QUESTIONS FOR YOUR HEALTHCARE TEAM INITIAL VISIT QUESTIONS  Can you determine the stage of my cancer at this time? What further tests are needed for staging? -Rationale: oftentimes staging cannot be determined from a CT scan alone, further testing may be needed for the most accurate diagnosis which will guide treatment decisions. 

Has the cancer spread (or "metastasized")? Where has it spread to? How does it change the treatment plan? -Rationale: cancer can spread locally or distantly. Local spread infiltrates tissues near the stomach (e.g. the lymph nodes), distant metastasis means that the cancer has spread to distant organs (e.g. the liver). The degree of spread can affect treatment options

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How much experience do you have in treating stomach cancer? -Rationale: This is an important question to ask your healthcare team and particularly your surgeon. An experienced healthcare team will improve the quality of your care. It is important to be your own advocate and request care from a qualified team. Please note that in more remote areas, your team may have limited experience in treating stomach cancer. It is up to you as the patient to decide how to proceed. For example, a technically skilled surgeon can improve your survival but to get access to this surgeon you may have to travel or wait on a wait list.

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Do I qualify for surgery? Is the goal of surgery curative or palliative? -Rationale: patients with early stage stomach cancer may be eligible for stomach removal surgery, called a gastrectomy. Later stage patients may need to get "neo-adjuvent chemotherapy" which is chemotherapy given before surgery to try to shrink the tumor size. Palliative surgery may be needed to remove a tumor that is causing symptoms.

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Will I need to stay in the hospital during/after my treatment? How should I prepare for hospitalization? How long do I need to stay? How can I arrange home care? -Rationale: Certain treatments may require hospitalization. Some hospitalization may be planned (e.g. after surgery), whereas other hospitalization may be unplanned (e.g. complications). Home care may be arranged in certain instances.

AFTER SURGERY  What is the stage of my cancer? -Rationale: In some cases, your team may tell you the stage of your cancer right at diagnosis. Other times exploratory surgery is needed to clarify the stage. Staging is important to treatment and prognosis. 

What is the grade of the tumor? - Rationale: After surgery, the tumor is sent to a pathologist. Tumor cells are given a "grade" or a "level of differentiation". Differentiation refers to how cells look and behave under a microscope. The degree of differentiation is an important consideration for prognosis and is often used to direct treatment. The tumor grade may be reported as grade 1-4 or as well, moderately or poorly differentiated. Well-differentiated or moderately-differentiated cancer cells look and behave similar to normal cells, they are slow-growing and less aggressive cells which correspond to grades 12. Undifferentiated or poorly-differentiated cells do not resemble normal cells, they tend to grow quicker and be more aggressive they correspond to grades 3-4.

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Does tumor pathology show HER2/neu mutation? - Rationale: A mutation in HER2 leads to the over-expression of an oncogene (a gene implicated in cancer). HER2 status is an important predictor of prognosis. There is a special medication called transtuzumab (marketed as Herceptin) that may be recommended to a HER2-positive patient which may improve survival

TREATMENT 

What are my treatment options? What do you recommend? -Rationale: There are many treatment options available for stomach cancer. Scientific findings guide your healthcare team to recommend one choice over another. The recommended treatment will depend on the patient, the tumor, the healthcare teams' level of experience, knowledge about clinical trials and the resources available in your area.

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What are the risks and benefits associated with each treatment option? -Rationale: Every treatment option has unique survival benefits, side effects and associated complications. Make sure to weigh these options and decide what is best for you and your family.

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How can I mitigate side-effects with my chosen treatment plan? -Rationale: You cannot mitigate all side effects; however your healthcare team may be able to provide resources and information that will make treatment easier.

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What treatment side-effects are most common? Which side-effects are rare but require emergency assessment? -Rationale: Your healthcare team will educate you on which side effects are common during your treatment. Be aware of the common side effects and understand how they present. For example, if a common side-effect is neuropathy, understand what this term means and how it presents. It is important to know which uncommon symptoms are serious but warrant a trip to the emergency department. What are the effects of treatment on family planning? -Rationale: Some treatment options may compromise your fertility and ability to breastfeed. If future fertility is important to you, you may need to take action to preserve your fertility. Have this conversation with your healthcare team before starting treatment. Where can I get help when the clinic is closed? -Rationale: In rare instances you may need medical assistance after hours. Your healthcare team should provide you with a contact sheet which will include important telephone numbers, including who to call in an emergency.

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What financial resources are available to a person in my situation? -Rationale: Most cancer treatments are covered under the universal healthcare act for Canadians with a valid health card. Additional medications may be covered by personal health insurance plans, ODB and ODSP. If you do not have a drug plan, your healthcare team can refer you to financial aid services that can help you get access to medications. If you have other financial concerns, a social worker can help connect you to resources.

ACCOMMODATIONS  How will my eating habits change before, during and after treatment? Are there any food I should avoid during treatment?

-Rationale: You may have difficulty eating due to the tumor itself or due to side-effects of treatment. Your healthcare team can refer you to a dietitian that will help you develop an eating plan at each stage of your treatment. Keep in mind that there are certain foods, herbal products and supplements that you should avoid during your treatment, make sure to ask a doctor what these may be. 

Are there lifestyle changes I need to make? -Rationale: Your doctor may suggest you take medical leave from work, alter your diet or exercise routine. Make sure to be honest with your team and express your concerns, fears and desires. If you are unable to leave work, your healthcare team may be able to provide you with alternative options. Your doctor may also refer you to an occupational therapist or physical therapist to accommodate your new needs and abilities.

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Do I carry a gene that causes stomach cancer that can be passed on to other family members (Is this cancer heritable)? -Rationale: If you are a young patient, have a family history of stomach cancer or a history of multiple related cancers you may be eligible for genetic testing. Please remember that heritable cancers are rare, but if you carry a genetic mutation for stomach cancer, other members of your family may be at risk for cancer and may need to be tested. Please see our guest speaker lecture on genetics and speak to your doctor if you are concerned about a heritable cancer.

IF FIRST-LINE TREATMENT FAILS 

Do you recommend a clinical trail for me? Are there clinical trials available at other healthcare centres that I could benefit from? -Rationale: Depending where you live, your treatment centre may be limited in the clinical trials available for stomach cancer in your locations. There are many clinical trials available across Canada and you may still wish to pursue these trials if re-location is possible.

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How will you manage my pain during treatment? -Rationale: Not all treatment options have a risk of pain. However pain can severely impact your quality of life and recovery. The doctor may suggest a referral to a palliative care team. A palliative care team has experts in pain management and are a valuable resource to you. Many people are scared of a palliative care team referral, it is important to recognize that early intervention will benefit your quality of life but it does not mean that your healthcare team is "giving up". You can continue to pursue active treatment but have the palliative team involved on an ongoing basis to manage pain This resource was prepared by My Gut Feeling – Stomach Cancer Foundation of Canada. For more information and resources visit www.mygutfeeling.ca