INTRODUCTION

In Brazil, cancer is recognized as a public health problem - given its epidemiological, social and economic magnitude - being the second leading cause of death from the disease in the country ¹. Brazil is undergoing demographic and epidemiological transition processes that have produced important changes in the profile of diseases that affect the population ². Infectious and parasitic diseases are no longer the leading cause of death, being replaced by diseases of the circulatory system and neoplasms ¹.

The estimate for Brazil, in the 2018-2019 biennium, points to the possibility of about 600,000 new cases of cancer. This data reinforces the magnitude of the problem in the country, especially when it is estimated that by 2060 the Brazilian population will be 218.2 million. Worldwide, in 2012, the estimate indicated 14.1 million new cancer cases and 8.2 million deaths ^{2 3 4}.

In most developed countries, the types of cancer associated with urbanization and development such as lung, prostate, female breast and rectum predominate. In the middle and low developing countries, cancer associated with infections such as cervix, stomach, liver is still high, which despite a lower incidence, mortality represents almost 80% of cancer deaths worldwide ^{4 5}.

Gastric cancer, although incidence rates have declined in many countries, is still the second most common cause of cancer death worldwide and the fourth in incidence. This cancer in other countries such as the United States and England has declined, while in Latin American countries such as Chile, Costa Rica and Colombia, the incidence and mortality rates are higher. The largest number of cases is in Japan with an average of 780 patients per 100,000 inhabitants ^{2 5 6 7}.

The present study focuses on stomach cancer due to its high morbidity and mortality. The number of Brazilians diagnosed with gastric cancer is high, making it the fourth malignant tumor among men and the sixth among women. In Brazil, for each year of the 2018-2019 biennium, it is estimated that 13,540 new cases of this disease appear among men and 7,750 in women ⁴.

Gastric cancer has a very heterogeneous etiology, including consumption of foods rich in sodium, nitrate and nitrites that become nitrosamines with direct mutagenic properties, Helicobacter pylori bacterium infection involved in 60% of gastric adenocarcinomas, low fiber, vitamin and salt diet. minerals from fresh fruits and vegeTables, alcohol consumption in large quantities, and tobacco. Also, high body mass index, increased abdominal fat and physical inactivity are associated with the development of gastric cancer ⁸.

Lower socioeconomic status, measured through education and income, has been strongly associated with twice the risk for developing gastric cancer in both high-risk and low-risk countries. The factors of this association are mainly attributed to the low socioeconomic condition, which increases the likelihood of H. pylori transmission and reinfection in households in large families with poor sanitation and less frequent use of antibiotic therapy. In addition, low socioeconomic status may indicate poor access to health services and reduced diet in fiber, vitamins and minerals ^{9 10}.

The production of scientific knowledge about gastric cancer and nursing care for this patient profile is still scarce in Brazilian nursing. Thus, this study is timely and relevant. In view of the above, a study was carried out to survey and analyze the profile of patients with gastric cancer enrolled at the José Alencar Gomes da Silva National Cancer Institute (INCA), the most prevalent nursing diagnoses identified during the consultation, at the Cancer Hospital I (HCI), outpatient abdomen, from October 1, 2015 to April 18, 2018.

METHOD

This is a cross-sectional study, which is characterized by the direct observation of a certain number of individuals at a single opportunity, obtaining various information in order to establish association or correlation relationships between the characteristics investigated. The study was developed at INCA / HC I, Abdominopelvic Surgery Section, where gastric cancer patients are enrolled and treated.

The study sample consisted of secondary data from medical records of 649 patients who are followed by the Gastric Cancer Study and Treatment Group - INCA.

Eligibility criteria were: patients with gastric cancer enrolled at INCA, aged over 18 years, with study variables recorded in physical or electronic medical records, from October 1, 2015 to April 18, 2018. The choice The temporal cutoff was due to the availability of information in the database of the Study Group and Treatment of Gastric Cancer - INCA, which optimized the time spent in collecting data from the cases to be studied.

The study variables were organized and entered into a Microsoft Excel® 2007 spreadsheet, namely: gender, color, age, histopathological type, smoking, alcoholism, tumor location, TNM 7th staging, presence of H. pylori, presence of cells. signet ring, Lauren classification, date of death, nursing diagnosis of the host consultation. The R® software - version 3.4.4 was used for statistical analysis of the data.

Descriptive and inferential statistical analysis was performed. The results were presented using descriptive measures of central tendency as mean and median and standard deviation, absolute and relative frequencies. For the normal or non-normal distribution test, the Shapiro-Wilk test was used, which directed the choice of nonparametric tests. For the hypothesis tests, the chi-square test (χ2), the Kruskal-Wallis test and the Wilcoxon test were used. In the application of statistical tests, it was adopted as a significance level of 5%, being considered significant the p-value of 0.05.

The research project was analyzed and approved by the INCA Ethics and Research Committee (CEP-INCA), under the number 11141412.0.0000.5274, and waiver of the consent form is allowed because it is collection and analysis of secondary data. In order not to allow the identification of individuals, confidentiality of the collected data was safeguarded, being anonymously analyzed and presented in aggregate form.

RESULTS

The study sample consisted of data from 649 patients with gastric cancer enrolled at INCA. The mean age of the group was 62.74 years, ranging from 21 to 96 years (median = 64; SD = 12.84), with 44.22% (n = 287) still in productive age.

Regarding gender distribution, 59.63% of the patients were male and 39.60% female (Table 1). Most patients were brown (52.70%).

Table 1. Frequency distribution related to the personal characteristics of patients with gastric cancer enrolled at INCA, from October 01, 2015 to April 18, 2018 (n = 649). 

Source: Gastric Cancer Study and Treatment Group Database - INCA.

As shown in Table 2, most were smokers (56.24%) and alcoholics (60.09%). H. pylori was not reported in 325 cases (50.08%). Poorly differentiated adenocarcinoma was the most prevalent histological type (n = 276; 42.52%). There were signet ring cells in 208 cases (32.05%), but in 427 cases (65.79%) there was no record. Regarding Lauren's classification for histological aspects, we highlight the diffuse type (n = 115; 17.72%), the intestinal type (n = 89; 13.71%) and not informed (n = 374; 57.63%). Regarding TNM staging of the disease, 305 patients had advanced disease (stages III to IV). Regarding the region affected by the stomach tumor, there was a predominance of the middle third of the stomach in 193 patients (29.74%), followed by the distal third in 147 patients (22.75%). Regarding death, 296 patients (45.61%) died during this period.

Table 2. Frequency distribution of clinical characteristics of gastric cancer patients enrolled at INCA, from October 1, 2015 to April 18, 2018 (n = 649). 

Source: Gastric Cancer Study and Treatment Group Database - INCA.

As shown in Table 3, the χ2 test was performed, and it was observed that tumor staging is independent of gender, color, alcoholism and smoking and has a dependence relationship with death. It was also found that the tumor site is independent of gender, color, alcoholism and smoking. Death, however, is independent of gender, but dependent on color. And histopathological diagnosis is independent of color and gender.

Table 3. Statement of chi-square test results (χ2) applied (p-value <0.05). 

^*Not relevant or duplicate

Through the Wilcoxon test, it is verified that there is a different distribution between the age variable and the death variable (p-value = 0.0001447), thus, the first influence on the second one; Between the variable age and the variable H. Pylori infection the distribution is equal (p-value = 0.9228), so there is no influence of one in relation to the other. Between the age variable and the presence of Signet Ring variable, the distribution is different (p-value = 0.0384), thus, the first influence on the second.

Table 4. Statement of Wilcoxon test results applied (p-value <0.05). 

The reading of graph 2allows us to affirm that age directly influences the type of tumor according to the Lauren Classification, being the median age located between 60 and 65 years, approximately.

Graph 2. Boxplot of variable age X Lauren classification 

When performing the Kruskal-Walllis test shown in Table 5, it appears that the age variable has equal distribution only as the local tumor variable, thus, it is noted that the first variable has no influence on the second. In addition, the age variable has a different distribution in relation to the other variables, such as TNM staging, Lauren's classification and the histopathological type, thus, the age variable directly influences the mentioned variables.

Table 5. Statement of Kruskal-Wallis Test results applied (p-value <0.05). 

A total of 22 different nursing diagnoses (ND) were detected according to NANDA taxonomy (2015-2017), identified through physical examination and interview at the first nursing consultation. Chart 1describes the 12 ND that were present in all patients in the sample studied.

DISCUSSION

The data analyzed in this research allowed us to delineate the profile of patients diagnosed with gastric cancer, enrolled at INCA, from October 01, 2015 to April 18, 2018. The study of the epidemiological profile of a population is very useful to guide the health policies of a country, for institutional internal planning and to guide the care actions of multiprofessional teams.

The distribution of gastric cancer cases according to gender and age, nationwide, followed the incidence rate observed in the rest of the world. It is almost twice higher in males than in females, with incidence peaks between 50 and 70 years old, being an uncommon condition at younger ages. The greater involvement of men can be explained by the participation of factors such as lifestyle, where males are usually more exposed to alcohol and tobacco consumption ^{11 12}.

Different studies cite, in common, interactions between personal lifestyle such as smoking and alcoholism, personal genetic factors and external agents such as ionizing radiation, chemical and biological carcinogens as the causes for the development of most cancers, including gastric câncer ¹³. In this study, the participants had exposure to risk factors, smoking and alcoholism, mostly.

The age of the patients in this research ranged from 21 years to 90 years. However, 16.64% of them were under 50 years of age, which requires more careful evaluation due to the suspicion of hereditary cancer syndrome. Refer to Genetic Counseling and advise the family on signs and symptoms of stomach tumors so that they seek primary care. Germline mutation in the e-cadherin gene is responsible for the familial autosomal dominant gastric cancer syndrome that leads to the development of gastric cancer at an early age. Criteria for suspicion of the syndrome include an individual diagnosed with gastric cancer before age 50, or two or more successive generations of affected families ^{1 14 15}.

The brown population was the most prevalent (52.51%), followed by white (28.51%), unlike that found in the literature where there is a predominance of white color. The mechanism responsible for this predominance cannot be attributed only to socioeconomic conditions or lifestyle, assuming that genetic factors may have relevance, since they determine different susceptibility among ethnic groups ^{16 17}.

Unfortunately, only 34.2% of the cases analyzed (n = 222) had a record of the presence or absence of signet ring cells. Of these, 208 were positive cases, representing 93.7% of those with information. The presence of signet ring cells is strongly associated with poor prognosis and recurrence of the gastric tumor ^{18 19}.

As shown in one study ²⁰, the presence of signet ring cells is the largest and strongest indicator of poor prognosis in patients with gastric adenocarcinoma and, among other recommendations, indicate an accurate investigation of the family history of cancer in these patients, because they are often caused by mutations in the CDH1 gene. Our analysis was not performed satisfactorily due to the high number of cases without information (n = 427, 65.79%).

Some authors ²¹, point out the usefulness of databases with complete records for the excellence studies, which was not observed in this study for the presence of signet ring cells, Lauren microscopic classification, H. pylori infection and TNM stage (Table 2). In one assessment ²², the completeness of the records ranged from poor to very poor. These authors recommend a score based on the concept of data completeness, which is classified into the following degrees of evaluation: excellent, when the variable has less than 5% of incomplete filling; good (5% to 10%); regular (10% to 20%); poor (20% to 50%); very bad (50% or more).

Regarding H. pylori infection, we found no record in 325 cases (50.08%). Of the 324 cases in which this information was present, infection was found in 117 patients, or 18.03%. By associating age with H. pylori infection, it was observed that there is no influence of one on the other. Scholars explore the importance of H. Pylori's research, showing that most cases of gastric cancer are related to sporadic somatic cell mutations, resulting from a long exposure of the gastric mucosa to the inflammatory process caused by the bacteria, making the need for alert evident. for risk factor for gastric cancer^{23 24}.

Regarding gastric cancer, regarding the histopathological type, 490 patients with adenocarcinoma were found, corresponding to 75.49% of the total patients analyzed. Among the histological types of gastric cancer, adenocarcinoma corresponds to 95% of cases, followed by lymphoma, which represents about 3% of cases ^{4 25}.

Staging of the tumors revealed that the most frequent tumors were in stage IV (n = 222, 35.29%), which indicates advanced disease with metastasis and palliative treatment. It is worth pointing out that the high percentage of uninformed staging (n = 261, 40.22%) becomes a limiting factor for study analysis.

Tumor localization, as described in the literature, is more prevalent in the distal third of the stomach, in the gastric antrum near the notch angularis. It is associated with nitrate (nitrosamine) ingestion or H. pylori infection. Some studies have shown a change in the presentation pattern of adenocarcinoma, from distal to proximal regions and with distinct histological characteristics. In our study, there was a predominance of the middle third (n = 193, 29.74%), followed by the distal third, unlike the literature ^{26 27}.

Regarding the Lauren classification, the findings indicated a higher prevalence of diffuse type (Table 2), followed by intestinal, and the tests performed suggest that age directly influenced the histological types of the Lauren Classification. Lauren's classification divides gastric neoplasms according to their microscopic configuration and growth pattern into two histological types: Intestinal type - the most common type in males and usually affects the distal region of the stomach (small curvature in the gastric antrum). It is of better prognosis when compared to the diffuse type. Diffuse has a family history (hereditary), is more common in women, affects younger individuals compared to intestinal type, and tumor localization is frequent in the proximal region of the stomach (closest to the esophagus)^{27 28}.

Regarding mortality, the frequency of death in the study period was 296 cases (45.61%), almost half of the cases, which coincides with the high mortality reported in epidemiological studies of the disease¹⁸. We note that most patients enrolled at INCA already arrive with advanced disease, which practically makes curative treatment unfeasible and justifies the high percentage of death.

Regarding nursing, specifically, knowing the patient profile of the unit in which they work is fundamental both for the development of prevention and health promotion actions, as well as for care actions in the hospital space, especially when it is intended to work with the Systematization. Nursing Care (SAE) and the Nursing Process (PE).

The Systematization of Nursing Care (SAE) allows the involvement of nurses in the planning, execution and evaluation of nursing actions that are implemented, enabling the global view of care ²⁹. It is a method of operationalizing the Nursing Process (PE), being the EP a methodological instrument that guides nursing care to the patient and allows the documentation of professional practice ³⁰.

In resolution ³⁰, the EP is organized into five interrelated, interdependent and recurrent stages: Data Collection (Nursing History), Nursing Diagnosis, Nursing Planning, Nursing Implementation and Evaluation.

Systematized nursing practice allows the identification of care needs expressed and / or reported by patients and family members, and provides dialogue with other members of the health team to direct care, composing a tactic appropriate to a person-centered practice and not only on tasks or illness.

Therefore, knowing the profile of this patient is of great value to the Nursing Professional, as it allows directing a deeper look at the signs and symptoms presented, verbalized or not, arising from the disease process and / or treatment imposed by the disease, to provide humanized nursing care and promote better quality of life for this patient and / or family member.

It is noteworthy that for the implementation of the EP, in its first stage - initial evaluation - it is essential to know the profile of the clientele served in order to link this profile to a nursing theory that will provide the support for the construction of the data collection instrument. Data that meets this patient profile, so that the apt and critical processing of inferences and judgments can be developed and thus the precise determination of the nursing diagnosis, the second step of the EP, and, consequently, for the advancement of the other stages of the process. PE ³¹.

Regarding the identified nursing diagnoses (ND), in the first nursing consultation of the patients in this study, there was a predominance of 12 ND in 100% of the sample, these diagnoses being in full congruence with the profile of the researched clientele.

Nursing diagnoses underlie the prescription of care to address the affected needs of patients. It opens up new possibilities for care, as it enables the sick The first is to apply scientific knowledge to identify problems and prescribe care according to their professional competence, using standard medical record language, based on signs and symptoms presented by patients, enabling clear communication among health team members ³².

It is also interesting to highlight the importance of this research to equip health professionals to develop actions aimed at health promotion and disease prevention in family health strategies.

FINAL CONSIDERATIONS

We conclude that the objectives of this study were achieved, that the knowledge of the clinical and epidemiological profile of gastric cancer patients is mostly compatible with the national and international literature and that the identified nursing diagnoses are aligned with this profile of patient.

One of the weaknesses of this study, as it is secondary database research, was the low degree of completeness observed for the presence of signet ring cells, Lauren microscopic classification, H. pylori infection and TNM stage. Therefore, due care is recommended and the development of a broader prospective study.

The high prevalence of cases with advanced disease reflects the difficulty of access of the Unified Health System users to early diagnosis. This finding leads us to identify what efforts should be made, universally and equitably, to identify groups and risk factors for the development of gastric cancer through the training of health professionals so that they can act in the planning and implementation. of gastric cancer prevention and control programs.

We think the study can help prepare nurses and students for the development and application of control, prevention and care strategies in primary, secondary and tertiary care. For the specialist nurse in cancer care, can collaborate in the development of skills to assist this clientele in all its dimensions and for comprehensive and humanized care in meeting the basic human needs of this patient profile, so assaulted by the disease and the treatment imposed. Knowing the profile of the gastric cancer patient and the most prevalent nursing diagnoses indicates the effectiveness of the Nursing Care Systematization with the operationalization of the Nursing Process, in order to offer quality, safe and humanized nursing care to the patient, family and community in INCA.