The routine history and physical examination are ordinarily of no assistance in the detection of stomach cancer, although occasionally some of the features to be noted later may be present in latent form in otherwise healthy individuals.

A history of pernicious anemia, diminished or absent stomach acid, or gastric polyps would, of course, serve to single out a patient for particular attention.

Laboratory Studies

The laboratory part of the cancer detection examination includes three tests which may be significant in regard to stomach cancer:

1. Hemoglobin or hematocrit

2. Stool for occult blood (guaiac)

3. Gastric analysis (tubeless method preferred for office practice)

The presence of anemia as reflected in the hemoglobin or hematocrit determination may be one of the early findings in gastrointestinal malignancy, including stomach cancer.

The presence of occult gastrointestinal bleeding as shown by a stool obtained under controlled conditions should suggest the possibility of cancer, and follow-up is essential to rule out the stomach as its site of origin.

Anemia and/or a positive stool, therefore, raise the very real possibility of malignancy. The person with these findings should be labeled a stomach cancer suspect, and intensive diagnostic investigation should be undertaken. The remainder of the gastrointestinal tract, especially the right colon, should be evaluated also under these circumstances.

On the other hand, although the demonstration of diminished or absent gastric acidity places a person in the higher-risk category, it does not ipso facto make him a stomach cancer suspect. The periodic screening of such individuals should, of course, be strict and fairly intense as will be noted.

It will be noted that x-ray examination of the stomach is not recommended as a routine screening procedure for the presence of stomach cancer in the asymptomatic individual. This omission reflects the generally disappointing experience in the last fifteen years of workers who have attempted to survey large numbers of persons by means of rapid fluoroscopy or photofluorography. There has been general agreement that the yield in surveys of this type has not justified the effort expended. By selecting the asymptomatic patients for survey on the basis of age, anacidity, and other factors, x-ray examination may still play a role as a secondary screening procedure, however.

Technique

The recommended techniques employed in the performance of the guaiac test and tubeless gastric analysis are described on pp. 73 and 75.

Follow-Up Of Abnormal Screening Tests

As a result of screening tests, the physician may find himself in one of two typical situations:

1. If anemia and/or occult intestinal bleeding are suggested by the initial screening test:

(a) Repeat the hemoglobin determination or preferably do a complete hemogram (to aid in ruling out a primary anemia).

(b) Repeat the guaiac test after a three-day meat-free diet (refer to p. 75 for causes of a false positive guaiac test).

(c) Do a complete x-ray examination of the gastrointestinal tract if anemia and/or occult bleeding persist on repeated studies.

(1) Should include:

Upper gastrointestinal series

Barium enema with air contrast studies

(2) May also include: Esophagram Small bowel series

Proctosigmoidoscopy, of course, will have been accomplished as part of the basic examination.

(d) Findings uncovered by the studies just outlined dictate the nature and scope of further investigation, which may include (see below) the following:

(1) Cytologic study of gastric washings

(2) Gastroscopy

(3) Surgical exploration

(e) It is, of course, essential that a thorough search be made for non-malignant causes of anemia and occult bleeding, such as:

(1) Hemolysis

(2) Deficiency of erythropoietic factors

(3) Red cell abnormalities

(4) Hemorrhagic diathesis

(5) Blood loss elsewhere in the gastrointestinal tract (e.g., duodenal ulcer, hiatus hernia)

(6) Blood loss from other organs (e.g., menorrhagia, etc.) Remember that occasionally two or more causes may coexist.

If anacidity (achlorhydria) is suggested by initial tubeless gastric analysis:

(a) Repeat the tubeless gastric analysis.

(b) The older method of gastric analysis with intubation may be done if tubeless gastric analysis is negative. This will afford a more precise estimate of the degree of anacidity and particularly its response to histamine stimulation. Less than 30 units of free HC1 under these circumstances is considered evidence of hypochlorhydria. Such a refinement is desirable but certainly not essential for office practice, since the tubeless method has been shown to compare very favorably with the tube technique, especially with respect to real achlorhydria.

(c) Do an upper gastrointestinal series. This may show:

(1) Normal findings (most cases).

(2) Abnormal findings suspicious of gastric cancer or its precursors. In this event the patient is handled as a stomach cancer suspect (p. 185 ff.).

(d) If pernicious anemia and anacidity are present, cytologic examination of the gastric contents may be done in addition to x-ray examination, since specific cells have been identified that are thought by some to represent the transition from atrophic to malignant mucosa. Such findings, therefore, may represent the first evidence of cancer development.

As a result of the procedures just outlined, there may be enough evidence to justify regarding an individual as a stomach cancer suspect. In this case, the management is essentially as outlined under steps to the diagnosis and initial management of the stomach cancer suspect (p. 185 ff.).