Stomach (gastric) cancer treatment and diagnosis in Germany

There are more than a dozen large private clinics and university medical centers that offer affordable treatment for stomach cancer in Germany that meets the world's best standards.

Malignant tumors of the stomach (cancer) usually develop as a result of uncontrolled mutations in gastric mucosa cells. In 95% of cases, cancer develops in glandular tissue – adenocarcinoma.

Tumors of lymphatic tissue (MALT lymphoma) or muscle tissue (sarcomas and gastrointestinal stromal tumors – GIST) are less common.

Adenocarcinoma in the upper part of stomach (cardia) can be considered esophageal cancer, which is treated accordingly.

Methods of stomach cancer treatment in Germany include endoscopic resection (ER) of the tumor, high-precision radiation therapy, chemo and targeted drugs against specific mutations.

For the timely diagnosis of a deadly disease, local doctors use high-resolution magnetic resonance imaging (MRI), endosonography (EUS), and sophisticated laboratory tests.

Causes, risk factors and stomach (gastric) cancer statistics

Each year, the Robert Koch Institute (Berlin) records 15,500 cases of gastric cancer, with incidence slightly higher in men. This disease is associated with smoking and eating habits. Despite the obvious improvements in treatment, the gastric carcinoma survival rate remains very low. This is due to late diagnosis of a cunning tumor that can be masked as a "harmless" gastritis.

Because of uncertain symptoms, only 20% of cases are diagnosed at an early stage. In Germany, the five-year survival rate (for all stages) is about 35%. This is significantly higher compared with most developing countries, but it is still far from the target.

The exact causes of gastric cancer are not fully understood by scientists.

In addition to strong genetic predisposition (Lynch syndrome), Helicobacter pylori infection, chronic atrophic gastritis, partial gastrectomy, and the use of certain food toxins and smoking play an important role in the development of this devastating disease.

1. Food: Canned foods, fried and processed food, smoked foods, food nitrites and nitrates, aflatoxins are considered potentially dangerous carcinogens.
2. Infections: Inflammation of the gastric mucosa caused by Helicobacter pylori bacteria is considered an important risk factor. H. pylori triples individual risk.
3. Pre-Diseases: Chronic atrophic gastritis, gastric polyps, pernicious anemia, peptic ulcer disease, Ebstein-Barr virus, previous surgical procedures.
4. Heredity: The individual risk of stomach cancer increases by 3-4 times if parents, children, and siblings suffered from this malignancy. Hereditary nonpolyposis colorectal cancer (also called HNPCC, Lynch syndrome) increases risk at a young age by 12 times.
5. Smoking: Tobacco toxins are considered an important gastric cancer risk factor. Carcinogens dissolve in saliva, being absorbed by the digestive tract. They damage DNA, causing dangerous cellular mutations. It is proved that smoking triples the risk.

Symptoms and early detection of stomach (gastric) cancer

The German Cancer Research Center (DKFZ) warns: pay attention to early symptoms!

• abdominal pain
• feeling of fullness
• excessive belching
• bad breath (halitosis)
• nausea and vomiting
• bloating and gases
• loss of appetite
• taste disorders
• weight loss
• constipation
• weakness
• paleness
• anemia

The symptoms listed above do not always mean cancer. Don't panic.



All these complaints can have simple explanations like overeating or GERD. But the sooner you pinpoint the exact cause, the better for your health. This is especially true if mentioned symptoms last longer than a month, regardless of your diet and lifestyle changes.

Targeted screening for early detection of stomach cancer does not exist.

If the tumor is detected in the early stages, until it has spread through the muscle layer, but is limited to the mucosa and connective tissue, the chances for recovery are very high! Unfortunately, almost every second patient in developed countries is asking for a doctor's help too late. The reason is only that the warning signals were not taken seriously enough.

Stomach (gastric) cancer diagnosis in Germany

If you have any symptoms, it's time to take care of your health. Using modern visualization options and lab tests, oncologists will find the cause, choosing the best therapy for each patient.

• physical examination
• ultrasound exam (sonography)
• endoscopic examination (gastroscopy)
• laboratory tests of blood and tumor samples
• magnetic resonance imaging (MRI)
• computed tomography (CT)
• upper GI X-ray contrast study
• laparoscopy

Ultrasonography

If suspicious clinical symptoms are present, doctor may refer the patient for ultrasound exam (sonography) of the abdomen. The cost of ultrasonography in Germany is about 100-200 euros.

It is worth mentioning that endosonography (when sensor is placed into the esophagus) is much more effective than traditional ultrasound exam. Despite the high cost, EUS provides us detailed information on the condition of the stomach, adjacent organs and lymph nodes. Endoscopic ultrasound can accurately describe how deep the tumor has grown into the wall of the stomach and nearby tissues. This is extremely important when planning a surgery.

Ultrasound is painless and completely safe. Unlike radiography and computed tomography, ultrasound can be repeated as often as required by the diagnostic process. With no risks.

Gastroscopy

In some clinical cases endoscopic examination of the stomach and esophagus is performed. Gastroscopy (as doctors call this study) reveals cancer, ulcers or gastritis quickly and safely. During a gastroscopy your doctor insert special probe with miniature camera into the stomach examining the inner surface of the upper GI tract and collecting samples of suspicious tissue. Endoscopic examination is especially important because the doctor can perform laboratory tests. Collected tissue samples are checked for atypical cells, mutations, infections, etc.

The average cost of gastroscopy in German clinics is about 1300-1500 euros.

For comparison, similar procedures in the United States will cost $ 3000.

Radiography

GI X-ray contrast study is rarely performed. German doctors used this method in addition to gastroscopy to clarify the diagnosis, but today there are much more effective technologies. On X-ray films oncologist can see the tumor mass assessing the impact of the disease on the functioning and structure of the digestive system, visualizing the sites of stenosis.

Chest X-ray is still used to search for lung metastases.

The cost of plain radiography in Germany is about 100 euros, which is three times cheaper in comparison with the United States. Another 250-300 euros you will have to pay for an online consultation of experienced oncologist who will read the images provided.

Laboratory tests

Laboratory tests for stomach cancer include a general blood test that informs about the patient's overall health, as well as the organ functions, including liver and kidneys.

Sometimes fecal occult blood test (FOBT) is also recommended to check for invisible blood in stool. This may indicate a gastric ulcer, as well as tumors of the stomach and intestines. German clinics offer a complex of modern tests tumor markers. These are specific substances released by cancer cells or the body itself in response to the development of the disease. Gastric cancer markers include CEA (carcinoembryonic antigen), CA 72-4, CA 19-9, etc.

However, tumor marker tests are nonspecific: sometimes they cannot be found in cancer, but sometimes they are present in healthy people. Thus, the use of CA today is limited. They give a hint, but do not give an answer. During follow-up, markers are used for monitoring

The cost of analysis for tumor markers in leading clinics in Germany is 300 euros or more.

Tumor biology is a new direction, which is actively studied by DKFZ scientists. Determination of the cancer genetic profile, the presence of HER2 receptors and other molecular targets allows us to choose the optimal therapy for everyone.

Laparoscopy

Tumor sprouting through the stomach wall can spread over the abdominal cavity. To assess the spread of cancer, endoscopic examination of the abdomen (laparoscopy) may be required. In some cases, surgeon prefers mini-laparoscopy. During procedure, miniature instruments are inserted into the abdominal cavity through 2-3 mm holes in the patient's body. Mini-laparoscopy doesn't require surgical sutures, and is usually performed without general anesthesia.

Laparoscopy in Germany cost several thousand euros, depending on the complexity.

Magnetic resonance imaging

MRI is often used to search for metastases throughout the body, including liver. Because liver is a prime target for malignant cells, doctors pay great attention to this organ. If suspicious lesions are detected on ultrasound, an MRI with subsequent biopsy may be required.

MRI in Germany costs 800-1000 euros or more for one researched area.

Unlike computed tomography, MRI does not use x-rays. Thanks to a powerful magnetic field and computers, magnetic resonance provides perfect images of soft tissues without harmful radiation. MRI can be repeated without cancer risk or other negative health effects.

Gastric cancer stages: what does TNM mean?

Initially, the tumor is limited to the area from which the cancer cells originate. For example, from cardiac mucosa (stage I). As it grows, cancer occupies deeper layers of the gastric wall, involving the muscles of the stomach and peritoneum. Disease progression is characterized by spreading of malignant cells into the nearby lymph nodes. Malignant cells can detach from the tumor and colonize the distant organs through the blood (hematogenic way) or through the lymph (lymphogenic way).

The resulting secondary tumors are called metastases. This is the late, metastatic stage (stage IV), when cancer can no longer be cured. Metastases are most commonly found in the peritoneum, liver and lungs, but other organs may be affected.

TNM staging system

Many patients see in medical history mysterious letters TNM with some numbers. This is an important criterion for choosing therapy. The stage predicts stomach cancer prognosis.

• the size of the growth (T)
• the involvement of lymph nodes (N)
• the presence of metastases (M)

The numbers after TNM give more accurate information about the prevalence of the primary tumor (T 1-4), the number of affected lymph nodes (N 0-3) and the presence of metastases (M1 or M0). An accurate TNM staging is sometimes possible only after surgical resection.



Another point that is important for planning therapy is the nature of the cancer cells (tumor aggressiveness). The degree of malignancy is determined by microscopy. In accordance with the Lauren classification, doctors distinguish fast-growing diffuse and less aggressive intestinal type.

Histological examination of the tumor determines further tactics.

Certified stomach (gastric) cancer clinics in Germany

• Evangelische Huyssens-Stiftung (Essen)
• HELIOS Kliniken Schwerin
• HELIOS Klinikum Pforzheim
• Interdisziplinäres Magenkrebszentrum der Charité (Berlin)
• Johannes-Wesling-Klinikum (Minden)
• Klinik am Eichert Göppingen (Goppingen)
• Klinikum Bogenhausen (Munich)
• Klinikum der Stadt Ludwigshafen am Rhein gGmbH
• Klinikum Dortmund (Dortmund)
• Klinikum Lippe (Detmold)
• Klinikum Sindelfingen (Böblingen)
• Klinikverbund Kempten-Oberallgäu (Kempten)
• Krankenhaus Barmherzige Brüder (Regensburg)
• Medizinische Hochschule Hannover
• RoMed Klinikum (Rosenheim)
• Sana Klinikum Lichtenberg (Berlin)
• Schwarzwald-Baar-Klinikum (Villingen-Schwenningen)
• SLK-Kliniken Heilbronn (Heilbronn)
• Städtisches Klinikum Dresden Friedrichstadt
• Uniklinik RWTH Aachen
• Universitätsklinikum „Carl Gustav Carus“ (Dresden)
• Universitätsklinikum Essen 
• Universitätsklinikum Frankfurt am Main
• Universitätsklinikum Gießen und Marburg (Giessen)
• Universitätsklinikum Köln
• Universitätsklinikum Münster
• Universitätsklinikum Regensburg
• Universitätsklinikum Schleswig-Holstein (Lübeck)
• Universitätsklinikum Tübingen
• Universitätsmedizin der Johannes Gutenberg (Mainz)
• Westpfalz-Klinikum (Kaiserslautern)

Any of the above-listed clinics meets world standards and provide high-level cancer care.

But we recommend medical tourists apply to largest university hospitals (Universitätsklinikum) where the latest techniques and medicines are available, and an extensive surgical experience is accumulated. Read the profile of the clinic before your appointment.

Treatment of stomach (gastric) cancer in Germany

After establishing the diagnosis and determining cancer stage, the doctor will discuss the treatment plan with the patient.

• resection
• chemotherapy
• targeted therapy
• radiation therapy
• palliative care

The most important stomach cancer treatment option is surgical resection.

Its goal is to completely remove the neoplasm curing the disease.

Endoscopic resection

If the tumor of the mucous layer does not exceed 2 centimeters and doesn’t penetrate the muscle layer, gastrointestinal endoscopic mucosal resection (EMR) provides good results. In the late stage, perioperative chemotherapy and radiotherapy are recommended along with endoscopic resection. Studies show that such combinations increase the likelihood of recovery and significantly improve the survival rate.

When large tumors that grows through the stomach wall, you may need a complete or partial gastrectomy (removal of the stomach). This is a more complicated and risky operation.

Unfortunately, a healing surgical procedure is not always possible.

If tumor spread into nearby lymph nodes, you need to start with chemotherapy.

With an adequate response to chemo, the tumor decreases, and it can be removed. Chemotherapy is then continued for another 6-8 weeks after surgery to prevent cancer recurrence.

• epirubicin + capecitabine + cisplatin (ECX)
• cisplatin + capecitabine (XP)

If metastases have appeared in the liver, peritoneal membrane, or distant parts of the body, a complete cure can’t be achieved. Surgical resection is performed only in cases of emergency, when serious complications arise (for example, massive internal bleeding). If surgical treatment is not enhanced with chemo, the remaining malignant cells multiply causing a subsequent cancer recurrence. Adjuvant therapy reduces the risk. If it is impossible to remove the affected lymph nodes, radiotherapy and cytostatics can prolong life without progression, delaying cancer recurrence as much as possible.

According to clinical studies conducted in Germany, neoadjuvant therapy is much better tolerated compared with adjuvant chemo. Therefore, doctors prefer to weaken cancer before surgery. The localization of tumor, the TNM staging, as well as the Lauren histological classification are key factors of treatment tactics.

The cost of gastric surgery in Germany reaches tens of thousands of euros.

Possible complications of gastrectomy

There are many complications after stomach removal, mainly for digestion and absorption of nutrients. Some patients almost don’t even notice it, while others complain of discomfort, lose weight and suffer a nutritional deficiency (anemia, bone loss, frequent infections). As a result of gastrectomy (usually total) so-called dumping syndrome develops, in which the contents of the stomach are evacuated to the small intestine too quickly.

• heartburn
• food intolerance
• nausea and vomiting
• loss of appetite
• flatulence
• abdominal pain
• weight loss
• osteoporosis
• anemia

Dumping syndrome can be corrected with diet and lifestyle modifications and medicines (enzymes). Over time, the body usually adapts to the consequences of complex surgery.

German doctors recommend replenishing vitamin B12 by intramuscular injections of cyanocobalamin every 3 months after gastrectomy.

Hyperthermic intraperitoneal chemotherapy

HIPEC (hyperthermic intraperitoneal chemotherapy) is designed to deliver high doses of heated chemotherapy drugs directly into the abdominal cavity during surgery. Direct injection provides a high concentration of cytostatics in the tumor, and heating enhances action of chemo. HIPEC kills the cells that remain after surgery. Procedure lasts about 2 hours.

• highest local efficiency
• increased sensitivity of cancer cells
• minimal systemic side effects

According to recent studies, hyperthermic intraperitoneal chemotherapy for gastric cancer in later stages increases life without disease progression by almost half.

The average cost of HIPEC in leading German clinics is 30,000 euros.

Chemotherapy for stomach cancer

The advantage of chemotherapy over other treatments is that cytotoxic agents can destroy malignant cells throughout the body. Gastric cancer, including adenocarcinoma, is considered very susceptible to chemo. Therefore, perioperative chemotherapy is widely used in clinical practice, increasing the chances of success.



The cost of chemo in Germany starts 1500 euros or more per course.

• cisplatin
• oxaliplatin
• 5-fluorouracil
• capecitabine
• epirubicin
• docetaxel
• leucovorin

In about 20% of cases, gastric carcinomas have an increased expression of epidermal growth factor receptors (HER2). These receptors stimulate uncontrolled tumor growth.

If stomach cancer demonstrates the overexpression of HER2, combinations of standard chemotherapeutic agents with target agents (trastuzumab) provide good results:

• trastuzumab + fluoropyrimidine + cisplatin

Targeted drug ramucirumab (Cyramza) blocks VEGFR2 cellular receptor of vascular endothelial growth factor. This agent stops the growth of blood vessels, helping the cytostatics and radiation finish off the cancer.

Modern combinations of cytostatics in 50% of cases allow resection of inoperable locally advanced tumors of stomach and gastroesophageal junction. Under certain circumstances, complete surgical removal of the tumor and is possible. Several years ago, FLOT regimen was developed in Germany. This is a promising combination therapy, including 5-fluorouracil, leucovorin, oxaliplatin and docetaxel. FLOT is now used around the world, including in the best cancer clinics of the United Kingdom.

The effectiveness of new drug combination therapy was 10% higher in comparison with alternative ECF and ECX regimens previously proposed by British researchers. Even with metastatic cancer (stage IV), cytostatics and targeted drugs significantly increase survival rate - in some cases for several years.

Germany is the world leader in the development of new cancer chemotherapy regimens.

Radiation therapy for stomach cancer

Radiotherapy is rarely used in this disease. But it can be useful in advanced stages, including treatment of metastases. Some studies show that irradiation of bone metastases relieves pain and reduces the risk of fractures.

Adjuvant chemoradiotherapy (CRT) after endoscopic resection prevent possible recurrence. Innovative technologies such as 3D-conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) make the treatment as safe as possible for healthy organs.

Proton therapy is one of experimental options for tumors of the gastroesophageal junction and stomach. According to some experts, high-precision proton therapy is much safer, and therefore it is able to radically change the idea of GI cancer radiotherapy.

Before the procedures, German radiation oncologists conduct simulation - this is planning, in which precise measurements are carried out, determining the optimal dose of radiation and the correct beam angles.

Despite modern computer navigation and precision techniques, radiotherapy has numerous side effects. Radiation affects blood, bone marrow, mucous membranes, digestive tract, nervous and even cardiovascular system.

Possible side effects of radiotherapy:

• fatigue
• weakness
• nausea and vomiting
• poor appetite
• skin burns
• leukopenia
• anemia

Radiation therapy in Germany costs 8000-10000 euros or more.

The choice of treatment depends on the stage of stomach cancer, the condition of internal organs and other factors. Be sure that German doctors will do their best for you and your loved ones.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator