What are the signs and symptoms of stomach cancer, particularly in older adults with a history of gastritis, ulcers, or a family history of stomach cancer?

Signs and Symptoms of Gastric Cancer

Gastric cancer is often asymptomatic in early stages, but in advanced disease, the most common signs and symptoms include weight loss, abdominal pain, dysphagia, vomiting, early satiety, indigestion, asthenia, and iron deficiency anemia. 1, 2

Clinical Presentation by Disease Stage

Early Gastric Cancer

• Most patients are completely asymptomatic when the tumor is confined to the mucosa or submucosa 3
• When symptoms do occur in early disease, they are nonspecific gastrointestinal complaints that often lead to misdiagnosis and treatment for presumed benign conditions for months to years 4
• Up to 95% of early gastric cancer patients present with vague, nonspecific symptoms that do not trigger urgent investigation 4

Advanced Gastric Cancer

The following symptoms indicate progression to advanced disease 1, 2:

• Weight loss (unexplained) - one of the most common presenting features 1, 5, 6, 2
• Abdominal pain - present in over 90% of symptomatic patients in the US 2
• Dysphagia (difficulty swallowing) - particularly when tumor involves the gastroesophageal junction or cardia 1, 5, 6
• Vomiting - indicates gastric outlet obstruction or advanced disease 1, 5, 6
• Early satiety (feeling full quickly) - suggests reduced gastric capacity from tumor burden 1, 5, 6
• Indigestion/dyspepsia - persistent symptoms warrant immediate investigation 1, 6
• Asthenia (weakness/fatigue) - reflects systemic effects of malignancy 1
• Iron deficiency anemia - may be the only presenting sign and should never be dismissed 1, 5, 6, 7

High-Risk Populations Requiring Heightened Vigilance

Patients with History of Gastritis or Ulcers

• Chronic atrophic gastritis significantly increases gastric cancer risk and represents a precancerous condition 1, 6, 8
• H. pylori-associated gastritis follows the Correa Cascade progression: non-atrophic gastritis → atrophic gastritis → intestinal metaplasia → dysplasia → cancer 1
• Patients with intestinal metaplasia plus any of the following should undergo endoscopic surveillance every 3 years: family history of gastric cancer, incomplete-type IM, or persistent H. pylori gastritis 1
• Peptic ulcer surgery performed over 20 years ago increases cancer risk 1

Family History Considerations

• Family history of gastric cancer in more than one first-degree relative warrants referral to genetics and heightened surveillance 1, 5
• Hereditary diffuse gastric cancer (HDGC) syndrome carries extremely high lifetime risk and requires specialized management 1
• BRCA2 carriers have 2.5 times higher risk of gastric cancer compared to general population 6
• Other hereditary syndromes include Lynch syndrome, familial adenomatous polyposis, Li-Fraumeni, and Peutz-Jeghers 1, 5

Age-Specific Considerations in Older Adults

• Median age at diagnosis is 68 years, making older adults the highest-risk demographic 2
• Dyspepsia in patients aged 55 years or older with onset less than one year ago or continuous symptoms since onset requires urgent endoscopy 1
• Older adults are more likely to present with anemia as the sole manifestation 5, 7
• Approximately 60% of gastric cancer patients are not eligible for curative treatment due to late presentation or comorbidities, which disproportionately affects older adults 1

Critical Alarm Symptoms Requiring Immediate Endoscopy

The following "red flag" symptoms mandate urgent referral for upper endoscopy within 2 weeks 1:

• Any dysphagia (difficulty swallowing)
• Dyspepsia combined with weight loss
• Dyspepsia combined with anemia
• Dyspepsia combined with anorexia
• Jaundice (suggests metastatic disease)
• Upper abdominal mass (palpable tumor)

Common Clinical Pitfalls to Avoid

• Do not dismiss persistent dyspepsia as benign, especially in patients over 55 years with new-onset symptoms 1, 6
• Do not fail to investigate iron deficiency anemia, which may be the only presenting sign and is frequently overlooked 5, 6, 7
• Do not treat presumed benign gastric disease for extended periods without endoscopic confirmation - 53% of early gastric cancer patients were treated for presumed benign disease for up to 48 months before correct diagnosis 4
• Do not rely on symptom severity to gauge cancer risk - most symptoms are reported as mild to moderate even in advanced disease 9

Co-Occurring Symptom Patterns

• Patients typically experience 3 to 17 concurrent symptoms (median = 7) across physical and affective/cognitive domains 9
• Female gender, advanced cancer stage, low socioeconomic status, and total gastrectomy are associated with greater number and severity of symptoms 9
• Symptom severity varies following treatment trajectories, with fluctuations throughout the disease course 9

Additional Risk Factors That Compound Symptoms

• H. pylori infection is associated with 90% of gastric body and antrum cancers globally 2
• Smoking increases risk and should be assessed in all patients 1, 5, 6, 8
• Heavy alcohol consumption is a modifiable risk factor 6, 8
• High salt intake and preserved foods increase gastric cancer risk 1
• Male gender - gastric cancer is approximately twice as common in men 6