Worried I Might Have Stomach Cancer

I am worried I might have stomach cancer. I have had symptoms of indigestion and heart burn as well as stomach pain for 10 months, given Omeprazole but no help. 

6 weeks ago I had a stool test for pylori which came back positive. I had treatment comprising of triple therapy and had no symptoms for 4 weeks after, but now they are all back.

I was told by my GP to take Omeprazole again but as no red flag symptoms I don't need any test I'm 54 years old female and very concerned. Trish, UK

Should I Be Worried I Might Have Stomach Cancer?

Sorry to hear about your symptoms and your comment "I am worried I might Have Stomach Cancer". Your general practitioner has been following guidelines set out either locally in conjunction with the hospital services or by the National Institute For Health and Care Excellence  which states that if under the age of 55 years with uncomplicated symptoms of dyspepsia (heartburn, indigestion, acid reflux) then it is okay to treat without referral for endoscopy.

Different countries have different rules on symptoms and investigation, but I am really going to address the UK guidelines for you.

Your GP checked your helicobacter pylori status correctly and gave you the appropriate eradication therapy which worked initially for you, but symptoms have unfortunately now returned.

The guidelines are misleading as some previous criteria for urgent referral for endoscopy have been changed with age no longer a factor nor anxiety about it (I will explain more later).

Factors that prompt urgent referral for endoscopy WHEN DYSPEPSIA IS PRESENT are:

  • Chronic GI Bleeding
  •  Unintentional Weight Loss
  • Persistent Vomiting
  • A Palpable Abdominal Mass
  •  Abnormal X-ray Investigations

So, why haven’t you been offered an endoscopy as you STILL HAVE SYMPTOMS and anxiety about this?

Well, NICE states in patients of 55 years or older with unexplained and persistent recent onset of dyspepsia alone, GP’s should refer for endoscopy.

However, there is no clear guidance in the under 55 year olds for this. NICE says that it is rare under the age of 55 years and really justify not doing the tests for this reason, further qualifying that if it is picked up in this group it is likely to be incurable (I suspect the reason is actually delay in diagnosis as well as more aggressive tumors) although I don’t think this is a reason for not doing the test. 

BUT, I would argue that someone with unexplained or persistent symptoms (4-6 weeks) (plus some anxiety about having a tumor, although not a criteria any more) should be investigated further.

It is this thorny issue which really provides the uncertainty, but I would always advise investigation over non-investigation if there is any doubt at all as to the diagnosis.

NICE ignores human traits such as anxiety, concern and works purely on facts and cost benefits in doing the tests, although they do also look at risk of performing endoscopy in their guidance which they quote as a morbidity of around 1 in 200 i.e. some ill effect from doing the test to 1 in 2000 endoscopies causing death.

These figures are high, but I suspect if you look at the data the mortality is in all endoscopies and are most likely related to the elderly who have other illnesses that contribute to this.

Morbidity can be anything from cough and short lived sore throat to more serious, rare complications such as perforation of the gullet.

Some people are looking at tumor markers and risk factors to target the right people for investigation. 

Coming back to your concerns, it is something you will need to discuss further with your GP, but if they are happy with their diagnosis of dyspepsia in you, have discussed lifestyle changes, reviewed any medications that you may be taking that can cause dyspepsia and feel that they are giving you adequate treatment which is providing some relief then they are quite at liberty to continue treating you this way.

You are, of course, also able to ask your GP for a specialist opinion or second opinion in this matter.

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