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 Stomach Cancer

Gastric cancer is often asymptomatic in early stages, but when advanced disease develops, the most common signs and symptoms include weight loss, abdominal pain, dysphagia, vomiting, early satiety, asthenia (weakness), indigestion, 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 1, 3
• When symptoms do occur in early disease, they are typically nonspecific gastrointestinal complaints that are often mistaken for benign conditions like gastritis or peptic ulcer disease 4
• Up to 53% of patients with early gastric cancer are treated for presumed benign disease for months to years before correct diagnosis 4

Advanced Gastric Cancer

The following symptoms emerge as the tumor progresses beyond the gastric wall:

• Weight loss (unintentional) - one of the most common presenting features 1, 5, 2
• Abdominal pain - frequently reported, often vague and persistent 1, 2
• Dysphagia (difficulty swallowing) - particularly with tumors at the gastroesophageal junction or cardia 1, 5
• Vomiting - indicates gastric outlet obstruction or advanced disease 1, 5
• Early satiety (feeling full quickly) - suggests reduced gastric capacity from tumor burden 1, 5
• Asthenia (profound weakness/fatigue) - reflects systemic effects of malignancy 1
• Indigestion/dyspepsia - persistent symptoms that fail to respond to standard therapy 1, 5
• Iron deficiency anemia - may be the only presenting sign in some patients, resulting from chronic occult bleeding 1, 5

Physical Examination Findings

• Upper abdominal mass - palpable in advanced cases 1
• Signs of anemia - pallor, tachycardia 6
• Jaundice - indicates metastatic disease to liver 1
• Cachexia - profound weight loss and muscle wasting in advanced disease 2

Symptom Patterns and Severity

• Three to 17 symptoms typically occur concurrently (median of 7 co-occurring symptoms) 7
• Most symptoms are reported as mild to moderate in severity, but this varies significantly with treatment trajectory 7
• Symptom burden is greater in older patients, females, those with advanced cancer stage, low socioeconomic status, and those undergoing total gastrectomy 7

Critical Clinical Context for High-Risk Populations

Patients with History of Gastritis or Ulcers

• The Correa Cascade describes progression from chronic gastritis → atrophic gastritis → intestinal metaplasia → dysplasia → cancer 1
• Patients with atrophic gastritis or intestinal metaplasia have substantially elevated cancer risk and warrant endoscopic surveillance every 3 years 1
• H. pylori-associated persistent gastritis increases cancer risk even after attempted eradication 1

Patients with Family History

• Family history of gastric cancer confers a 2-3 fold increased risk 1
• Patients with family history plus intestinal metaplasia should undergo surveillance endoscopy every 3 years 1
• Consider referral to genetics if hereditary diffuse gastric cancer (HDGC) or other familial cancer syndromes are suspected 1, 6

Older Adults

• Median age at diagnosis is 68 years 2
• New-onset dyspepsia in patients aged 55 years or older warrants urgent endoscopic evaluation, especially if symptoms began less than one year ago or have been continuous since onset 1
• Older patients experience greater symptom burden and more severe symptoms 7

Common Diagnostic Pitfalls to Avoid

• Do not dismiss persistent dyspepsia as benign, particularly in patients over 55 or those with risk factors—clinical diagnosis without endoscopy is highly inaccurate 8
• Do not overlook iron deficiency anemia as it may be the sole presenting sign of gastric cancer 1, 5
• Do not delay investigation when "alarm symptoms" are present: these non-specific symptoms frequently fail to trigger urgent evaluation, resulting in 60% of patients being ineligible for curative treatment at diagnosis 1
• Do not accept treatment failure for presumed benign disease—if symptoms persist despite appropriate therapy for gastritis or ulcers, proceed directly to endoscopy 4

When to Refer Urgently for Endoscopy

The following warrant referral within 2 weeks for upper endoscopy 1:

• Any dysphagia at any age
• Dyspepsia combined with alarm symptoms: weight loss, anemia, anorexia
• Age 55 or older with new dyspepsia (onset <1 year ago) or continuous symptoms since onset
• Dyspepsia plus high-risk features: family history of gastric cancer in multiple first-degree relatives, known Barrett's esophagus, pernicious anemia, peptic ulcer surgery >20 years ago, known dysplasia, atrophic gastritis, or intestinal metaplasia
• Upper abdominal mass on examination
• Jaundice

Diagnostic Approach

• Upper endoscopy with multiple biopsies (5-8 samples) is the gold standard for diagnosis 1, 8
• Stop proton pump inhibitors before endoscopy as they can mask endoscopic findings and heal malignant ulcers, potentially causing misdiagnosis 8
• Endoscopy can miss gastric cancer in 10% of cases at first examination, so repeat endoscopy is warranted if clinical suspicion remains high despite negative initial findings 8
• Routine blood tests should assess for iron deficiency anemia and organ function 6, 5