Prevention for Gastric Cancer - Case Study Example

Screening/Prevention for Gastric Cancer: the role of Primary Care Providers (internal medical MDs and nurse practitioners) Despite extensive search, little information could be found exclusively on the role of nurse practitioners and internal medical MDs in respect of screening and prevention for gastric cancer. “There is no primary prevention measure specific to stomach cancer, although the promotion of a healthy diet, which should be a top public health priority in health promotion and disease prevention, is expected to also decrease the risk of stomach cancer. The benefits of radiologic screening for stomach cancer have been well established in Japan, but the methods are difficult and costly”. (Manual on the prevention and control of common cancers 1998 p 284,285) Hence this study will go into these aspects for cancer in general and suggest how nurse practitioners and internal MDs can play a constructive role in screening and prevention of gastric cancer. Primary care professionals in cancer care carry a large patient workload having to look for common warning signs and symptoms in their efforts to identify risk groups. In primary care practice, both the nurse practitioners and internal Medical MDs discuss with potential patients for as many as ten common symptoms of cancer though not all result in cancer. The symptoms are pain, nausea & vomiting, cachexia which is a condition weight-loss anorexia along with weakness and fatigue, dysphagia, lymphoedema, breathlessness, fistulae, pruritus. The primary care in cancer screening and prevention has been traditionally holistic encompassing physical, social, psychological factors. Holistic refers to treating the whole person not only with symptoms but also giving the person support from social and psychological support. The primary care health team consists of professionals in the order of General Practitioner, Practice Nurse, Palliative care nurse, pharmacist and administration. The support team for the above core team consists of Specialist nurses, Physiotherapists, Dietician, Voluntary groups, clinical psychologist and others. Nurses have expanded their role and have become nurse practitioners to work independently of doctors. This in a way helps reduce burden on doctors and also results in lesser costs. The primary care professionals encourage patient participation in screening and prevention and speak to non-attenders and allay their fears and suspicions and enable them to venture out for screening. The cancer journey has screening and prevention on top of the list before suspected malignancy referral, diagnosis, treatment, follow-up and palliative care. The WHO and Cancer Charities have six declared principles one of which is affording equal opportunity for potentially affected persons in screening and prevention.(Gore and Russell 2003) Cancer prevention strategies should involve macro approaches starting from the Governmental and population levels though intervention at personal level also can make an impact. Through prevention strategies, two out of three cancer mortality can be prevented..Since the public is overloaded with information often with conflicting opinions and since there is interest in alternative medicine without scientific evidence, clinical staff should hone their appraisal skills so as to give patients their appropriate advice. In this connection, primary care organisations also should make available scientifically evaluated information on cancer to the clinicians and patients as well through accessible websites of health services. The potentially avoidable causes of cancer being environmental contributions reported as early as in 1981 are smoking, improper diet, alcohol, sexual behavior, occupation, industrial products, medical procedures, geophysical factors and infections. (Doll and Peto 1981) Cancer prevention should be both at primary and secondary levels. The primary prevention are the efforts to halt the disease before it starts such as avoiding the above said environmental and dietary elements connected with cancer risk. Secondary prevention is detecting the disease at a precancerous or treatable stage. Primary prevention therefore gains significance in tackling the above said environmental conditions. The primary health care teams which include nurse practitioners and medical doctors should have cancer prevention in their Programs. In fact they should have these preventive strategies as major part of their activities of health promotion. The role of primary care will change from diagnosis, referrals and support methods to a cancer prediction and cancer prevention methods. This is part of anticipatory care model of family practice by nurse practitioners and medical M.Ds. As primary prevention goes beyond primary care health teams to a macro population level, the primary care professionals attached to primary care organizations should make their organization to form alliances with other local agencies involved in taxation of tobacco and alcohol, advertising restrictions or banning them, restricting the sponsorships of tobacco and alcohol companies, environmental health and safety legislation and radiation regulations. Smoking is one of the causes of gastric cancer besides cardiovascular disease, cancer in the bladder, uterine cervix, esophagus, oropharynx, kidney and pancreas and leukemia. Hence primary care medical professional should assist existing smokers to stop and prevent young people to take to smoking. The highly addictive Nicotine is used by adolescent boys and girls and therefore adolescent population should be mainly targeted. Smoking record of the patients should be maintained and updated. A non-smoker status in the record might not reveal his past history of smoking i.e having stopped 20 years of smoking just the day before recording and restarting immediately after recording. The advice of a doctor for just three minutes has led 2% of patients to stop smoking at one year. Increasing the duration of advice to ten minutes can increase the percentage to four. Individual and group counseling and telephone counseling would help stopping of smoking to some extent but face to face intervention have been proved to be more effective. Nicotine replacement therapy (NRT) and prescription of Bupropion are also part of gastric cancer prevention strategies that should be adopted by the primary care practitioners. And with the addition of NRT and Bupropion, the smoking cessation rate has been reported to have increased from 4 to 8 %. (Ruseel and Davies 2003 p 47-50) Body awareness by patients themselves is another strategy of cancer prevention. This public education by nurse practitioners and medical M.Ds motivates the general public to recognize possibilities of cancer incidence in them. With this cancer is expected to be detected at an early age. The primary care team is well placed to promote body awareness while registration of new patients, and routine medical examinations. As a part of gastric prevention strategies, ‘Cancer-site-specific prevention’ messages as follows are helpful in delivering the message to the targeted population. a) Do not smoke, b) Eat plenty of fruits and vegetables, c) Limited consumption of smoked and heavily salted foods, d) Eradicate Helicobacter pylori As said above screening for cancer is an important part of health care delivery. Screening for cancer helps prevent the disease at the pre-cancerous stage. Primary care professionals should target potential patients categorized by sex and age range, family history, working under certain environmental conditions. In so far as gastric cancer is concerned, most of the population is asymptomatic and do not have the disease. As it involves ethical question when an apparently healthy population is approached for screening, advantages of the results should outweigh the disadvantages of so doing. W HO manual says that primary prevention for gastric cancer (stomach cancer) can only be in respect of promoting healthy diet habits consisting mainly avoidance of food with too much of salts, and food that are pickled and smoked and this should be supplemented by consuming vegetable and fruits at increased level. Secondary prevention will include a special contrast radiographic technique, double contrast upper gastrointestinal series though mass screening where incidence of gastric cancer is very high. This has resulted in increased survival rates to five years and reduction in the rate of death among screened patients. The health worker is expected to ensure that above said foods are avoided and instead vegetables and fruits are consumed by the potential patients. They should suspect gastric cancer in patients if they report recurrent epigastric discomfort especially after anti-ulcer medication, vomiting, unexplained anemia, and weight loss. They should make early referrals for diagnosis and treatment. (Manual on Prevention and control of Common Cancers 1998 p 207) A brief literature review will be helpful. Due to late presentation at the end stages, prognosis of this cancer has been poor. If diagnosed at an early stage, it is curable “Vaccine Development H. pylori have been shown to be heterogeneous at the genomic level with a high variability in some genes. The feasibility of preventive vaccination has been proven in animal models (mice, dogs) using whole cell vaccines as well as subunit vaccines comprising selected antigens such as VacA, CagA, NAP, hsp, urease or catalase. One of the difficulties met in vaccine studies is the absence of correlates of protection; another is to develop a vaccine that will be efficacious at the mucosal level. In humans, several Phase I studies have been conducted using: recombinant attenuated Salmonellas expressing H. pylori urease, that showed mediocre immunogenicity by the oral route; an oral whole-cell vaccine adjuvanted with wild-type LT, that was discontinued because of excessive side effects; purified urease co-administered with LT, also put on hold; a recombinant VacA, CagA and NAP vaccine in alum that proved to be safe and strongly immunogenic. The companies which were involved are Antex, Acambis and Chiron in the USA and the Commonwealth Serum Labs in Australia. A prophylactic vaccine would be cost-effective in preventing gastric cancer and duodenal ulcer” (WHO). The study of KG Yeoh (2007) gives four approaches to tackle the disease. (i) screening of high risk groups for early detection, (ii) confirmation of the hypothesis that eradication of Helicobacter pylori wherever it is present in endemic proportions, (iii) clinical trials supplemented by molecular study of tumors, and (iv) enhancing the understanding of gastric carcinogenesis. Early diagnosis of gastric cancer at the stage of mucosa and sub mucosa will help in achieving a 90% survival rate of 5 years. Gastric cancer has been responsible for major mortality in countries where cancer affected persons are asymptomatic and hence screening of such asymptomatic population is advised. Patients majority of whom present with symptoms of benign of peptic ulcer must be targeted for screening which will improve the detection rate of gastric cancer. Endoscopy or its alternative of serology testing will isolate patients with gastric cancer. (Fielding Jw & Tan YK 2006) Cost effectiveness of treatment worldwide is satisfactory except in Japan where prevalence of gastric cancer is very high. Cost of averting one death due to cancer is $ 247,600 in the United States. Screening a cohort of population of 199,000 suspected persons prevents 743 deaths due to gastric cancer and has saved 8234 life years. (Yeoh KG et al 2006) Intervention of nurses in giving emotional support to family care givers to cancer patients who are said to undergo extreme conditions of stress and diminished quality of life have been found to be met with positive results. Since the impact of the same within the context of hospice care could not be assessed, a randomized controlled trial from 1999 to 2003 with a sample of 354 family care givers revealed that coping skills taught by nurses were effective in that it improved the quality of life of the family care givers as also in hospice care and emotional support. The families who are already receiving the facilities of hospice care are better placed to cope with difficult environmental conditions at the end-of-life situations. (McMillan SC et al 2006) Gastric cancer cannot be detected on physical examination and hence diagnostic imaging should be done as an effective means of screening. Patients with epigastric pain, unexplained loss of weight, and other such symptoms should be subjected to diagnostic procedures. Patients with family history of gastric cancer, and those who have come from endemic areas such as Hawaii and Japan should be made to undergo endoscopy and biopsy of gastric mucosa. In case of multifocal atrophic gastritis, repetitive diagnostic imaging should be done every once in 12 to 36 months. Since patients who had subtotal gastrectomy are likely to be affected by gastric cancer after 15 to 20 years, resection of dysplastic lesion found on endoscopy should be resorted to. Even if there are no such symptoms, patients should be advised to undergo endoscopy and biopsy tests especially at anastomotic site after 20 years of their gastrectomy. Such individuals should be advised to avoid tobacco and have a healthy diet besides being treated for Barrett’s esophagus and H.Pylori colonization which are conditions suggesting potential malignancy. (Layke C and Lopez P 2004) Primary care providers should look for premalignant conditions such as germline mutation carrier in the gene which has 70 to 80% chances for developing diffuse type of gastric cancer, and a high-grade intraepithelial neoplasia having 60-70% chances for blowing into gastric cancer and HNPCC syndrome so that prophylactic surgery can be done or high surveillance is undertaken.( Vogelsang H et al 2005) Primary care professionals should advise potential risk groups to quit smoking which is a major risk factor for stomach cancer and subject them to attend smoking cessation programs and suggest other methods to quit smoking. They should also be asked to limit alcohol consumption since too much of it makes chemical changes in the body promoting cancer cell growth. Their dietary habit should be changed towards consuming fresh fruits and vegetables besides dietary fiber and at the same time reduce intake of red meats that are processed as nitrates used in the process contribute to stomach cancer. The risk groups should be also advised to avoid salty, smoked and pickled foods. Monitoring their weight is also equally important since obesity is a risk factor for stomach cancer. Avoidance of occupational hazards like exposure to coal dust, asbestos and nickel that are found to have toxins causing stomach cancer. The primary care professionals also will look for digestive symptoms such as nausea, vomiting, bloating, diarrhea, constipation or abdominal pain since if ulcers causing them are due to H.Pylori bacteria, they will result in stomach cancer. They should advise likely groups to avoid taking NSAIDs without physician’s advice since though these drugs especially aspirin are capable of reducing the risks of stomach cancer, they are also capable of causing internal bleeding which will result further complications in susceptible patients. (Oren Mark) As there is no mass screening for gastric cancer in the US unlike in Japan where it is widespread, primary care professionals have the difficult task of identifying risk groups. Hence when the signs and symptoms are found in people, are they able to isolate the patients with such risks. They should be advised by the professionals to undergo endoscopy which alone can diagnose gastric cancer. This will be followed by imaging, laparoscopy and lab tests depending on the outcome of the endoscopy tests. Besides, tumor markers have not been identified for stomach cancer though for many other cancers they have been identified. As these markers are a type of protein found in the blood or urine, it is possible to detect cancer early in blood and urine tests. (American Cancer Society 2007) This makes even tougher for the primary care providers their tasks of screening and prevention. Besides they should advise the general population to avoid storage of food in the refrigerators since H.Pylori infection is said to enter the food in their storage period. (Hohenberger et al 2003) It will be pertinent to mention here that a study conducted by Susan A et al (1997) revealed a “relationship between chronic disease status and cancer preventive services over a 3 year period methods. The study concluded that “The presence of common chronic health problems in older adults is associated with lower levels of cancer screening services” (Susan et al 1997) Conclusion Since cancer had been the number 2 killer in the U.S. next to heart disease, President Nixon declared war on cancer in 1971. Despite this, cancer death rates continue to increase. The cancer project says that instead of struggling to research on newer drugs and treatments, often in vain, efforts should be directed towards prevention as the large body of data suggests that cancer is preventable. (Cancer Project) Since 30 % of cancer is due to tobacco, and another 35 % due to dietary reasons, eradication of cancer is well within our reach with the will of the people and primary care providers. The Medical MDs and Nurse practitioners involved in gastric cancer prevention and screening should play their key roles in arresting the incidence of gastric cancer by assimilating the above brief literature review and by following preventive measures recommended by the WHO and National Cancer Control Programs. References American Cancer Society 2007 Stomach cancer accessed November 17, 2007 http://www.cancer.org/docroot/PED/ped_1.asp?sitearea=PED Cancer Project accessed November 17, 2007 http://www.cancerproject.org/survival/cancer_facts/major_killers.ph. Doll R, Peto R. The causes of cancer. Journal of National Cancer Institute. 1981; 66: 1191-308 Fielding JW and Tan YK “Early diagnosis of early gastric cancer” European Journal of Gastroenterology Hepatology. 2006 Aug; 18(8):821-9. Gore Martin and Russell Douglas 2003 “Cancer in Primary Care” Published by Martin Dunitz, London and New York. Hohenberger, Peter, and Stephan Gretschel.2003 “Gastric cancer. (Seminar). ”The Lancet.  362.9380 (July 26, 2003): 305 Layke C. John and Lopez P.Peter 2004 1 March 2004 “Gastric Cancer: Diagnosis and Treatment Options” American Family Physician (A peer reviewed journal) March 1, 2004 Manual on Prevention and Control of Common Cancers, 1998 WHO Regional Publications. Western Pacific Series No 20. McMillan SC, Small BJ, Weitzner M, Schonwetter R, Tittle M, Moody L, Haley “Impact of Scoping skills intervention with family caregivers of hospice patients with cancer: a randomized clinical trial.” Cancer. 2006 Jan 1; 106(1):214-22 Copyright 2005 American Cancer Society. Oren Mark “Stomach Cancer” iVillage Total Health accessed November 17, 2007< http://totalhealth.ivillage.com/stomach cancer.html? pageNum=8#a10b5c49bff361107fcb2963611078c3d240_ Russell Douglas and Davies R Gareth 2003 “Cancer in Primary Care” Published by Martin Dunitz, London and New York. Susan A., Fontana, Baumann Linda C. , Helberg Clay, and Love.R Richard "The delivery of preventive services in primary care practices according to chronic disease status.” The American Journal of Public Health.  87. n7 (July 1997): 1190(7).  .Vogelsang H, Ott K, Mehler J, Keller G, Siewert JR. “Prophylactic gastric surgery” Chirurg. 2005 Dec; 76(12):1115-24. Yeoh KG, So JB, and Dan YY 2006 “ Endoscopic screening for gastric cancer” Clinical Gastroenterology and Hepatology 2006 Jun;4(6):709- 16 WHO > Programmes and projects > Initiative for Vaccine Research (IVR) > Selection of Diseases in IVR Portfolio Accessed November 29, 2007< http://www.who.int/vaccine_research/diseases/soa_bacterial/en/index1.html> Read More