidate for surgery. During the scan, your doctor may take further tissue samples from the oesophagus, lymph nodes and nearby organs.
If the biopsy shows you have stomach or oesophageal cancer, you will have a number of other tests to find out whether the cancer has spread to other areas of your body. This is called staging. The following information describes tests that are commonly used to help stage stomach and oesophageal cancers. Some tests may be repeated during or after treatment to check your health and how well the treatment is working.
"A routine check-up with my GP, involving various blood tests, led to gastrointestinal testing that unearthed early-stage oesophageal cancer." – June
You might have blood tests to assess your general health, and to see how well your liver and kidneys are working. The test results can help you and your doctor to make treatment decisions.
A computerised tomography (CT) scan uses x-rays and a computer to create a detailed picture of an area inside the body. It helps determine how far the cancer has spread from the primary tumour site. You may have a CT scan of your:
- chest, abdomen and pelvis for stomach cancer
- neck, chest and abdomen for oesophageal cancer.
Before a CT scan for stomach cancer, you may have an injection or be asked to drink a liquid dye. This helps ensure that anything unusual can be seen more clearly. The dye might make you feel hot all over and leave a strange taste in your mouth for a few minutes. Rarely, more serious reactions can occur.
The CT scan machine is large and round like a doughnut. You will need to lie still on a table while the scanner moves around you. The scan itself is painless and takes only a few minutes, but the preparation can take 10–30 minutes.
The dye used in a CT scan can cause an allergic reaction in some people. If you have had an allergic reaction to iodine or dyes during a previous scan, let the medical team know in advance.
A positron emission tomography (PET) scan combined with a CT scan is a specialised imaging test. The two scans provide more detailed and accurate information about the cancer. A PET-CT scan is most commonly used to help determine whether stomach or oesophageal cancer has spread to other parts of the body.
A PET scan is able to detect cancer cells that may not have been detected with just a CT scan. Before the scan, you will be injected with a glucose solution containing a small amount of radioactive material. Cancer cells show up brighter on the scan because they take up more glucose solution than the normal cells do.
You will be asked to sit quietly for 30–90 minutes as the glucose spreads through your body, then you will be scanned. The scan itself will take around 30 minutes. Let your doctor know if you are claustrophobic as the scanner is a confined space.
This procedure allows your doctor to look inside your abdomen and examine the outer layer of the stomach to see if the cancer has spread. A laparoscopy is used to stage:
- stomach cancer to see whether it involves the lining of the abdomen (peritoneum) or other organs
- oesophageal cancer located in the gastro-oesophageal junction that also involves the upper part of the stomach.
A laparoscopy is usually done as day surgery. You will be admitted to hospital and given a general anaesthetic. The doctor will inflate your abdomen with gas and make small cuts in your abdomen. A tube with a light and camera attached (a laparoscope) will be inserted into your body. Through this tube, the doctor can see cancer cells that are too small to be seen on CT or PET scans. The doctor may take further tissue samples for biopsy. Your doctor will explain the risks before asking you to agree to the procedure.
Gene mutation testing
Some cancers in the stomach and gastro-oesophageal junction are linked with genetic abnormalities. These abnormalities can contribute to the growth of tumours. If other tests show that the stomach cancer is advanced, your doctor might test a tissue sample to see if it contains a particular genetic mutation that may respond to some medicines. See targeted therapy for stomach cancer for more details.
The tests described above help show whether you have stomach or oesophageal cancer, and whether it has spread from the original site to other parts of the body. Working out how far the cancer has spread is called staging and it helps your health care team decide the best treatment for you.
The TNM staging system is the method most commonly used to describe the different stages of stomach and oesophageal cancers. Each letter is assigned a number to describe the cancer (see table below).
|TNM staging system
|T (Tumour) 0-4
||Indicates how far the tumour has grown into the oesophagus or stomach wall. The higher the number, the deeper the tumour.
|N (Nodes) 0-3
||Shows if the cancer has spread to nearby lymph nodes. N0 means the cancer has not spread to the lymph nodes; N1, N2 or N3 indicate increasing node involvement.
|M (Metastasis) 0-1
||Indicates if the cancer has spread (metastasised) to other parts of the body. M0 means the cancer has not spread; M1 means the cancer has spread.
Based on the TNM numbers, the doctor then works out the overall stage (I–IV) of the cancer:
- Stage I – tumours are found only in the stomach or oesophageal wall lining (known as early or limited disease).
- Stages II and III – tumours have spread deeper into the layers of the stomach or oesophageal walls and to nearby lymph nodes (known as locally advanced disease).
- Stage IV – tumours have spread beyond the oesophageal/stomach wall to other parts of the body, such as the bones or lungs, or to distant lymph nodes (known as advanced or metastatic disease).
If you are finding it hard to understand staging, ask someone in your medical team to explain it in a way that makes sense to you. You can also call Cancer Council 13 11 20 to clarify the information you have been given and what it means.
Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease. Instead, your doctor can give you an idea about the general prognosis for people with the same type and stage of cancer.
Generally, the earlier stomach or oesophageal cancer is diagnosed, the better the chances of successful treatment. If cancer is found after it has spread from the primary tumour site, the prognosis is not as good.
Test results, the type of cancer, the rate and depth of tumour growth, the likelihood of response to treatment, and factors such as your age, level of fitness and medical history are important in assessing your prognosis. These factors will also help your doctor advise you on the best treatment options.
Which health professionals will I see?
Your GP will arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a specialist doctor who will arrange further tests.
You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is called a multidisciplinary team (MDT). This team will meet regularly to discuss and plan the most appropriate treatment for you. The table below lists some of the people who make up this MDT.
||specialises in disorders of the digestive system; performs endoscopies; inserts feeding tubes
|upper gastrointestinal surgeon*
||treats diseases of the upper digestive system with surgery; performs endoscopies; inserts a feeding tube if required
||treats cancer with drug therapies such as chemotherapy and targeted therapy
||prescribes and coordinates the course of radiotherapy
||plans and delivers radiotherapy treatment
|cancer nurse coordinator, clinical nurse consultant
||coordinate your care, liaise with other members of the MDT, and support you and your family throughout treatment
||administers drugs, including chemotherapy; provides care, information and support
||recommends an eating plan for your nutritional needs while you are in treatment and recovery
||assists in physical rehabilitation and restoring movement after surgery
||links you to support services and helps you with emotional, practical and financial issues
||help you manage your emotional response to diagnosis and treatment
|palliative care team
||specialise in pain and symptom control to maximise wellbeing and improve quality of life
- A range of tests are used to diagnose stomach and oesophageal cancers.
- Endoscopy is the main diagnostic test. This allows your doctor to look inside the digestive tract and take tissue samples (biopsies).
- You may have an endoscopic ultrasound (EUS) to show how far the cancer has spread into the oesophageal wall.
- A pathologist examines the biopsied tissue under a microscope to find out more about the cells. This shows if cancer is present and how quickly it is growing.
- After the diagnosis is confirmed, you will have further tests to find out whether the cancer has spread.
- A CT or PET-CT scan will help show how far the cancer has spread from the stomach or oesophageal wall.
- Other procedures, such as a laparoscopy, can show whether the cancer has spread to other organs or the abdomen.
- Gene mutation testing of tissue samples is recommended only for some people with advanced (metastatic) stomach cancer.
- Staging a cancer helps your doctors to determine the most appropriate treatment for you.
- Your doctor will talk to you about your prognosis, which is the expected outcome of a disease.
- You will be cared for by a range of health professionals who work together in a multidisciplinary team (MDT).
Expert content reviewers:
Prof David Watson, Head, Flinders University Department of Surgery, Flinders Medical Centre, SA; Prof Bryan Burmeister, Senior Staff Specialist, Cancer Services, Princess Alexandra Hospital, QLD; Dr Fiona Day, Medical Oncologist, Calvary Mater Hospital, Newcastle, and Conjoint Senior Lecturer, University of Newcastle, NSW; Mark Diggle, Consumer; Merran Findlay, Executive Research Lead – Cancer Nutrition and Oncology Specialist Dietitian, Royal Prince Alfred Hospital, NSW; Rosie Newth, 13 11 20 Consultant, Cancer Council NSW; Dr David Ransom, Medical Oncologist, Fiona Stanley Hospital, WA; Megan Rogers, Specialist Nurse, Upper Gastrointestinal Cancer Service, Peter MacCallum Cancer Centre, VIC. We also thank the health professionals, consumers and editorial teams who have worked on previous editions of this title.