After stomach cancer spread, she wanted to enjoy a meal again

Grace came to dislike being watched while she ate.

Her family meant well. They served her rice, put food on her plate and hoped she might manage a little more than the day before. She understood their concern. But sometimes she felt nauseated; sometimes her abdomen hurt. On several occasions, a bowel obstruction meant she had to stop eating altogether and undergo gastrointestinal decompression.

Before she became ill at 40, dinner had rarely required much thought. She and her husband both worked; whoever got home first would cook. If they were both late, something simple would do. They ate, cleared up and got on with the rest of the evening.

Later, when someone asked how her day had been, the answer often began with whether she had managed to eat.

In May 2022, Grace developed upper abdominal pain, nausea and vomiting. Tests found a large amount of fluid in her abdomen and a mass near her stomach.

Doctors drained the fluid and took a biopsy of the mass. The tissue contained metastatic adenocarcinoma, and cancer cells in the abdominal fluid also suggested a tumor originating in the digestive tract.

She was still trying to understand the abdominal discomfort when she heard that the cancer had already spread. She wanted the next tests to establish where it had started.

But a gastroscopy and colonoscopy in June found no clear malignancy. A subsequent laparoscopy revealed multiple nodules on the greater and lesser omentum, folds of tissue within the abdomen. Samples showed poorly differentiated adenocarcinoma with signet-ring cells.

The cancer was confirmed. Its original site was still uncertain.

Grace had expected a diagnosis to come first and treatment to follow in order. Instead, some answers were clear while others remained out of reach. She wondered whether the negative gastroscopy meant there might be another explanation. The doctors had to explain that it did not undo the cancer findings in the abdominal nodules and fluid.

In June, she began chemotherapy at Zhongshan Hospital, Fudan University, with albumin-bound paclitaxel, fluorouracil and leucovorin. The search for the primary tumor continued alongside treatment.

She handed over her work, and her family took on things she had usually managed at home. At first, she wanted to know how every task was being done. Eventually, she let some of them go. She needed her energy for treatment, and sometimes needed a little time without questions to answer.

More detailed tissue and molecular testing looked for features that might guide treatment. One finding stood out: amplification of the FGFR2 gene.

The name meant little to Grace. The explanation was that FGFR2 helps transmit signals for cell growth; extra copies of the gene could make that signaling abnormally active. The result suggested a possible target.

The doctors considered adding pemigatinib, an FGFR inhibitor, to her chemotherapy. For this form of stomach cancer, it was an individualized approach based on the molecular finding. The test offered a reason to consider the drug, but could not establish in advance whether her tumor would respond.

She wanted to understand the evidence, what additional adverse effects she might face and whether the plan could be adjusted if she struggled with it.

Pemigatinib was added in August 2022.

During treatment, her liver enzymes rose repeatedly, sometimes to levels requiring medical attention. The team treated the abnormalities and used her recovery to guide subsequent medication.

She began recognizing entries on blood test reports that she had never paid attention to before. Alongside the question of what was happening to the cancer was another question at almost every visit: what could her body tolerate next?

Bowel obstructions interrupted treatment and daily life too. Each episode meant no food by mouth and measures such as gastrointestinal decompression until bowel function improved.

She dreaded the disruption just as she thought she was settling into a routine. A meal prepared at home went uneaten. Plans were canceled. Hospital care took over again.

Over time, she became more direct with her family about the help she needed. Some days she wanted company. On others she wanted quiet. When she could not eat, she did not want to explain herself repeatedly or feel that leaving food meant she had not tried hard enough.

“I'll tell you when I can eat,” she told her husband.

The questions at the table became less frequent. When she had an appetite, she could take her time. When she felt unwell, she no longer had to put on a reassuring expression for everyone else.

In January 2023, another gastroscopy finally found a lesion in the body of the stomach. Pathology confirmed signet-ring cell carcinoma. Months after the first abdominal symptoms, there was a clearer answer about where the disease had begun.

It did not make treatment easier. It did help her understand how the stomach tumor related to the disease already found throughout the abdominal lining.

CT assessments showed stable disease in January and again in March.

At first, Grace found “stable” disappointing. She wanted to hear that the tumors were shrinking. After the obstructions, difficulty eating and liver problems, stability seemed a modest return for what she had endured.

The doctor explained what the assessment meant: the cancer had neither grown enough to meet the criteria for progression nor shrunk enough to qualify as a response. Holding metastatic disease in check for a time mattered, even though it was not the improvement she had hoped for.

She was still hoping for more. But between treatments, there were days when she could sit at her own table, eat something she wanted and listen to her husband talk about something unrelated to the hospital.

In March 2023, she received treatment at another hospital. Her chemotherapy continued, pemigatinib was not used, and the immunotherapy drug nivolumab was added.

Her bilirubin and liver enzymes then rose substantially, reaching grade 3 abnormalities. The doctors suspected that the liver injury might be related to immunotherapy.

She returned to Zhongshan Hospital and received treatment including methylprednisolone and immunoglobulin. It took about a month for her liver tests to improve to a milder level of abnormality.

Grace worried about delaying cancer treatment. She also worried about taking more medication before her body had recovered. The decision could no longer be reduced to how quickly she could start the next course.

In April, pemigatinib was restarted at a lower dose, without further chemotherapy.

The regimen had changed several times: chemotherapy with pemigatinib, a period that included immunotherapy, then reduced-dose pemigatinib alone. Those changes reflected both the disease and her ability to tolerate treatment.

In May, the cancer progressed.

She had followed the plans, attended the appointments and dealt with one complication after another. She knew nobody had promised lasting control. That knowledge did not make the result easy to hear.

The case report recorded a progression-free interval of ten months during this course of first-line treatment, which had included chemotherapy, targeted treatment and the subsequent adjustments.

Grace had lived those months in smaller increments: beginning treatment, waiting for a scan, recovering from an obstruction, watching her liver tests slowly improve. There had been days that resembled life before illness, and others when everything depended on how her body was doing.

Now another assessment and another decision lay ahead.

Her husband listened to the results with her. He did not immediately tell her to keep going. Back where they were staying, she said she did not want to discuss the report for a while. They sat together and talked about a small unfinished matter at home.

Later, she picked up her papers and began noting questions for the next appointment. She wanted to know what else could be done, and how much more treatment her body could take. She wanted the doctor to understand what mattered to her, too. When she could eat, she hoped to sit down to a meal in peace.