Stomach cancer

Stomach cancer | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotlands Service Directory 0 Home Illnesses and conditions Cancer Cancer types in adults Stomach cancer Stomach cancer About stomach cancer Symptoms of stomach cancer Causes of stomach cancer Diagnosing stomach cancer Treating stomach cancer Living with stomach cancer About stomach cancer Stomach cancer, or gastric cancer, is a fairly uncommon type of cancer. The initial symptoms of stomach cancer are vague and easy to mistake for other less seriousconditions.They include: persistent indigestion and heartburn trapped wind and frequent burping feeling very full or bloated after meals persistent stomach pain Symptoms of advanced stomach cancer can include: blood in your stools, or black stools loss of appetite weight loss As the earlysymptoms of stomach cancer are similar to those of many otherconditions, the cancer is often advanced by the time its diagnosed. Its therefore important to get any possible symptoms of stomach cancer checked by your GP as soon as possible. Read more about diagnosing stomach cancer Whos affected The exact cause of stomach cancer is still unclear, although youre more likely to develop it if you: are male are 55 years of age or older smoke have a diet low in fibre and high in processed food or red meat have a diet that contains a lot of salted and pickled foods have a stomach infection caused by Helicobacter pylori (H. pylori) bacteria Read more about the causes of stomach cancer . Types of stomach cancer There are several different types of stomach cancer. More than 95% of stomach cancers develop in the cells of the stomach lining and are known as adenocarcinomas. Less common types of stomach cancer include lymphoma of the stomach, which develops in the lymphatic tissue (tissue that drains away fluid and helps fight infection), and gastrointestinal stromal tumours (GISTs), which develop in the muscle or connective tissue of the stomach wall. How stomach cancer is treated Many cases of stomach cancer cant be completely cured, but its still possible to relieve symptoms and improve quality of life using chemotherapy and in some cases radiotherapy and surgery. If operable, surgery can cure stomach cancer as long as all of the cancerous tissuecan be removed. Surgery to remove some or all of the stomach is known as agastrectomy. It will still be possible to eat normally after a gastrectomy, but youll probably have to adjust the size of your portions. Chemotherapy can also be used before surgery to help shrink the tumour and sometimes after surgery to help prevent the cancer returning. Read more about treating stomach cancer Living with stomach cancer Living with stomach cancer and the effects of surgery can be tough, but there are a range of services that can provide social, psychological and financial support. Read more about living with stomach cancer Symptoms of stomach cancer Many symptoms of stomach cancer are similar to less serious conditions, so it can be difficult to recognise in the early stages. Early stage symptoms include: persistent indigestion trapped wind and frequent burping heartburn feeling full very quickly when eating feeling bloated after eating feeling sick pain in your stomach or breastbone difficulty swallowing ( dysphagia ) vomiting (the vomit may be streaked with blood), although this is uncommon in the early stages Advanced stomach cancer Symptoms of more advanced stomach cancer include: blood in your stools, or black stools loss of appetite weight loss tiredness lumpiness and swelling in your stomach (caused by a build-up of fluid) anaemia (a reduced number of red blood cells that can cause you to feel tired and breathless) yellowing of the skin and whites of the eyes (jaundice) When to seek medical help Stomach cancer is usually easier to treat if its diagnosed early. Its thereforeimportant for your GP to refer you to a specialist as soon as possible if stomach cancer is suspected. Stomach cancer is much more common in older people, with 90 out of 100 cases occurring in people who are over 55 years of age. Indigestion is a very common symptom in the general population. However, its unlikely that someone with indigestion whos under the age of 55 will have stomach cancer. However,see your GP if you have indigestion and weight loss, anaemia or persistent vomiting. Theyshould refer you to a specialist for further testing. Also see your GP if you have difficulty swallowing. Thisisnt a common symptom among the general population and the cause should always be investigated. Read more about diagnosing stomach cancer Causes of stomach cancer Stomach cancer is caused by changes in the cells of the stomach, although its unclear exactly why these changes occur. Cancer begins with a change (mutation) in the structure of the DNA in cells, which can affect how they grow. This means cells grow and reproduceuncontrollably, producing a lump of tissue called a tumour. Left untreated, cancer can spread to other parts of the body, usually through the lymphatic system (a network of vessels and glands called lymph nodes located throughout the body). Once the cancer reaches your lymphatic system, its capable of spreading to other parts of your body, including your blood, bones and organs. Its not known what triggers thechanges in DNAthat lead to stomach cancer and why only a small number of people develop the condition. Increased risk However, evidence suggests that a number of different factors can affect yourchances of developing stomach cancer. Age and gender Your risk of developing stomach cancer increases with age. Most cases occur in people aged 55 or over. For reasons that are unclear, men are twice as likely as women to develop stomach cancer. Smoking People who smoke are about twice as likely to develop stomach cancer compared with non-smokers. This is because you swallow some cigarette smoke when you inhale and it ends up in your stomach. Cigarettes containharmful chemicals which can damage the cells in your stomach. The more you smoke and the longer youve been smoking, the bigger the risk.In the UK, around 1in every 5 cases of stomach cancer (20%) is thought to be caused by smoking. H. pylori infection Helicobacter pylori (H. pylori)is a common type of bacteria. In most people, these bacteria are harmless, butin some people an H. pylori infection can cause problems such as stomach ulcers , recurring bouts of indigestion orlong-term inflammation of the stomach lining (chronic atrophic gastritis). Research has foundpeople with severe chronicatrophic gastritis havean increasedrisk of developing stomach cancer, although this risk is still small. Diet A diet rich in pickled vegetables, such as pickled onions or piccalilli, salted fish, salt in general and smoked meats, such as pastrami or smoked beef, increases your risk of stomach cancer. Countries where this type of diet is popular, such as Japan, tend to have much higher rates of stomach cancer than the UK. A high fibre diet with 5 portions of fruit and vegetables a daywill help protect against stomach cancer, and a diet high in fats and processed food and red meat will increase your risk of getting stomach cancer. Family history Youre more likely to develop stomach cancer if you have a close relative with the condition, such as one of your parents or a sibling (brother or sister). In such cases, it may be appropriate for your doctor to arrange genetic counselling. Its not fully understood why stomach cancer seems to run in families. It may be because of shared risk factors, such as having similar diets or having an H. pylori infection, or because of certain genes you inherit from your parents. In around 1 in 50 cases of stomach cancer, testing has found that people share a mutation in a gene known as E-cadherin. You may be more at risk of getting the condition if you have the blood type A. Yourblood type is passed on from your parents, so this could be another way in which family history may increase your risk of developing stomach cancer. Theres also a condition that runs in families called familial adenomatous polyposis (FAP), which may increase your risk of developing stomach cancer. FAP causes small growths, called polyps, to form in your digestive system, and is known to increase your risk of developing bowel cancer . Having another type of cancer Your risk of developing stomach cancer is increased if youve had another type of cancer, such as cancer of the oesophagus or non-Hodgkin lymphoma (cancer that develops in your white blood cells). For men, the risk of getting stomach cancer is increased after having prostate cancer , bladder cancer , breast cancer or testicular cancer . For women, the risk of developing stomach cancer increases after having ovarian cancer , breast cancer or cervical cancer . Certain medical conditions Having certain medical conditions can also increase your risk of developing stomach cancer, such as pernicious anaemia (a vitamin B12 deficiency, which occurs when your body cant absorb it properly), and peptic stomach ulcers (an ulcer in your stomach lining, often caused by H. pylori infection). Stomach surgery If youve had stomach surgery, or surgery to a part of your body that affects your stomach, you may be more likely to develop stomach cancer. This can include surgery to remove part of your stomach (known as a partial gastrectomy), surgery to remove part of your vagus nerve (the nerve that carries information from your brain to organs such as your heart, lungs and digestive system), or surgery to repair a stomach ulcer. How stomach cancer spreads There are 3 ways stomach cancer can spread: directly the cancer can spread from the stomach into nearby tissues and organs, such as the pancreas, colon, small intestine and peritoneum (the lining of the inside of the abdominal cavity) throughthe lymphatic system  the lymphatic system is a series of glands (nodes) located throughout your body, similar to the blood circulatory system; the glands produce specialised cells needed by your immune system to fight infection throughthe blood which can cause the cancer to spread from the stomach to other parts of the body, most commonly the liver Stomach cancer that spreads to another part of the body is known as metastatic stomach cancer. Diagnosing stomach cancer Speak to your GP as soon as possible if you have stomach cancer symptoms such as indigestion, unexpected weight loss, anaemia and persistent vomiting. Your GP will ask about your symptoms and examine your stomach for any lumpiness or tenderness. If they think that stomach cancer may be a possibility theyll refer you to a specialist for further investigation. In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of stomach cancer and refer people for the right tests faster.Find out who should be referred for further tests for suspected stomach cancer . Hospital tests If your GP thinks you may have stomach cancer, theyll refer you to a specialist for tests. These may include a blood test and chest X-ray , which will assess your overall health. A sample of your stools may also be tested for blood. Because ofthe potentially serious nature of stomach cancer, you should be referred to the specialist within 2 weeks. Read more about waiting times . Endoscopy and endoscopic ultrasound An endoscopy is a procedure where the inside of your body is examined using a piece of equipment called an endoscope (a long, thin flexible tube with a light and a video camera at the end). If you need to have an endoscopy, you wont be able to eat or drink for four to eight hours before the procedure. This is to ensure your stomach and duodenum (top of the small intestine) are empty. Youll be awake during the endoscopy, but may be given a sedative by injection to make you feel drowsy and relaxed. A local anaesthetic may also be sprayed onto the back of your throat, so the area is numbed. The endoscope will be passed down your gullet (food pipe) and into your stomach so the specialist can look for any stomach ulcers or signs of cancer. If tissue is found that may be cancerous, a sample will be taken for testing. This procedure is known as a biopsy . The sample will be examined under a microscope in a laboratory. The results will show whether the cells are cancerous (malignant) or non-cancerous (benign) and will usually take 7 to 10 days to come back. The endoscopy itself usually takes about 15 minutes, although you should allow about 2 hours in total for your visit. If your specialist thinks you may have cancer in the top part of your stomach, you may have an ultrasound scan at the same time as an endoscopy. This is known as an endoscopic ultrasound and uses high-frequency sound waves to produce an image of your stomach (this method is commonly used to view an unborn baby in the womb). If you have an endoscopic ultrasound, an ultrasound probe will be attached to the end of the endoscope before its passed down your throat. The scan will help determine the stage of any cancer in the top part of your stomach. After an endoscopy, or an endoscopic ultrasound, you wont be able to drive for several hours because of the sedative. You may also have a sore throat , although this should pass within a few days. Barium meal X-ray A barium meal X-ray or barium swallow involves drinking a chalky liquid containing a substance called barium, which makes your stomach show up on an X-ray. Nowadays, however, its less commonly used to diagnose stomach cancers. Organs such as your stomach dont usually show up on an X-ray because theyre made of soft tissue that isnt dense enough to stop the X-rays passing through. However, when these organs are filled with barium, it blocks the X-rays and shows up white on an X-ray screen. You wont able to eat or drink for at least 6 hours before the procedure because your stomach and duodenum need to be empty. You may be given an injection to relax the muscles in your digestive system. A barium swallow usually takes about 15 minutes. Afterwards, youll be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system. You may feel slightly sick, and the barium may cause constipation . Your stools may be white for a few days afterwards as the barium passes through your system. Further testing If youre diagnosed with stomach cancer, further tests may be needed to help determine how far its spread and how quickly its likely to spread (known as the stage and grade). Your cancer specialist (oncologist) will discuss this with you. However, it may not always be possible to identify the exact stage of your condition until your treatment starts. Laparoscopy Your specialist may need to examine your stomach in more detail to see if the cancer has spread, particularly to the lining of the abdominal cavity (peritoneum). If it has, you may need to have a small operation called a laparoscopy. This procedure is carried out under a general anaesthetic , so youll be unconscious during it. During the procedure, a thin viewing tube with a camera at the end (a laparoscope) will be inserted into your stomach through a small incision in the lower part of your tummy. In some cases, your specialist may need to examine more than one area of your stomach and make more than one incision. Computerised tomography or positron emission tomography scans During CT scans or PET scans , a series of X-ray images of your body are taken. A computer is then used to put the images together and create a detailed picture of the inside of your body. These scans will help your doctor assess how advanced your cancer is. It allows them to see whether the cancerous cells have formed tumours anywhere else in the body. The scans can alsohelp your doctors work out which type of treatment will be most effective and appropriate for you. Liver ultrasound scan If your specialist thinks your stomach cancer may have spread to your liver, you may need to have a liver ultrasound . This type of scan uses high-frequency sound waves to produce an image of your liver. Staging and grading After all of the tests have been completed and your test results are known, it should be possible to tell what stage and grade of stomach cancer you have. Staging is a measurement of how far cancer has spread. There are a number of different ways stomach cancer can be staged.One method uses a numbering system from 1 to 4. The higher the number, the further the cancer has spread. The majority of stomach cancers are at stage 3 or 4 when diagnosed, which means a cure isntusually possible. Grading describes how quickly the cancer is likely to spread in the future. There are 3 grades of stomach cancer: low-grade  the cancer tends to grow slowly medium-grade  the cancer grows a bitfaster high-grade  the cancer is aggressive and likely to grow quickly Cancer Research UK has more information about the staging and grading of stomach cancer. Treating stomach cancer The treatments recommended for stomach cancer will depend on your general health and how far the cancer has spread. Most hospitals use multidisciplinary teams made up of a number of different specialists (see below) who work together to plan and carry outthe best treatment, tailored to your circumstances. Feel free to discuss treatment with your care team at any time and ask questions. Your treatment plan The main treatments for stomach cancer are surgery, chemotherapy and radiotherapy . You may have 1 of these treatments or a combination. If surgery is recommended, you may have chemotherapy beforehand. If the tumour is in the upper part of your stomach, including the junction between the oesophagus and stomach, you may also have radiotherapy prior to surgery. Surgery is mainly used if stomach cancer is diagnosed at an early stage, whereas chemotherapy and radiotherapy tend to be used when the condition is diagnosed at a later stage. Where possible, the primary aim of treatment is to completelyremove the tumour and any other cancerous cells in your body.Its estimated that a cure is possible in 20 to 30% of stomach cancer cases. If its not possible to remove the tumour, your doctors will focus on trying to prevent it from getting any bigger and causing further harm to your body. This may be done using surgery or chemotherapy. In some cases, its not possible to eliminate the cancer or slow it down. In this case, your treatment will aim to relieve your symptoms and make you as comfortable as possible, usually with surgery or radiotherapy. A relatively new medication calledtrastuzumab (see below) can also be used to treat some types of advanced stomach cancer. Your healthcare team will talk to you about which treatments are most suitable. Surgery If youre diagnosed with stomach cancer at an early stage,it may be possible for the cancer to be completely removed during surgery. In some cases, it may be possible to pass a thin, flexible tube (endoscope) down your oesophagus (gullet),rather than making incisions in your tummy. This is known as endoscopic surgery, and can be used toremove a sample of the tumour for testing ( biopsy ). It can also be used to remove the tumour completely if stomach cancer is diagnosed at an early stage. However, if your cancer has spread beyond your stomach, it may not be possible to remove it completely. If this is the case, you may still have surgery to remove any cancer blocking your stomach, to ease your symptoms. This will depend on whether your symptoms can be controlled and the risks and side effects of undertaking major surgery. Any type of surgery for stomach cancer will involve a large operation and a long recovery time. If you have stomach cancer surgery, youll usually need to stay in hospital for around 2 weeks. Youll also need several weeks at home to recover. Surgery to remove your stomach You mayneed to have part or all of your stomach removed. Surgery to remove part of your stomach is known as a partial or sub-total gastrectomy, and surgery to remove all of your stomach is known as a total gastrectomy. In some cases, your surgeon may remove part of your oesophagus as well as all ofyour stomach, usinga procedure known as an oesophagogastrectomy. These operations may be carried outusing either a large incision in your tummy (open surgery), or a number of smaller incisions through which surgical tools can be passed (laparoscopic or keyhole surgery). Both of these techniques are carried out under general anaesthetic , which means youll be unconscious throughout the procedure. During these operations, your surgeon will also remove the lymph nodes (small glands that help fight infection) nearest to the cancer. Its possible that your stomach cancer may have spread to these lymph nodes, and removing them helps prevent the cancer returning. Partial gastrectomy If your cancer is in the lower part of your stomach, you may have a partial gastrectomytoremove it. After surgery, your stomach will be smaller than it was before the operation. However, the top part of your stomach, where your oesophagus feeds into it, wont be affected. Total gastrectomy or oesophagogastrectomy If your cancer is in the middle or at the top of your stomach, you may need to have a total gastrectomy. If the cancer is close to the end of your oesophagus, where it meets your stomach, you mayneed to have an oesophagogastrectomy. If you have a total gastrectomy, the end of your gullet will be joined to the top of your jejunum (the top part of your small intestine). If you have an oesophagogastrectomy, the remaining part of your gullet will be joined to your jejunum. Surgery to ease your symptoms If your stomach cancer has spread beyond your stomach, it may not be possible to remove it using surgery. However, if your stomach has been significantly affected by cancer it can cause a blockage, which prevents food from being properly digested. A blocked stomach can cause symptoms such as stomach pain, vomiting and feeling very full after eating. If your stomach is blocked, there are a few options: stenting  a stent is a plastic or wire mesh tube inserted through the oesophagus using an endoscope under local anaesthetic ; after being inserted, the stent will be expanded and open up the stomach partial or total gastrectomy  to remove the blockage and improve your symptoms bypass surgery  an operation where part of your stomach above the blockage is joined to yoursmall intestine, leaving the blocked part of your stomach out of your digestive system Chemotherapy Chemotherapy is a specialist treatment for cancer that uses medicines, called cytotoxic medicines,to stop cancer cells dividing and multiplying. As it circulates through your body, the medicine can target cancer cells in your stomach and any that may have spread to other parts of your body. You may have chemotherapy for stomach cancer before surgery to reduce the amount of cancer that has to be removed during the operation. Chemotherapy can also be used after surgery to destroy any remaining cancer cells and prevent the cancer from coming back. Chemotherapy can also help to slow the progression of cancer and ease the symptoms of more advanced stomach cancer, which may not be suitable for surgery. If may be given orally (as tablets) or intravenously (by injection or a drip through a vein directly into your bloodstream), or a combination of both. Intravenous chemotherapy is usually given in hospital, while oral chemotherapy is taken at home. Chemotherapy is often given in cycles, each usually lasting about three weeks. Alternatively, chemotherapy may be administered through a small pump, which gives you a constant low dose over a few weeks or months. The pumps are portable and can be worn at home, which means fewer trips to hospital. Side effects of chemotherapy Chemotherapy works by preventing cancerous cells from growing rapidly. However, it also destroys non-cancerous cells such ashair follicles and red and white blood cells. Side effects may include: tiredness nausea and vomiting nerve damage ( peripheral neuropathy ) hair loss diarrhoea anaemia (a lack of red blood cells) weight loss skin changes  such as redness, swelling and a tingling sensation in the palms of the hands and/or soles of the feet The side effects you experience after having chemotherapy will depend on the type of chemotherapy and the number of treatment sessions you need. Youll be told who to contact if youre experiencing serious side effects from chemotherapy, and its very important that this contact information is recorded carefully. If you experience nausea and vomiting as a result of chemotherapy, you may be able to take anti-sickness medication to counter it. This may be given intravenously (by injection directly into your bloodstream) at the same time as your chemotherapy. The side effects of chemotherapy will only last for as long as your course of treatment lasts. Once your treatment is over, thehair folliclesand blood cellswill repair themselves. This means your hair will grow back, although it might look or feel different from how it did before chemotherapy (for example, it may be a slightly different colour, or be softer or curlier than before). Radiotherapy Radiotherapy uses beams of high energy radiation to destroy cancer cells. Its not often used to treat stomach cancer because theres a risk that other organs close to your stomach might be damaged by the treatment. However, if you have advanced stomach cancer thats causing pain or bleeding,you may need to have radiotherapy. In some cases, following surgery, you may have chemotherapy and/or radiotherapy to help prevent the stomach cancer from recurring. If a cancer is bleeding slowly and causing anaemia , a single fraction of radiotherapy can be used to try to prevent further bleeding. If you need radiotherapy, your treatment will usually begin 2 or 3 months after surgery or chemotherapy, to give your body a chance to recover. This is a painless procedure where you lie under a radiotherapy machine while it directs radiation at your stomach. Youll be positioned by a radiographer (a specialist in radiotherapy) so that the machine targets the cancer cells and avoids as much healthy tissue as possible. Radiotherapy often involves having treatment sessions 5 days a week. Each session will only last a few minutes. The radiation doesnt stay in your system afterwards, and its perfectly safe to be around others between your treatments. How long youll need to have radiotherapy for will depend on how its used. Radiotherapy used after surgery to help prevent stomach cancer coming back usually lasts 5 weeks. If its being used to control symptoms of advanced stomach cancer, it may only last 1 or 2 weeks. Side effects of radiotherapy You may experience the following side effects after having radiotherapy: tiredness nausea diarrhoea irritation and darkening of your skin where the treatment takes place These side effects will usually improve within a few weeks of treatment finishing. Trastuzumab Trastuzumab(sold under the brand name Herceptin) is a medicationused to treat breast cancer and some cases of advanced stomach cancer. Some stomach cancers are stimulated by a type of protein called human epidermal growth factor receptor 2 (HER2). Trastuzumab works by blocking the effects of this protein. This doesnt cure stomach cancer, butit can slow its growth and increase survival time. If youre diagnosed with advanced stomach cancer and tests show high levels of the HER2 protein in the cancerous cells, your doctors may recommend treatment with a combination of chemotherapy and trastuzumab. Trastuzumab is given intravenously, through a drip, and youll have the treatment in hospital. Each treatment session takes up to 1 hour and youll usually need a session once every 3 weeks. Trastuzumab can cause side effects, including heart problems. Therefore, it may not be suitable if you have a heart problem such as angina , uncontrolled high blood pressure ( hypertension ) or heart valve disease. If you need to take trastuzumab, youll also need regular tests on your heart to check for any problems. Other side effects of trastuzumab may include: an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever diarrhoea tiredness aches and pains Living with stomach cancer Being diagnosed with cancer is a tough challenge for most people, but support is available to help you cope. You may find the followingadvice helpful: keep talking to your friends and family they can be a powerful support system talk to others in the same situation research your condition set reasonable goals take time out for yourself Cancer charities, such as Macmillan Cancer Support , are a good source of information and support. Recovery Getting back to normal after surgery can take time. Its important to take things slowly and give yourself time to recover. During your recovery,avoid lifting heavy things such as children or shopping bags, and strenuous tasks such as housework. You may also be advised not to drive. Some other treatments, particularly chemotherapy and radiotherapy , can make you very tired. You may need to take a break from some of your normal activities for a while. Dont be afraid to ask for practical help from family and friends. Follow-up After your treatment has finished, youll be invited for regular check-ups, usually every three months for the first year. During the check-up, your doctor will examine you and may arrange blood tests or scans to see how youre responding to treatment. Diet after surgery If youve had an operation to remove part of your stomach (partial gastrectomy), youll only be able to eat small amounts of food for a while after your operation. This is because your stomach wont be able to hold as much food as it could before the surgery, and your body will need to adjust to its new stomach capacity. You should gradually be able to increase the amount you eat as your stomach begins to expand. If youve had surgery to remove all of your stomach (total gastrectomy), it may be some time before you can eat normally again. As with a partial gastrectomy, youll only be able to eat small amounts of food until your body adjusts. You may have to eat little and often, and make changes to the types of food you eat. Your care team will be able to advise you about what and when you should eat. Having surgery to remove your stomach also means youll need to have regular injections of vitamin B12. Vitamin B12 is usually absorbed through your stomach from the food you eat and is needed to help preventa condition called anaemia and nerve problems. Looking after yourself Eat regularly and healthily. You may not have time to sit down for every meal, but you should make time to do so at least once a day. Its understandable if there are times when you feel resentful, and then guilty for feeling so. You may also feel exhausted, isolated and worry about the person you care for.Remember: youre human, and those feelings are natural. Dealing with dying If your stomach cancer cant be cured, your GP will give you support and any necessary pain relief (often alongside chemotherapy or radiotherapy, which can be used to reduce your symptoms).This is called palliative care .Support is also available for your family and friends. Source: NHS 24 - Opens in new browser window Last updated: 14 November 2023 How can we improve this page? Help us improve NHS inform Thank You Your feedback has been received Dont include personal information e.g. name, location or any personal health conditions. 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