Q&A: What is driving ‘disturbing’ rise in metastatic stomach cancer in young adults?
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In 2021, Jessica Sheth Bhutada, MD, MS, and colleagues uncovered a startling 2% annual uptick in metastatic stomach cancer in young adults, despite declining rates in older adults. Three years later, they are still trying to understand why.
“We found that the rates of advanced stage disease were similar to older adults, except for stomach cancer, where over half of young adults were presenting with advanced disease vs. only about one-third of older adults,” Sheth Bhutada, a pediatric oncologist at Children’s Hospital Los Angeles, told Healio. “We don’t have a clear reason for why this is happening; it’s a worldwide phenomenon.”
In their study published in JNCI Cancer Spectrum, Sheth Bhutada and colleagues also found that adolescents and young adults of historically underrepresented groups — in particular Hispanic and Asian individuals — had a 3.5% higher risk of metastatic stomach cancer vs. non-Hispanic whites.
Given the dismal 5-year survival rates for metastatic stomach cancer, this is “almost a death sentence” for young adult patients, Sheth Bhutada noted, but one that could be commuted by examining individual risk factors and social determinants of health unique to young adults.
In an interview with Healio, Sheth Bhutada discusses her intention to answer these lingering questions on cancer disparities in an upcoming study, and potentially unravel the clinical, social and environmental risks that could driving late-stage stomach cancer among young adults.
Healio: What do we know about the rise in stomach cancer in younger adults?
Dr. Sheth Bhutada: This area of literature is completely lacking. There’s no literature to explain why we’re seeing this disturbing trend. We have some ideas, since in colorectal cancer we know that potential etiologies include changes in dietary patterns, antibiotic usage [and] alterations of the gut microbiome. However, there are no studies investigating if and how this might be related to the rising incidence of stomach cancer.
Healio: What is the purpose and aim of your study?
Sheth Bhutada: I became interested in stomach cancer in young adults because my prior study looked at whether young adults are more likely to present with advanced stage disease, meaning cancer that has spread to other parts of the body, compared with older adults. The fact is that young adults are at such a unique and vulnerable stage in their life, sometimes with limited access to health care. Our theory was that young adults would be more likely to present with advanced stage disease than older adults.
Surprisingly, in my prior study, we found that the rates of advanced stage disease were similar to older adults, except for stomach cancer, where over half of young adults were presenting with advanced disease vs. only about one-third of older adults.
I was concerned that this was a health disparity and health equity issue, when we saw that lower income and lower education level patients, as well as minority patients, were more likely to present with advanced stage disease vs. white and higher income counterparts. That, coupled with the fact that incidence was rising in younger adults vs. declining in older adults, is really what pushed me to study this. What’s most disturbing is that 5 years after a diagnosis of metastatic or advanced stage disease, only about 4% of people are still alive. It is almost a death sentence.
This prompted the current study to try to understand why young adults are getting stomach cancer and how can we potentially catch it earlier and even prevent it.
The goal is to do a multi-level analysis on individual factors, such as exposure to chronic Helicobacter pylori infection, obesity risk and connecting that with a patient’s neighborhood risk factors, such as living in food deserts or with limited walkability or access to health care. How do these social determinants of health influence a person’s risk for developing stomach cancer, particularly when they’re young?
Healio: What could be driving a rise in cases in underrepresented populations?
Sheth Bhutada: We know that stomach cancer has a higher rate in Asian people, particularly those from Japan and Korea. There are screening programs available in Japan because the rates of stomach cancer are so high.
This is interesting because there are different patterns of immigration, exposure to diet and different rates of this disease in patients who are born in a foreign country vs. those who are born in the U.S. Further, the timing of when they immigrated might also explain why there are some differences in the risk for minorities. Additionally, there may be different genetic risk factors in certain populations.
Healio: Why could there be a decline in metastatic stomach cases in older adults?
Sheth Bhutada: We don’t have a clear reason for why this is happening. It’s a worldwide phenomenon. In older adults, the index of suspicion for cancer is much higher, and you are more likely to get necessary testing done in a more expedited fashion. In addition, insurance is different once you hit Medicare age and your ability to access some of these screening or diagnostic tests changes.
When you think about symptoms for stomach cancer, such as stomach aches or having some heartburn, cancer is not even on anyone’s mind and health care providers and patients might not think it is something to be worried about. That’s one reason that we might be seeing a difference.
Healio: Are there ways to curb the rise of stomach cancer in younger adults?
Sheth Bhutada: It’s a hard question to answer, since we don’t know what’s driving this. I worry that diet is a big factor, but we don’t know which specific dietary risk factors are out there. For example, we know for colorectal cancer, having a high-fiber diet and limited exposure to red meats can be helpful preventive measures, but the stomach environment is different than the colon. This speaks to the fact that there’s little known about this disease, especially in younger patients. So, it’s hard to think about preventative factors.
We also know that in older adults, stomach cancer may be driven by chronic infection with a bacteria called Helicobacter pylori. One preventive strategy that has been utilized in China is to aggressively test and treat for H. pylori, which has reduced the rates of stomach cancer in one town.
The challenge is that we don’t know to what extent H. pylori infection drives stomach cancer in young adults and whether or not this would be an effective strategy.
Healio: What is next on the horizon?
Sheth Bhutada: We anticipate having some publishable results within the next 6 to 12 months. We are working on identifying geographic hot spots, or areas in Los Angeles County where we might be seeing the highest rates of young-onset stomach cancer. We also hope to partner with communities in those areas as we start to think about preventative measures, whether that be increased health education, awareness for medical providers in the safety net hospitals in those areas or public health education campaigns.
Having strong community partnerships will be a critical aspect of translating the findings of this study into actionable items. We’re looking forward to seeing these results so we can finally start to make an impact in this deadly disease. Whenever we see patients who live in poverty or have limited access to health care who are at risk for more lethal disease, it’s important to consider the impact of social determinants of health. I want to emphasize that within oncology and many aspects of medicine, there is already momentum toward finding new drugs and interventions to target specific genetic mutations and genetic pathways.
However, social determinants of health require the same level of fervor and need to have additional studies testing interventions to improve outcomes for the most vulnerable populations.
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