Toby Keith’s death shined a light on an uncommon form of cancer

Country music superstar Toby Keith’s death of stomach cancer earlier this year has helped raise awareness of a type of cancer that is not very common in the United States. The American Cancer Society estimates that there will be about 26,890 new cases in 2024 and 10,880 deaths. It is more prevalent in men, with an estimated 16,160 men who will be diagnosed compared to 10,730 women.

Unfortunately, unlike breast or colon cancer, gastric cancer has no screening test that is regularly done, explained oncologist Edward J. Wyluda, DO at the Davenport-Mugar Cancer Center at Cape Cod Hospital in Hyannis. That means it usually isn’t detected early enough to completely cure the patient.

“By the time we’re seeing them on medical oncology, they are often in Stage IV disease and they aren’t curable,” he said. “Stage IV means that it has spread to the abdomen or another organ. It’s an advanced cancer. So, then we get to the point where we’re talking about treatments that are palliative in nature.”

Even if it is caught earlier, the prognosis for overall survival isn’t great. If you’re diagnosed with a gastric cancer Stage II B or higher, your five-year survival rate is only about 35 percent or less, Dr. Wyluda said.

The causes of stomach cancer include:

• A history of ulcers – about 25 percent of cases have this history.
• The stomach infection H. pylori.
• Drinking too much alcohol.
• Eating or drinking other foods that irritate the stomach like coffee and salty or smoked foods.

The best way to prevent getting stomach cancer is to be cautious about drinking too much alcohol or coffee or eating too many salt-cured or smoked foods, Dr. Wyluda said. Exercise is also preventive because it reduces stress which can increase the risk of ulcers.

Symptoms

The symptoms of gastric cancer can be either subtle (in early stages) or more obvious (in later stages), he said. They also depend on where the tumor is located and if it has spread. A common symptom is weight loss. This could occur because the patient is nauseous and not inclined to eat, or if the tumor is large and taking up space in the stomach, making it feel full.

“Sometimes too, depending on the location of the tumor, it could be closer to where the esophagus is meeting the stomach and it can sometimes impede your intake in that way,” Dr. Wyluda said. “For example, maybe you’re getting food stuck right at that esophagus/stomach junction.”

Other symptoms include fatigue, night sweats and abdominal pain in the mid to upper abdomen. About 25 percent of patients will bleed, causing their stool to turn black in color. The bleeding could be from an ulcer or from a tumor that is growing on blood vessels.

Treatment

Oftentimes, people with symptoms are first treated with a proton-pump inhibitor (PPI) like Prilosec, for heartburn, ulcers or gastric reflux.

If symptoms aren’t improving, they may be referred to (a gastroenterologist), who may perform an endoscopy procedure, said Dr. Wyluda. An endoscopy involves a camera which goes through the mouth and esophagus into the stomach so the gastroenterologist can visualize the area. If they see anything of concern, they take samples of the tissue (a biopsy) and send the tissues to a pathologist for a diagnosis.

For earlier stage stomach cancer, there are options including surgery, he said. “Sometimes we do chemotherapy up front to try to shrink the tumor down and then do the surgery. Sometimes we do chemo and radiation. But I would say the majority of patients we see here in the medical oncology clinic are advanced tumors.”

If it is a more advanced cancer that has spread to the nearby lymph nodes or the peritoneum (the layer that overlaps the intestines), patients could experience fluid in their belly, abdominal distention and acute abdominal pain. If it has spread to the liver, patients’ skin turns yellow from jaundice. Those patients would need a CT scan and then a biopsy of one of the spots detected on the CT.

Still Treatable

“Unfortunately, in those circumstances we know this is a Stage IV cancer and one that would not be curable, but it is treatable,” Dr. Wyluda said. “We do have some therapies that can help decrease the tumor burden to improve symptoms and to improve overall survival.”

These therapies include a combination of chemotherapy drugs called FOLFOX. The tissue from tumors of patients with Stage IV gastric cancer also gets checked for Next Generation Sequencing (NGS) to see if they harbor any mutations that can be targeted. If a tumor expresses HER2, Dr. Wyluda gives them the same medication that is used for HER2 positive breast cancer patients.

“We also check something called a PDL1 expression because, if it is elevated, it suggests there could be benefit to adding immunotherapy, too,” he said. “When we are talking Stage IV, it’s one where we’re trying to treat the symptoms, decrease the symptoms and decrease the tumor burden and improve the survival time."

Dr. Wyluda starts patients on a regimen that is continued indefinitely if the tumor is responding. For example, the FOLFOX regiment is done every two weeks for two to three months. At that point, imaging is repeated to see if the tumor is responding before continuing. Once the tumor becomes refractory to treatment, he switches to a different line of therapy with different drugs.

Without treatment, patients with Stage IV gastric cancer have six months or less to live. With treatment, they can live an average of a year.

“Sometimes we get lucky, though,” he said. “Somebody has that HER2 receptor mutation or something to that effect that we can target and we can sometimes get more robust responses but on average the prognosis is poor and unfortunately life expectancy is short.”

Toby Keith lived two years after diagnosis, with treatment that included surgery, chemotherapy and radiation.