Stomach (gastric) cancer treatment in Israel: therapy and surgery

In recent years, stomach (gastric) cancer treatment in Israel becomes popular among medical tourists from around the world.

The secret of success is a surprising combination of high professionalism, advanced technologies and surprisingly low prices.

Gastric cancer remains one of the most deadly oncological diseases in developed world. In the United States, this cancer is #15 for incidence and #4 for the number of deaths.

These numbers highlight the need for new methods of diagnosis and treatment.

Why does stomach (gastric) cancer occur?

The causes of this insidious disease are spontaneous mutations that allow cells to multiply uncontrollably capturing new tissues and internal organs.

Why do we suffer from cancer?

Scientists and oncologists are still looking for an answer to this question. According to the latest research, the risk largely depends on our lifestyle and nutrition.

Among the known risk factors for stomach (gastric) cancer:

• Modifiable factors: Helicobacter pylori infection, heavy smoking, bad dietary habits (smoked meat, canned foods, added salt, and low fruit consumption).
• Unmodifiable factors: advanced age, male gender, heredity, chronic atrophic gastritis, Birmer's anemia, polyps, intestinal metaplasia, giant hypertrophic gastritis.

What are the symptoms of stomach (gastric) cancer?

In the early stages, the disease can be asymptomatic.

Possible cancer symptoms: pain, discomfort, and digestive problems. These minor issues are so “harmless” that patients usually ignore them. Moreover, these symptoms may resemble already existing chronic gastrointestinal diseases (gastritis, peptic ulcer). In the early stages, there may be epigastric discomfort or pain, a feeling of fullness after meals, loss of appetite, nausea and heartburn. Why should these symptoms worry you?

Only after a few months the patients begin to sound the alarm. GI bleeding, vomiting with blood, anemia, severe abdominal pain, jaundice and ascites – obvious signs your body is in trouble. Unfortunately, at the stage of locally advanced and metastatic cancer, treatment is usually ineffective, and life expectancy is extremely low.

Survival rate and prognosis for tumors

Distal stomach (gastric) tumors at early stages are cured in half the cases, and the 5-year survival rate exceeds 70-80%. Proximal tumors behave differently and are less treatable. Unfortunately, the disease is diagnosed at an early stage in less than 20% of cases. The remaining patients turn to clinic with a neglected form, including metastatic cancer.



With stage IV gastric cancer, the 5-year survival rate barely exceeds 5%. Disseminated cancer cannot be cured, but oncologists can prolong life and alleviate the condition of such patients.

The best stomach (gastric) cancer treatment in Israel

Israel is a tiny country in the heart of a troubled Middle East.

Why it attracts thousands of medical tourists from Europe, America, and Russia?

If we talk about technical equipment, training of doctors and the level of oncology in general, Israel is not inferior to the United States or Germany. At the same time, prices for treatment are 25-50% lower compared to Western Europe. Moreover, some diagnostic tests and surgical procedures are 3-6 times cheaper than in the US.

Israeli gastro-oncology, despite its similarity with the American one, has unique features. Local oncologists and oncosurgeons pay greater attention to practical training and self-education. Strict rules and safety standards are applied in every clinic and doctor’s office. Instead of acquisition of foreign technologies, Israeli clinics implement inexpensive and effective inventions of local institutions. This approach allows them providing extra-class services at surprisingly affordable prices.

Among the leaders of Israeli gastro-oncology:

1. Assuta Hospital in Tel Aviv
2. Sourasky Medical Center (Ichilov) in Tel-Aviv
3. Moshe Ben-Maimon (Rambam) Hospital in Haifa
4. Herzliya Medical Center in the city mentioned above
5. Chaim Sheba Medical Center in Ramat Gan
6. Hadassah Medical Center in Jerusalem
7. Yitzhak Rabin Medical Center in Petah Tikva
8. Soroka Medical Center, Beer Sheba
9. Kaplan Medical Center in Rehovot
10. Ramat Aviv Medical Center in Tel Aviv
11. Shaarei-Zedek Medical Center in Jerusalem
12. Schneider Children's Medical Center in Petah Tikva
13. Meir Medical Center in Kfar-Saba
14. Edith Wolfson Clinic in Holon
15. Elisha Hospital in Haifa

Cost of stomach (gastric) cancer treatment in Israel

The approximate cost of consultations and diagnostic tests:

• Oncosurgeon consultation: $450 or more
• Oncologist consultation: $400 or more
• Basic laboratory tests: $100 or more
• Blood biochemistry test: $300 or more
• Tumor markers blood / urine tests: $800 or more
• PET / CT scan: $1600 or more
• MRI of one body part: $1000 or more
• Computed tomography: $800 or more
• Immunohistochemical study: $700 or more
• Endoscopy with biopsy: $1200 or more

The approximate cost of surgical treatment, chemo and radiotherapy:

• Gastrectomy (partial removal of the stomach): $12,000 or more
• Robotic gastrectomy (Da Vinci system): $25,000 or more
• Chemotherapy: $2500-3000 or more per course
• Immunotherapy (pembrolizumab): $2000 or more
• Hyperthermic chemotherapy (HIPEC): $40,000 or more
• Radiation therapy: $10,000 or more

Add to these benefits such factors as low prices for accommodation and food, excellent tourism infrastructure and unlimited opportunities for rehabilitation.

This is the secret of Israeli medicine.

Diagnosis of cancer patients in Israel

Local doctors usually ask to repeat some tests that you have already passed. The truth is that in some cases the initial diagnosis is not confirmed, and the patient goes home healthy and happy. Sometimes the initial diagnosis must be reformulated or clarified.

This is a critical factor for choosing proper therapy.

Physical examination and medical history

The patient’s body is like an open book. An experienced physician can learn a lot of useful information from it. What did the patient's relatives suffer from? How does the patient eat? Does he suffer from chronic diseases? All this factors are taken into consideration.

Laboratory blood tests

Complete blood test reveals anemia which is a possible sign of bleeding.



Biochemical test, blood electrolytes and liver function test allow evaluating the condition of vital organs.

Tumor marker blood / urine tests suggest the direction for further search. Israeli oncologists were among the world’s first to use CEA, gastric tumor marker CA 72-4 and some other specific molecules for cancer diagnosis and monitoring.

Stomach visualization

Esophagogastroduodenoscopy (EDG) is a widely used visualization technique. EGD allows looking inside the stomach and esophagus, examining the mucous membranes of the upper gastrointestinal tract for signs of a tumor. During the procedure doctor can perform a biopsy of suspicious tissues.

Barium X-ray of the stomach and esophagus with barium requires preliminary intake of a special liquid containing the radiopaque agent barium sulfate. After ingestion of barium, the upper GI tract is examined using a series of X-ray images.

CT scan. In fact, computed tomography is the same 3D radiography, performed under the machine control at different angles. This high-tech method gives your doctor a detailed picture of the esophagus, stomach, pancreas, and other internal organs and nearby bones.

Magnetic resonance imaging (MRI) largely resembles CT. The same room, the same shape. But this technique is very different: MRI uses electromagnetic waves, not X-rays. MRI helps to find even the smallest tumors throughout the body.

Positron Emission Tomography. Used alone or in combination with a CT scan, PET is technically complex and very expensive. In gastric cancers, PET plays a secondary role.

Laparoscopic surgery provides access to the organs of the abdominal cavity. Laparoscopy is a minimally invasive procedure that is performed through several miniature holes in the abdomen.



Sentinel lymph node mapping. This technique has proven effective in melanoma. But today some clinics use mapping (topography) to assess the involvement of lymph nodes in stomach cancer. Thanks to the mapping oncosurgeons can remove the affected nodes and stop the disease Nevertheless, this is an experimental technique. Since the early 2000s, the Assaf-Arofe Institute of Oncology in Beer Ya'akov is actively working on adapting this technique in gastro-oncology.

A tumor biopsy is a procedure that is indispensable in the diagnosis. The tumor cells removed during gastroscopy are studied with a microscope and treated with special reagents.

Histological analysis reveals the type of cells that make up the tumor. Adenocarcinoma of the stomach is up to 95% of the samples, lymphoma - up to 5%, and less than 1% is such tumors as leiomyosarcoma, squamous cell carcinoid tumors, etc. Each histological type of cancer requires unique approach to treatment.

Molecular analysis helps to detect increased activity of genes, such as HER2. These tumors respond well to monoclonal antibodies (trastuzumab), whereas HER2-negative cancers do not respond to costly targeted therapy.

Stomach (gastric) cancer treatment in Israel: technology and drugs

The success of treatment is the result of well-coordinated teamwork. This medical team includes a gastroenterologist who specializes in general GI conditions, a medical oncologist, radiologists, pathologists, psychologists, nutritionists and rehabilitation specialists.

The main option for stomach (gastric) cancer of stage I-III is surgical removal of the tumor followed by radiotherapy and chemo. When we talk about metastatic cancer, it is impossible to completely remove the tumor, so treatment is based on chemotherapy, immunotherapy and radiation.

Optimal treatment tactics depend on many factors: the stage, the presence of metastases, side effects, patient's health condition, age, individual preferences, and financial opportunities. Israeli oncologists do everything to provide you the most effective treatment.

Surgical options

The type of surgery depends on the cancer stage.

Endoscopic mucosal resection (EMR) is performed in the early stages, when the tumor is confined to the wall of the stomach. The procedure is minimally invasive, but it is also demanding to the equipment of the clinic and the surgeon's practical skills.

In the early stages, when the tumor does not affect liver and nearby organs, doctors choose partial gastrectomy. It is a open surgery to remove part of the stomach along with the adjacent lymph nodes. The remaining parts are connected with the esophagus and small intestine. If the tumor has spread further, there is a need for subtotal or total resection of the stomach. In the latter case, the organ is removed completely, and the lower end of the esophagus is connected directly to the intestine.

Treatment is always combined with chemo or radiotherapy.



Israeli doctors, in contrast to their American colleagues, usually pay more attention to lymph nodes, considering them the main cause of subsequent relapses of cancer.

Gastrectomy is a difficult and risky surgery. Among possible complications: dumping syndrome (nausea, diarrhea, and abdominal cramps), vitamin B12 deficiency, anemia, and weight loss.

Radiotherapy

Radiation damages and kills rapidly dividing cancer cells.

The main option for tumors of the stomach and esophagus is external-beam radiation therapy. This involves exposure to high energy rays from a source that is outside the body. Radiotherapy is ordered before surgery (to reduce tumor size) or after gastrectomy (to prevent relapse).

Possible complications of radiation therapy include: skin redness, diarrhea, weakness and fatigue. These effects usually pass after therapy is finished.

Chemotherapy for stomach (gastric) cancer

Chemotherapy drugs interact with vital molecules in cells, disrupting their ability to grow. Chemo is highly toxic treatment, so it requires continuous monitoring. Chemotherapy for stomach (gastric) cancer is administered IV or taken orally in capsules and tablets. Israeli oncologists usually prescribe 2-3 drugs in combination to enhance their effect. Such regimes may be designated by acronyms (FOLFOX, XELOX, FOLFIRI).

Most chemotherapy regimens contain cisplatin or 5-fluorouracil.

Other chemotherapeutics:

- Docetaxel
- Paclitaxel
- Irinotekan
- Epirubicin
- Oxaliplatin
- Capecitabine

For example, combinations of capecitabine / 5-fluorouracil + cisplatin + docetaxel and FOLFOX / XELOX are often used to treat metastatic stomach (gastric) cancer (stage IV). Side effects of chemo are quite serious: nausea, diarrhea, alopecia, leukopenia, frequent infections, loss of appetite, weakness, neuropathy, and anemia.

Some chemotherapeutics increase the risk of developing secondary cancers.

Targeted therapy

This type of treatment is aimed at specific receptors and genes of cancer cells. Due to high selectivity, targeted therapy is less toxic than conventional chemo and usually well tolerated. Stomach tumors, even within a single histological type, contain different biological targets. Laboratory tests help to determine the molecular portrait of cancer and find the best drug. Angiogenesis inhibitors stop the growth of the vasculature necessary for tumor growth and development. Israeli oncologists use ramucirumab (Cyramza), either alone or in combination with standard chemotherapy drugs.

HER2-targeted therapy acts on the cellular receptor of the epidermal growth factor. Trastuzumab (Herceptin) is a typical representative of this class. It is widely prescribed for patients with later-stage HER2-positive gastric cancer.

Immunotherapy

This method is also called biological therapy. Immunotherapy activates immune defense mechanisms to fight cancer and its metastases throughout the body. It is used at the stage IV, after the failure of alternative treatment options.



Modern biological agents block CTLA4 and PD-1 cell receptors, preventing malignant cells from avoiding the patient's immune system attacks. Gastric cancer immunotherapy is largely experimental, but Israeli doctors are recognized experts in this field.

Metastatic stomach cancer treatment in Israel

Unfortunately, sometimes the disease is diagnosed too late. At the stage IV, cancer spreads to other organs. Tumor cells are found in the blood and lymph. In fact, at this stage the patient's body is completely "infected" with cancer.

In such cases it is recommended to talk with several doctors and repeat the necessary tests. Foreign patients often seek a second opinion from leading oncologists of such well-known clinics as Assuta, Hadassah or Ichilov. Their advice helps to make the best decision.

But science does not stand still. A couple of years ago, the oncologists of Rambam Medical Center and their colleagues from Tel Aviv University tested so-called biomarker-driven therapy: choosing chemotherapy regimen under the strict control of blood biomarkers.

Biomarker-driven therapy in metastatic gastric cancer increases survival by 29-30%.

But the goal of treating this stage is to prolong life and make the last years as comfortable as possible. Aggressive chemotherapy, immunotherapy, radiation therapy and palliative surgery play a major role in these cases.

Stomach (gastric) cancer treatment is always stressful. But you are in good hands: experienced and passionate Israeli 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