Gastrointestinal and Hepato-pancreatico-biliary cancers include the cancers of the gastrointestinal tract like the esophagus, stomach, duodenum, small bowel, colon, and rectum. The Hepato-pancreatico-biliary cancers include the cancers of the liver, bile duct, gallbladder, and pancreas.
This article will highlight the presentation, early detection, diagnostic, and staging modalities and treatment options for these cancers in general and also explain why you need to visit a specialist for these cancers.
Most of these cancers present in advanced stages i.e. stage 3 and 4. Stage 3 implies that the spread is loco-regional either to the surrounding or nearby lymph nodes or adjacent organs, whereas in stage 4 disease there is spread to the distant organs, for example, to the liver, lungs, or distant lymph nodes. The symptomatology of cancer depends on the organ involved, the extent of involvement of the organ, for example, an early-stage cancer of stomach would present with minimal symptoms, whereas advanced cancer might present with pain, vomiting, weight loss, and decreased appetite.
Detection of these cancers at an early stage can result in an improvement in cure rates. There needs to be a lot of emphasis on awareness regarding the red-flag or warning symptoms amongst the public as well as general healthcare practitioners, who are the first point of contact in most parts of our country. This can result in an early visit and a timely referral to the concerned specialist. Similarly, screening programs are helpful in early detection. The main limitation of these programs is their cost-effectiveness and hence their implementation in a vast country like ours is questionable. However, screening programs can be selectively used in regions with a high incidence of a particular type of cancer for that region.
The diagnosis of these cancers depends on the organ of involvement. For example, the diagnosis of carcinoma esophagus, stomach, duodenum, colon, and rectum requires endoscopy and biopsy from the cancerous growth. Ultrasound of abdomen done by an experienced radiologist along with some basic investigations is helpful in most cases to pick up cancers of the gallbladder, liver, pancreas, and bile duct.
Cancer staging before the start of treatment is also called clinical staging. This helps in diving. This helps the clinician in formulating the treatment plan and prognostication. Commonly used staging investigations include CT scan, MRI, PET scan. However, the staging investigations are determined by tumor size and type. For example, staging investigations for a stomach adenocarcinoma include a CT scan of chest, abdomen, and pelvis. However, the staging of a neuroendocrine tumor of the stomach requires a special scan called DOTANOC scan.
Is tissue diagnosis or biopsy required in all cases?
A tissue diagnosis should be obtained whenever it is possible in the form of biopsy or cytology.
Tissue diagnosis is important:
- Before the start of cancer-directed therapy like chemotherapy, radiotherapy
- To know the type of tumor i.e. to differentiate lymphoma from adenocarcinoma
- When it can alter plan and intent of management e.g: obtaining tissue from a liver lesion in carcinoma stomach
- To differentiate some cancerous conditions from conditions that mimic cancer like tuberculosis.
Tissue diagnosis is not however mandatory in some situations. These include:
- When a negative biopsy will not alter the plan eg: a radiologically convincing pancreatic or gall-bladder mass that is suitable for surgery.
Introducing a biopsy needle in such a situation has the potential for tumor spread along the needle tract.
The treatment of these cancers depends on the clinical stage, tumor type, patient’s overall performance status, associated medical problems, and patient preference. In general, most of the early stage (stage I) cancers surgery is the treatment of choice. For most of the higher stage cancers with limited spread (stage II, III), combined modality treatment with chemotherapy, radiotherapy, and surgery ensures better outcomes compared to a single modality approach.
Whom to visit and why?
It is important to consult a clinician who specializes in the care and treatment of these cancers. In today’s day and age, oncology is moving towards organ-based specialization and practice. This has been shown in scientific literature to improve short and long-term outcomes. A clinician with formal training in treating these cancers is thus preferred.