Incidence and mortality from stomach cancer in Japan, Slovenia and the USA

Screening for gastric cancer in Korea: population-based preferences for endoscopy versus upper gastrointestinal series

This study assessed the screening rates for gastric cancer by two different screening methods, upper gastrointestinal (UGI) series and endoscopy; intentions to undergo future gastric cancer screening; and the preferred method of screening. The study population was derived from the 2006 Korean National Cancer Screening Survey. The Korean National Cancer Screening Survey is an annual cross-sectional survey that uses nationally representative random sampling to investigate cancer screening rates. A total of 1,625 Koreans over 40 years of age participated in this study. Logistic regression was used to identify the factors associated with undergoing gastric cancer screening, having an intention to be screened, and preferring one of the two screening tests. Among the 1,625 subjects, 15.1% had received a UGI, 33.2% had received an endoscopy, and 43.1% had undergone either or both of the tests in the previous 2 years. About 52% of people reported the intention to be screened within the next 2 years. The odds ratio for intending to be screened was 11.8 and 6.2 higher among those who had undergone a prior UGI test and an endoscopy test within the previous 2 years, respectively, than for those who had never been screened. Among the 1,625 individuals, 67% chose endoscopy and 33% UGI for their preferred future screening method. Collectively, our results highlight the preference for endoscopy testing as a gastric cancer screening method. Providers' assessments of individuals' screening preferences in combination with intervention strategies to promote performance of the preferred test may increase patient compliance with gastric cancer screening recommendations.

Prognostic significance of insulin-like growth factor II mRNA-binding protein 3 expression in gastric adenocarcinoma

BACKGROUND

Insulin-like growth factor II mRNA-binding protein (IMP) 3 is expressed in embryonic tissues and multiple cancers. The aim was to establish the prognostic value of IMP-3 expression in gastric adenocarcinoma.

METHODS

IMP-3 expression in resected gastric adenocarcinomas was analysed by immunohistochemistry.

RESULTS

IMP-3 was expressed in 183 (58.1 per cent) of 315 tumours. Expression was associated with older age (P < 0.001), larger tumour size (P = 0.009), deep tumour invasion (P < 0.001) and lymph node metastasis (P < 0.001). IMP-3-positive tumours were associated with poorer 5-year survival than negative tumours at all stages (stage I, 82 versus 97 per cent; stage II, 55 versus 78 per cent; stage III and IV, 11 versus 25 per cent; P = 0.005, P = 0.033 and P = 0.036 respectively). Multivariable analysis identified IMP-3 (hazard ratio (HR) 1.93), depth of tumour invasion (HR 3.69, 9.77 and 10.69 for pathological tumour stage (pT) 2, pT3 and pT4 respectively versus pT1), and lymph node metastasis (HR 1.57, 3.29 and 3.40 for pathological node stage (pN) 1, pN2 and pN3 respectively versus pN0) as independent prognostic factors.

CONCLUSION

IMP-3 expression correlates with the metastatic potential of gastric adenocarcinoma and is an independent prognostic factor.

Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction

BACKGROUND

We aimed to establish the superiority (or noninferiority if superiority was not achieved) in terms of time to progression (TTP) of irinotecan/5-fluorouracil (IF) over cisplatin/5-fluorouracil (CF) in chemonaive patients with adenocarcinoma of the stomach/esophagogastric junction.

PATIENTS AND METHODS

Patients received either IF: i.v. irinotecan 80 mg/m(2) 30 min, folinic acid 500 mg/m(2) 2 h, 5-fluorouracil (5-FU) 2000 mg/m(2) 22 h, for 6/7 weeks or CF: cisplatin 100 mg/m(2) 1-3 h, with 5-FU 1000 mg/m(2)/day 24 h, days 1-5, every 4 weeks.

RESULTS

In all, 333 patients were randomized and treated (IF 170, CF 163). Patient characteristics were balanced except more IF patients had Karnofsky performance status 100%. TTP for IF was 5.0 months [95% confidence interval (CI) 3.8-5.8] and 4.2 months (95% CI 3.7-5.5) for CF (P = 0.088). Overall survival (OS) was 9.0 versus 8.7 months, response rate 31.8% versus 25.8%, time to treatment failure (TTF) 4.0 versus 3.4 months for IF and CF, respectively. The difference in TTF was statistically significant (P = 0.018). IF was better in terms of toxic deaths (0.6% versus 3%), discontinuation for toxicity (10.0% versus 21.5%), severe neutropenia, thrombocytopenia and stomatitis, but not diarrhea.

CONCLUSION

IF did not yield a significant TTP or OS superiority over CF, and the results of noninferiority of IF were borderline. However, IF may provide a viable, platinum-free front-line treatment alternative for metastatic gastric cancer.

Bmi-1 expression predicts prognosis for patients with gastric carcinoma

BACKGROUND AND OBJECTIVE

The Bmi-1 gene is a transcriptional repressor involved in oncogenesis in various human cancers. Here, we examine Bmi-1 expression in gastric carcinoma (GC) and investigates whether its expression correlates with patient prognosis.

METHODS

Immunohistochemistry was performed using an anti-Bmi-1 antibody on primary tumor samples of 146 cases of GC. The association between Bmi-1 expression and the clinicopathological status and prognosis of GC patients was statistically analyzed. Furthermore, reverse transcription-PCR (RT-PCR) and Western blotting were performed to determine the expression levels of Bmi-1 in an additional 8 GC and the adjacent non-cancerous samples.

RESULTS

Using immunohistochemistry, we found that 99 of 146 paraffin-embedded GC samples expressed Bmi-1 extensively. Statistical analysis showed that Bmi-1 overexpression was highly correlated with tumor size, clinical stage, lymph node metastasis and T classification (P < 0.05), Patients with Bmi-1 expression had shorter overall survival time than those without Bmi-1 expression (P < 0.01). Multivariate analysis indicated that Bmi-1 expression is an independent prognostic factor of GC. RT-PCR and Western blotting showed that Bmi-1 was up-regulated at both the transcriptional and translational levels in the GC tissues compared with the adjacent non-cancerous tissues.

CONCLUSIONS

Bmi-1 may serve as a valuable marker for diagnosis and prognosis of GC.

Prevalence of synchronous colorectal neoplasms detected by colonoscopy in patients with gastric cancer

PURPOSE

Our purpose was to study the characteristics of colorectal neoplasms in patients with gastric cancer (GC).

METHODS

The study group comprised GC patients who underwent colonoscopy before resection of their GC. We examined the prevalence, site, and histology of colorectal neoplasms, as well as the clinicopathological features and treatment of the patients who had synchronous colorectal cancers (CRC). The logistic regression model was applied to investigate the features of the GC patients with concurrent CRC.

RESULTS

We studied 466 GC patients (mean age 64.5 years; 147 women, 319 men), 143 (31%) of whom had a family history of gastrointestinal cancer. Synchronous colorectal adenoma and cancer were detected in 182 (39%) and 18 (4%) patients, respectively. Among the 18 synchronous CRCs, 11 were in the early stages and 10 of these were resected endoscopically. The other eight required simultaneous open radical surgery. All the GC patients with synchronous CRC were older than 50 years. Statistical analysis did not show a significant difference between the features of the patients with and those without concurrent CRC.

CONCLUSIONS

The possibility of synchronous colorectal neoplasms in GC patients cannot be disregarded in clinical practice; however, screening of the large bowel may not be necessary in GC patients younger than 50 years.

Geographical conservation of short inserts in the signal and middle regions of the Helicobacter pylori vacuolating cytotoxin gene

Short nucleotide sequence inserts within the signal (s) and mid (m) regions of the vacuolating cytotoxin gene (vacA) of Helicobacter pylori provide the basis for defining the allelic forms widely used for strain typing and as markers for toxin functionality and severity of interactions with host gastric epithelial cells. Here 484 signal region and 411 mid-region sequences (new and from public databases) from 32 countries were analysed to determine the effect of geographical location on insert diversity, which is currently undefined. Short (27 bp) inserts of 52 mol% G+C from 201 sequences (98 %) of the s2 allelic family encoded a highly conserved nine amino acid sequence irrespective of geographical origin. The longer (75 bp) mid-region insert of 38 mol% G+C in 255 sequences of the m2 allelic family was more diverse and represented by 23 peptide variants, with one predominant sequence (MRI type 4) representing 62 % of inserts. Mid-region inserts were widespread throughout European/North American (Western) sequences in the dataset whereas a lower insert frequency was a geographical feature of East Asian sequences. Each insert was preceded by an associated conserved motif that provided a marker of the insertion sites within vacA, and facilitated identification of the Chinese m2b genotype. It is concluded that the observed sequence conservation supports the continued global use of vacA genotyping, and that inserts could have a functional significance in the mature protein, particularly the s2 form of the toxin, as the same combination of signal and mid-region insert type and preinsert motif was highly conserved.

Prevalence and prognosis of gastric cancer detected by screening in a large Japanese population: data from a single institute over 30 years

BACKGROUND AND AIM

In Japan, screening examination with photofluorography is widely performed to reduce the mortality due to gastric cancer. The possibility of a future decline in gastric cancer cases and changes in its characteristics is suggested. The aim of this study was to examine the usefulness of direct radiology as a general health screening technique and the historical changes of gastric cancer in Japan.

METHODS

This study involved 936 patients with gastric cancer whose carcinomas were detected by direct radiology as part of a general health screening at the Aichi Prefectural Center for Health Care from 1970 to 2000. We studied the prevalence of gastric carcinoma, its prognosis, differences between the two histological types of carcinoma and historical changes.

RESULTS

The age-adjusted cancer detection rate slightly decreased. Comparing two histological types, diffuse-type carcinoma cases relatively increased. Intestinal-type carcinomas increased in the lower portion of the stomach, whereas diffuse-type increased in the upper portion. The 5-year survival rate was 92.7% for intestinal-type carcinoma and 84.8% for diffuse-type. Diffuse-type carcinomas were further progressed than intestinal-type when detected by direct radiology; however, detection of diffuse-type improved, so the percentage of early gastric cancer of diffuse type significantly increased, and the survival rate significantly improved, from 70.4% to 90.5%.

CONCLUSION

The prevalence of gastric cancer has been decreasing, but the proportion of diffuse-type carcinoma localized in the upper portion of the stomach has been increasing in Japan.

Prognostic significance of VEGF expression in correlation with COX-2, microvessel density, and clinicopathological characteristics in human gastric carcinoma

BACKGROUND

Many studies have shown that angiogenesis plays an important role in the process of cancer development and progression. Vascular endothelial growth factor (VEGF) has a potent angiogenic activity, and cyclooxygenase-2 (COX-2) supports angiogenesis by regulated production of angiogenic factors, including VEGF. The purpose of this study was to examine the expression of VEGF in combination with COX-2 and CD34, their correlation with various clinicopathological factors, and their prognostic significance in human gastric carcinoma.

METHODS

Specimens from 169 patients with different grade and stage gastric carcinoma were investigated by immunohistochemistry for COX-2 and VEGF expression. Tumor microvessel density was assessed with CD34 immunostaining. Correlations between the expression of VEGF, COX-2, CD34, and various clinicopathological factors were studied. The effect of these proteins on patient survival was determined.

RESULTS

COX-2 and VEGF were positively expressed in 36.7% and 50.3% of the patients, respectively. Positive correlation was found between VEGF and COX-2 and between VEGF and CD34. VEGF expression was correlated with depth of invasion; metastatic lymph nodes; lymphatic and venous invasion; and tumor, node, metastasis system stage. Patients with positive staining for VEGF showed far lower disease-free (64.9% vs. 81.3%) and overall (58.3% vs. 76.9%) survival rates than VEGF-negative patients. In multivariate analysis, only tumor location, depth of invasion, and lymph node metastasis were shown to be independent prognostic factors.

CONCLUSIONS

VEGF expression correlates with angiogenesis and tumor progression and is a valuable prognostic factor in patients with gastric carcinoma.

Helicobacter pylori infection in Ontario: prevalence and risk factors

BACKGROUND

Helicobacter pylori has been classified by the World Health Organization as a type I carcinogen. Nearly 50% of the world's population is estimated to be infected with H pylori. Prevalence patterns of the infection are different between developing and developed countries. The present study had two objectives - to estimate the prevalence of H pylori infection in Ontario, and to evaluate the relationship between the infection and various demographic characteristics and selected lifestyle factors.

METHODS

Ten microlitres of plasma were aliquoted from stored blood of 1306 men and women, 50 to 80 years of age, from Ontario. The blood samples belonged to control patients of a colorectal cancer population-based study group. Serological testing was used to detect H pylori infection; information was obtained on dietary intake and lifestyle habits, as well as past and present medical history, education, income, number of siblings, ethnicity and place of birth.

RESULTS

The overall weighted seroprevalence of H pylori was 23.1% (95% CI 17.7% to 29.5%), with men having higher infection rates (29.4%, 95% CI 21.1% to 39.3%) than women (14.9%, 95% CI 10.1% to 21.4%). Seroprevalence of the infection increased significantly with age and number of siblings. Increased risk was also associated with being nonwhite, being born outside of Canada and immigrating at 20 years of age or older. An inverse association with seroprevalence was found for education and alcohol consumption.

CONCLUSION

The prevalence of H pylori infection in Ontario is comparable with that of other developed countries. Age, sex, number of siblings, ethnicity, place of birth and age at immigration are among the factors associated with H pylori infection.

Features of Gastric Neoplasm Detected during the Screening Examination

BACKGROUND/AIMS

Gastric cancer is the leading malignancy in Korea and early detection through the health screening seems to be important. The aims of this study were to investigate the features of gastric neoplasms detected during screening, and to figure out the risk factors of these lesions.

METHODS

From October 2003 to September 2005, subjects who visited Seoul National University Hospital Healthcare System Gangnam Center for health check-up were included in the study. The program included a questionnaire and tests including anti-Helicobacter pylori (H. pylori) antibody, esophagogastroduodenoscopy or double contrast upper gastrointestinal study. To figure out the risk factors, an age and gender-matched, four-fold sized control group was selected from the subjects.

RESULTS

Of 25, 432 subjects, 122 cases of gastric neoplasms were detected including 61 adenocarcinoma (45 early gastric cancers), 53 adenoma, 7 mucosa-associated lymphoid tissue lymphoma, and one metastatic cancer. There was no significant statistical difference in basal characteristics of the subjects between gastric adenocarcinoma and adenoma. When comparing with the control group those without gastric neoplasms, smoking history, family history of stomach cancer, and H. pylori seropositivity were found to be significant risk factors for gastric neoplasms. Metabolic syndrome was more prevalent in adenoma than in the control (p<0.05).

CONCLUSIONS

The health screening may be beneficial in early detection of gastric cancer. In addition, metabolic syndrome might be related with gastric adenoma.

Trends in stomach and pancreatic cancer incidence and mortality in England and Wales, 1951–2000

Background

The aim of this study was to describe period and cohort effects in incidence and mortality of stomach and pancreatic cancer in England and Wales.

Methods

National figures for mortality (1951–2000) and incidence (1971–2000) were analysed using log-linear Poisson regression models to obtain relative risks (RR) for period (year of incidence or death) and cohort (year of birth).

Results

Stomach cancer shows a pronounced cohort effect in mortality with a decline in RR in men from 2·20 (1876) to 0·47 (1946) and a reduction from 2·79 to 0·41 for women. Mortality to incidence ratios are now less than 0·70. Pancreatic cancer mortality (men) RR rose from 0·91 (1951–1955) to a peak 1·11 (1976–1980) and then declined to 0·90 (1996–2000). Women showed a similar pattern. Cohort RR (men) increased to a peak of 1·14 in 1916 and declined to 1·01 in 1946, and continued to fall; the peak occurred slightly later in women. Mortality to incidence ratios were near 1 in the first 20 years, declining to 0·95 in the last 10 years.

Conclusion

Stomach cancer incidence has fallen continuously from 19th century birth cohorts onwards. Incidence of pancreatic cancer has fallen in successive birth cohorts after 1920; peak period risk was 1976–1990. Age-standardized mortality and case mortality for pancreatic cancer are declining.

Trends in stomach cancer mortality in relation to living conditions in childhood. A study among cohorts born between 1860 and 1939 in seven European countries

AIM

To assess whether secular trends in stomach cancer mortality were correlated with trends in infant mortality rate (IMR) or gross domestic product (GDP).

METHODS

Data from seven European countries were analyzed. We used Poisson regression to describe mortality trends among birth cohorts of 1865-1939 and correlation coefficients to determine associations with IMR/GDP.

RESULTS

Large differences were observed between birth cohorts in mortality from stomach cancer. In each country, these cohort differences were closely related to IMR/GDP levels at birth time. However, stronger associations were observed with measures of living conditions during later life. In comparisons between countries, stomach cancer mortality rates were not consistently related to national levels of IMR/GDP.

CONCLUSION

General living conditions in childhood do not seem to have had a predominant effect on secular trends in stomach cancer mortality. The mortality decline is likely to be related to more 1specific factors, such as declining Helicobacter pylori prevalence.

Clinical profile of gastric cancer in Khuzestan, southwest of Iran

AIM: To analyze the characteristics of epidemiological, clinical and survival patterns among patients with carcinoma of the stomach.

METHODS: We retrospectively studied the characteristics of 186 gastric adenocarcinoma patients at Ahwaz Jundishapur University Hospitals (AJSUH) from September 1, 1996 to September 1, 2002. All the patients had histopathologically-confirmed malignancy. Demographic variables, family history of gastric cancer (GC), clinicopathologic characteristics and treatment-related variables were analyzed. Univariate analysis was performed with the log-rank test and multivariate analysis with Cox regression. P < 0.05 was considered statistically significant.

RESULTS: Male to female ratio was 2.6:1. The mean age was 60.6 years and 14% of the patients were younger than 40 years. Adenocarcinoma, gastric lymphoma, and gastric metastasis were found in 94.5%, 2.3%, and 3% patients, respectively. There was an average of 6-mo delay between the initial symptoms and the diagnosis. Among adenocarcinoma groups, intestinal type was the commonest (55.9%) and the distal third was the most common localization (88.4%). One hundred and thirty-four patients (72.1%) were males. Thirty-one patients (17%) had a family history of GC. Surgery was performed in 90% of patients (non-curative).

CONCLUSION: The epidemiological features of GC in south Iran mimic those in high-risk areas. There is a higher frequency of GC in young patients at our institution. Patients are detected and treated after a relatively long delay. Most patients present in advanced stages, which favors a poor overall survival. Family history of GC has a significant problem in our area. Studying the etiology of this cancer in south Iran and earlier diagnosis and subsequent better cares are recommended.

Comparing mass screening techniques for gastric cancer in Japan

AIM: To discuss the efficacy of endoscopic mass screening for gastric cancer.

METHODS: The data used in this study were the results of mass screening programs for gastric cancer in Niigata City from 2002 to 2004. The number of participants was 35 089 in 2002, 34 557 in 2003 and 36 600 in 2004. The finding ratio referred to the final diagnosis of gastric cancer after a double check of endoscopic files and histological findings. The costs of identifying one case of gastric cancer were calculated based on the total expense for each screening program and additional close examinations.

RESULTS: From the analysis of individual screening program with endoscopy, individual screening program with X-ray (ISX) and mass screening program with photofluorography (MSP) in reference to the finding ratio of gastric cancer, endoscopic examination was the best for detecting early gastric cancer, the finding ratio was 0.87% in 2004, approximately 2.7 and 4.6 times higher than those of the ISX and MSP groups. In addition, this novel method was the cheapest means regarding the cost of identifying one case of gastric cancer, which was estimated to be 1 608 000 Japanese yen in 2004.

CONCLUSION: Endoscopic mass screening is a promising method and can be effectively applied if a sufficient number of skilled endoscopists become available to staff the system and if city offices support it.

Uso de teste de químio-sensibilidade para escolha da quimioterapia adjuvante no câncer gástrico avançado

OBJETIVO: Introduzir e familiarizar em nosso meio o uso do teste de químio-sensibilidade MTT avaliando a ação de agentes quimioterápicos sobre células tumorais de 30 doentes com câncer gástrico avançado. Correlacionar os resultados do teste MTT com os aspectos clínicos, anátomo-patológicos e estádio utlizando a mesma metodologia do estudo realizado em pacientes japoneses na Universidade de Keio, Japão. MÉTODO: Foi realizado o teste MTT em tumores de 30 pacientes com diagnóstico de adenocarcinoma gástrico, submetidos ao tratamento cirúrgico no Departamento de Cirurgia da Faculdade de Ciências Médicas da Santa Casa de São Paulo. Foram estudados in vitro os seguintes agentes quimioterápicos: mitomicina C, doxorrubicina, cisplatina e 5-fluorouracil. RESULTADOS: Os índices de atividade sobre células tumorais foram: 16,6% para a mitomicina C, 10,0% para a doxorrubicina, 6,6% para a cisplatina e 6,6% para o 5-fluorouracil. Os resultados do teste MTT não tiveram correlação com a idade, sexo, aspectos microscópicos e estádio (p0,05). CONCLUSÕES: A ação dos agentes quimioterápicos estudados sobre células tumorais do câncer gástrico foi baixa. Os resultados da ação dos quimioterápicos in vitro não apresentou correlação estatística com a idade, sexo, aspectos microscópicos e estádio destes doentes. Utilizando a mesma metodologia, tanto em nosso meio como em pacientes japoneses, a quimio-sensibilidade se mostrou baixa em ambos os estudos, podendo-se deduzir também que os resultados da químiosensibilidade independe da etnia. Com o surgimento de novos agentes quimioterápicos, a expectativa é grande para melhores resultados na prática clínica. Com a utilização e difusão do teste MTT em nosso meio, poder-se-á criar protocolos e estudos multicêntricos para selecionar os quimioterápicos a serem utlizados.

Difference in the incidence trend of nasopharyngeal and oropharyngeal carcinomas in Taiwan: implication from age-period-cohort analysis

Lifestyle factors are considered important for the pathogenesis of both nasopharyngeal and oropharyngeal carcinomas. In Taiwan, the incidence of nasopharyngeal carcinoma gradually decreased over the past 20 years, whereas that of oropharyngeal carcinoma increased rapidly. To compare the incidence trends of nasopharyngeal and oropharyngeal carcinomas in Taiwan, the age-period-cohort model was used to analyze epidemiologic data from 1981 to 2000 obtained from the Taiwan Cancer Registry. The calendar time period of 1986 to 1990 and the 1931 to 1940 birth cohort were used as reference groups for estimates of relative risk. For nasopharyngeal carcinoma, the incidence seemed to decrease in most age groups and was more prominent in women (30%) than in men (23%). For oropharyngeal carcinoma, the incidence increased in all age groups and was more prominent in men (391.4%) than in women (59.2%). Cohort effect was found for both nasopharyngeal and oropharyngeal carcinomas. The relative risk of nasopharyngeal carcinoma for the 1971 to 1980 birth cohort was 0.38 for women and 0.68 for men. The relative risk of oropharyngeal carcinoma for the 1971 to 1980 cohort was 45.67 for men and 2.69 for women. Change in lifestyle seemed to be an important factor for the difference in the incidence trend between nasopharyngeal and oropharyngeal carcinomas and between men and women.

Expression of hepatoma-derived growth factor is correlated with lymph node metastasis and prognosis of gastric carcinoma

PURPOSE

Hepatoma-derived growth factor (HDGF) is a unique nuclear/growth factor and might play an important role in the development and progression of carcinomas. In the present study, association of HDGF expression with recurrence and prognosis of gastric carcinoma was examined.

PATIENTS AND METHODS

HDGF expression in 317 patients with gastric carcinoma (233 males and 84 females) with ages ranging from 26 to 81 years (median, 60 years) was analyzed by immunohistochemistry. Samples with >90% of tumor cells to express positive immunoreactivity similar to or stronger than that in endothelial cells both for nucleus and cytoplasm were regarded as HDGF index level 2, and others as HDGF index level 1.

RESULTS

One hundred and eighty-two cases showed level 1 HDGF expression, whereas 135 cases showed level 2 HDGF expression. Patients with level 2 expression showed higher rates of proximal tumor location (P < 0.0001), large tumor size (P < 0.0001), infiltrative tumor growth (P < 0.0001), presence of vascular and lymphatic invasion (P < 0.0001 for both), presence of lymph node metastasis (P < 0.0001), deep tumor invasion (P < 0.0001), and poorer disease-free and overall survival (P < 0.0001 for both) compared to those with level 1 expression. Multivariate analysis revealed HDGF expression level as an independent prognosticator for disease-free and overall survival.

CONCLUSION

HDGF expression level was shown to be a prognostic factor for gastric carcinoma.

Detection and treatment of early cancer in high-risk populations

In this paper we describe how to more efficiently detect and treat early gastric cancer (EGC) in high-risk populations. For detection, we first assess the value of known risk factors from the viewpoint of availability for cancer screening. Serum pepsinogen appears to be the most useful and realistic of the factors examined, although its adequacy needs to be assessed in high-risk populations other than those in Japan. Helicobacter pylori infection is known to be a universal risk factor (or gastric carcinogen), and several interventional studies have recently shown positive results. However, H. pylori infection can be eradicated from at-risk populations, thereby decreasing its availability for cancer screening. Smokers are thought to be at risk epidemiologically, but the efficacy of screening in this population has yet to be elucidated, and further studies are warranted. Gender and aging can be risk factors in Japanese populations; male gender and old age are predominant in the intestinal type of carcinoma which is dominant in Japan, although this is not the case in the West. As for early diagnosis of cancer, only endoscopy can be commonly used for the detection of gastritis-like EGC, seen as a faint mucosal irregularity or discoloration. To make early diagnosis more accurate, it is indispensable to carry out detailed endoscopy together with careful scrutiny of the mucosa using dye-spraying techniques. The remarkable progress of early diagnosis in Japan prompted the endoscopic treatment for less invasive EGCs. The first success was with endoscopic mucosal resection (EMR). Although convenient, its therapeutic efficacy is inadequate, particularly for larger lesions. Endoscopic submucosal dissection (ESD) has no limitation on resection size and is expected to replace surgery, although it needs a high level of skill and there are several technical problems to be solved.

Secular trends in the incidence, mortality, and survival rate of gastric cancer in a general Japanese population: the Hisayama study

To examine secular trends in the incidence and mortality of gastric cancer in a Japanese community, Hisayama, we established three study-cohorts of Hisayama residents aged > or =40 years in 1961 (1637 subjects), 1974 (2054), and 1988 (2602). Each cohort was followed up for ten years. The age-standardized mortality from gastric cancer significantly decreased from 2.4 per 1000 person-years in the first cohort to 0.8 in the third cohort for men, and from 1.0 to 0.2, respectively, for women (p < 0.01 for trend in both sexes). The five-year survival rate after gastric cancer significantly improved from the first (32.6%) to the third cohort (73.0%, p < 0.01) for men and from 43.2% to 72.3% (p < 0.05), respectively, for women. The age-standardized incidence of cancer in men was not different among the cohorts (4.3 per 1000 person-years in the first, 5.0 in the second, and 4.9 in the third cohort), while it decreased significantly in women (2.0, 1.8, and 1.2, respectively, p < 0.01 for trend). In conclusion, our findings suggest that in a Japanese population, the mortality from gastric cancer declined during the past 40 years, due mainly to the improvement of survival in both sexes and a decrease in the incidence for women.

Epidemiology of gastric cancer in Japan

Despite its decreasing trend in Japan, gastric cancer remains an important public health problem. Although the age standardised rates of gastric cancer have been declining for decades, the absolute numbers are increasing because of the rapid aging of the population. A large proportion of Japanese gastric cancers are detected at an early stage, with a better overall survival rate. As with Western developed countries, a change in the social environment such as reduced salt use and increased fresh vegetable and fruit intake as well as improvement of food storage may play an important part in the decline. Differences in Helicobacter pylori infection rates between generations presumably have contributed to the generation related variation in the declining trends. It is expected that most gastric cancers in Japan may be preventable by lifestyle modification such as salt reduction and increased fruit and vegetable intake, together with avoidance of smoking and countermeasures against H pylori infection so that the level now evident in Western developed countries can be reached.

The optimal age threshold for screening upper endoscopy for uninvestigated dyspepsia in Taiwan, an area with a higher prevalence of gastric cancer in young adults

BACKGROUND

It is estimated that 1% to 2% of patients with dyspepsia are associated with gastric cancer. To avoid missing gastric cancer, most guidelines recommend that patients over 45 years old should undergo EGD for uninvestigated dyspepsia. In Taiwan, however, the prevalence of gastric cancer in younger patients is higher than that of Western countries. The optimal age threshold for endoscopy in patients with uninvestigated dyspepsia in Taiwan remains controversial. Therefore, we aimed to determine an optimal age threshold for screening endoscopy in patients with uninvestigated dyspepsia to avoid missing gastric cancer in Taiwan.

METHODS

We reviewed the findings in all adult patients who underwent upper endoscopy because of uninvestigated dyspepsia at the National Taiwan University Hospital. In those patients with confirmed gastric cancer histology, further analysis was performed. Cumulative age frequency distributions for gastric cancer were calculated according to gender and to the presence or the absence of alarm features. The stages of gastric cancer also were analyzed according to the presence or the absence of alarm symptoms.

RESULTS

During the 5-year period, a total of 17,894 patients received upper endoscopy caused by uninvestigated dyspepsia. Gastric cancer was found in 225 (12.6 cases per 1000 EGDs) patients who presented with uninvestigated dyspepsia, 135 men and 90 women. Thirty-one (13.7%) and 17 (7.6%) patients were aged less than 45 and 40 years old, respectively. Among these 225 patients with gastric cancer, 114 (50.7%) patients did not have alarm symptoms (simple dyspepsia), whereas 111 (49.3%) had alarm symptoms. About 5.3% (12/225) of gastric cancer cases would have been missed if endoscopy had been omitted in patients without alarm symptoms and aged less than 45 years. The cumulative age relative frequencies of patients with gastric cancer who presented with simple dyspepsia were 1.8 (12/6720), 1.02 (5/4920), and 0.59 (2/3411) cases per 1000 EGDs for uninvestigated dyspepsia in patients aged less than 45, 40, and 35 years, respectively. When the frequencies of gastric cancer were stratified by age and gender, we found a trend of male predominance in older patients but not in younger patients. The cutoff age was 60 years old ( p < 0.05). Early gastric cancer was detected in 9.9% (11/111) and 26.3% (30/114) of patients with and without alarm symptoms, respectively (p = 0.002).

CONCLUSIONS

Gastric cancer is not uncommon in patients with dyspepsia aged less than 45 years in Taiwan. The age threshold of screening endoscopy for uninvestigated dyspepsia should be the same for both genders in view of comparable frequencies of gastric cancer in a young age population. Because more than 5% of gastric cancer cases would be missed in Taiwan if endoscopy was omitted in simple dyspeptic patients who were aged less than 45 years, we recommend that 40 years old might be an optimal age threshold for screening endoscopy for uninvestigated dyspepsia in Taiwan, in both men and women patients.

Impact of fasting plasma glucose levels on gastric cancer incidence in a general Japanese population: the Hisayama study

OBJECTIVE

Several studies have shown associations between diabetes and various types of cancer other than gastric cancer. The aim of this cohort study was to evaluate the impact of fasting plasma glucose (FPG) levels on gastric cancer occurrence.

RESEARCH DESIGN AND METHODS

A total of 2,466 Japanese subjects aged > or =40 years were stratified into three groups according to FPG tertiles (<5.3 mmol/l, low FPG; 5.3-5.8 mmol/l, modest FPG; >5.8 mmol/l, high FPG) and followed up prospectively for 9 years.

RESULTS

During the follow-up, 66 subjects experienced gastric cancer. In men, the age-adjusted incidences were significantly higher in the modest-FPG (7.0 per 1,000 person-years, P < 0.05) and high-FPG (7.2, P < 0.05) groups than in the low-FPG group (2.2). In women, the high-FPG group also had a significantly higher age-adjusted incidence of gastric cancer compared with the low-FPG group (2.5 vs. 0.8, P < 0.05). The multivariate analysis with Cox's proportional hazards model revealed that the risks of gastric cancer in the modest-FPG (relative risk [RR] 2.3 [95% CI 1.1-5.0]) and high-FPG (3.1 [1.5-6.4]) groups were significantly higher than that in the low-FPG group, even after adjusting for other comprehensive risk factors, including Helicobacter pylori status, smoking, and dietary factors. However, this FPG-cancer association was observed only among H. pylori-seropositive subjects.

CONCLUSIONS

Our findings suggest that a modest increase in FPG is a risk factor for gastric cancer and that hyperglycemia is a possible cofactor increasing the risk posed by Helicobacter pylori infection.

Serum Levels of Insulin-like Growth Factor I, II, and Binding Protein 3, Transforming Growth Factor β-1, Soluble Fas Ligand and Superoxide Dismutase Activity in Stomach Cancer Cases and Their Controls in the JACC Study

BACKGROUND: The prognosis of stomach cancer with advanced stage remains poor. New biomarkers of the disease that may contribute to establish the potential screening strategy would be of value for the early detection of individuals at high risk of the disease.

METHODS: We conducted a prospective, nested case-control analysis among apparently healthy men and women who were followed for up to 8 years in the Japan Collaborative Cohort (JACC) Study, to evaluate serum levels of insulin-like growth factor I, II, and binding protein 3 (IFG-I, IGF-II, and IGFBP-3), transforming growth factor β-1 (TGF β1), soluble fas (sFas) and superoxide dismutase activity (SOD) in 210 stomach cancer cases diagnosed in the JACC Study in relation to those levels in their 410 controls.

RESULTS: Among 6 serum biomarkers tested for case-control differences, only sFas level in female stomach cancer cases was significantly higher than that of controls (2.22 pg/ml vs. 2.04 pg/mL, respectively; P = 0.013 by two-way analysis of covariance controlling for matching variable).

CONCLUSION: None of the biomarkers consistently predicted future risk of stomach cancer in both men and women in the present analysis. Serum sFas level in women, however, should be studied much more thoroughly whether it provides meaningful refinement of risk stratification, or it elucidate the mechanisms of tumorigenesis in women.

The Impact of High-Density Barium Use in Double Contrast Radiographic Methods for Gastric Cancer Screening in Niigata, Japan

Use of high-density barium (= or > 180 w/v%) has been widely spread in community-based mass screening for gastric cancer in Japan. However, the impact on outcomes of the screening has not been fully evaluated. Then, we investigated the advantage of high-density barium use by comparing the outcomes between a period with high-density barium and that with low-density barium (< 180 w/v%) each for 3 consecutive years between 1991 and 2002 at 5 medical examination organizations in Niigata Prefecture, Japan. Multivariate logistic regression analysis adjusted for age, sex and medical organization revealed that the introduction of high-density barium decreases the positive finding rate in initial mass screening x-ray examinations by 12% (odds ratio, 0.88; 95% confidence interval, 0.86 - 0.90) and increase the gastric cancer detection rate by diagnostic examination by 15% (odds ratio, 1.15; 95% confidence interval, 1.01-1.31). We conclude that introduction of high-density barium has improved the efficiency of mass screening for gastric cancer by decreasing unnecessary diagnostic examinations and reducing the total personal and public health costs. Thus, nationwide use of high-density barium is recommended for mass gastric cancer screening in Japan.

Increasing mortality rates of common malignancies in Colombia: an emerging problem

BACKGROUND

As a result of a major social and demographic transition, Colombia is currently undergoing major changes in disease-specific mortality rates, including an increasing burden of cancer death. The current article described some aspects of the evolution of cancer mortality in Colombia and, in particular, highlighted the trends for the most common causes of cancer death in Colombia.

METHODS

Cancer deaths registered in the national mortality database from 1981-1996 were used to obtain age-standardized mortality rates by gender and site using the world standard population. The estimated annual percentage change was obtained by fitting a simple log-linear model to the rates in the last decade of recorded data, to gauge recent and near-future cancer mortality trends.

RESULTS

Between 1987 and 1996, the most common causes of cancer death were gastric carcinoma (17% of all cancer deaths), followed by lung (10.5%), prostate (6.2%), cervical (6%), and colorectal carcinoma (5.4%). There were observed declines in mortality trends noted in both genders for gastric carcinoma. Trends in lung carcinoma appeared to be reaching a plateau among men, but increased among women. There were apparent increases in rates of death from colorectal carcinoma for both genders, and from prostate carcinoma for men. Cervical carcinoma appeared to be increasing moderately.

CONCLUSIONS

The authors reported that mortality rates from the most common malignancies are increasing, indicating that effective strategies for cancer control need to be put into immediate practice. To monitor and evaluate future trends, the provision of high-quality data also needs to be addressed.

Estrogen and Risk of Gastric Cancer: A Protective Effect in a Nationwide Cohort Study of Patients with Prostate Cancer in Sweden

Background: The global pattern of male predominance in gastric cancer incidence remains unexplained. We tested the hypothesis that estrogen prevents gastric cancer in a cohort of men heavily exposed to estrogen.

Methods: We conducted a nationwide cohort study of men with a diagnosis of prostate cancer recorded in the Swedish Cancer Register in 1961-2000. Because estrogen therapy was the treatment of choice for prostate cancer in Sweden between 1950 and 1980, cohort members diagnosed earlier than 1980 were considered exposed to estrogen. Standardized incidence ratios (SIR) estimated relative risk. Complete follow-up was achieved through cross-linkages within the cancer register and the Swedish nationwide registers of emigration and causes of death.

Results: In 515,961 person-years of follow-up, we observed 304 gastric cancers as compared with 349 expected for the cohort members in the predefined “exposed” period 1961-1980, rendering a 13% decreased risk (SIR, 0.87; 95% confidence interval (95% CI), 0.78-0.98). Among patients with a latency of ≥15 years after a prostate cancer diagnosis in 1961-1980, SIR was 0.57 (95% CI, 0.30-0.97), suggesting a dose-response relation. Similarly, reduced risks were found for cardia cancer and noncardia gastric cancer. No decreased risk was found for the cohort members in 1981-2000, when estrogen treatment was less common (SIR, 0.99; 95% CI, 0.89-1.11).

Conclusions: Our study indicates a reduced risk of gastric cancer in a male cohort exposed to estrogen. These results support the hypothesis that estrogen may prevent gastric cancer, but additional studies are warranted.

A report card on outcomes for surgically treated gastrointestinal cancers: are we improving?

INTRODUCTION

Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades.

MATERIALS AND METHODS

Using the SEER cancer database (1973-1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990-2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057).

RESULTS

Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade.

CONCLUSIONS

For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care.

Differential trends in the intestinal and diffuse types of gastric carcinoma in the United States, 1973-2000: increase in the signet ring cell type

CONTEXT

During the last 50 years, the incidence and mortality of gastric cancer has declined in many countries. This decline has primarily included the intestinal type (Lauren classification). However, there is an impression among pathologists that the diffuse type, especially the signet ring cell subtype, has become more prevalent.

OBJECTIVES

Using data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, we analyzed the trends of the 2 primary types (intestinal and diffuse) of gastric carcinomas from 1973 through 2000.

DESIGN

Trends in age-adjusted rates were determined for gastric carcinomas through the SEER statistical program (SEER*Stat), which is available on the Internet to the public.

RESULTS

During the period studied, the intestinal type continued to decline in males, females, African Americans, and whites. The intestinal type was more common in males than in females and more common in African Americans than in whites. In contrast, a consistent increase in the rate of the diffuse type of gastric carcinoma was seen during this period. The rate increased from 0.3 cases per 100 000 persons in 1973 to 1.8 cases per 100 000 persons in 2000. This increase was seen in males, females, African Americans, and whites. The predominant increase occurred in the signet ring type.

CONCLUSIONS

The results indicate a progressive decrease in the incidence of the intestinal type of gastric cancer and an increase in the diffuse type of gastric carcinoma, especially the signet ring cell type. The clinical implications of the increase are considered.

Prediagnostic Levels of Serum Micronutrients in Relation to Risk of Gastric Cancer in Shanghai, China

Data on blood levels of specific carotenoids and vitamins in relation to gastric cancer are scarce. Little is known about the relationship between prediagnostic serum levels of carotenoids other than β-carotene and risk of gastric cancer especially in non-Western populations. Prediagnostic serum concentrations of α-carotene, β-carotene, β-cryptoxanthin, lycopene, lutein/zeaxanthin, retinol, α-tocopherol, γ-tocopherol, and vitamin C were determined on 191 cases and 570 matched controls within a cohort of 18,244 middle-aged or older men in Shanghai, China, with a follow-up of 12 years. High serum levels of α-carotene, β-carotene, and lycopene were significantly associated with reduced risk of developing gastric cancer (all Ps for trend ≤ 0.05); the odds ratios (95% confidence intervals) for the highest versus the lowest quartile of α-carotene, β-carotene, and lycopene were 0.38 (0.13-1.11), 0.54 (0.32-0.89), and 0.55 (0.30-1.00), respectively. Increased serum level of vitamin C was significantly associated with reduced risk of gastric cancer among men who neither smoked cigarettes over lifetime nor consumed ≥3 drinks of alcohol per day; the odds ratios (95% confidence intervals) for the second, third, and fourth quartile categories were 0.69 (0.28-1.70), 0.36 (0.14-0.94), and 0.39 (0.15-0.98), respectively, compared with the lowest quartile of vitamin C (P for trend = 0.02). There were no statistically significant relationships of serum levels of β-cryptoxanthin, lutein/zeaxanthin, retinol, α-tocopherol, and γ-tocopherol with gastric cancer risk. The present study implicates that dietary carotenes, lycopene, and vitamin C are potential chemopreventive agents for gastric cancer in humans.

Firm measures are required to effect any significant decrease in the Japanese age-adjusted mortality rate from malignant neoplasms for the 21st century

The Japanese have the longest lifespan worldwide, but this has been mostly due to reductions in the mortality rates from diseases other than malignant neoplasms. Changes in the age-adjusted mortality rates (AMRs) for malignant neoplasms in Japan from 1950 to 2000 are analyzed to elucidate the overall trend. The overall AMRs for all malignant neoplasms in men increased from 1950 to 2000, and decreased slowly in women during the same period. Changes since 1990 have been small in both genders, but show a hopeful trend towards a decrease in the total AMR since 1995. These trends reflect a balance between the decreased AMR from gastric (both male and female) and uterine cancers and increases in many other malignant neoplasms. However, in the period 1990-2000, the decrease in the AMR from gastric and uterine cancers has shown a trend towards leveling off. Therefore, improving the trend towards reductions in cancer incidence and mortality in the 21st century and beyond will depend on achieving changes in other cancer sites, which can only be realized through the twofold approach of preventative medicine and research as well as improvements in the levels of diagnosis and therapy. Much more emphasis must therefore be placed on primary prevention, in particular on anti-smoking campaigns, as well as stepping-up research into the etiology of, and novel treatments for other malignant neoplasms, especially colorectal and breast cancers.

Analysis of geospecific markers for Helicobacter pylori variants in patients from Japan and Nigeria by triple-locus nucleotide sequence typing

Human migrations and geographical separation over long periods may have resulted in ecologically distinct populations of Helicobacter pylori infecting individuals in different continents. This study used nucleotide sequence analysis with the aim of defining population-specific genomic motifs in isolates from East Asian and African dyspeptic patients. Sequences of internal fragments (542-627 bp) of three housekeeping genes (ureI, ahpC and atpA) were analysed for 85 isolates from individuals in Japan and China (30 isolates), Nigeria and South Africa (14 isolates), the United Kingdom (32 isolates), and nine miscellaneous reference strains. Phylogenetic analyses showed a high degree of intra-set relatedness amongst sequences from the Japanese and Nigerian isolates, with each robustly segregated as distinct lineages irrespective of cagA presence and vacA allelic type. All strains had unique combined sequence types except for identical paired (antrum/corpus) isolates. Population-specific polymorphisms were identified within each gene which were combined to provide unique motifs defining the Japanese and Nigerian regional populations. The alleles were present at variable frequencies in UK and South African isolates. The findings provide unique evidence of positive selection for conserved nucleotide sites linked to the geographical separation in Japan of a strain subpopulation for which we propose the designation H. pylori geovar 'orientalis'.

An impaired accommodation of the proximal stomach to a meal is associated with symptoms after distal gastrectomy

OBJECTIVE

The aim of this study was to assess gastric emptying and postprandial proximal gastric tone variations depending on the presence of postoperative symptoms after Billroth II gastrectomy (BII).

METHODS

A total of 16 consecutive patients were prospectively studied 10 +/- 3 months after distal gastrectomy for antral cancer. No evidence of cancer recurrence was detected at the time of the study. Ten patients were asymptomatic after surgery, whereas six patients were considered as symptomatic because of at least one weekly epigastric pain, postprandial fullness, nausea, or vomiting. The fasting fundus volume and tone, the onset of a gastric relaxation after a standard 200-kcal liquid meal, and the characteristics of this relaxation (delay of occurrence, amplitude) were determined with a barostat. Patient results were compared to normal values obtained in 12 healthy volunteers. Gastric emptying studies were performed in all patients using the C(13) acid octanoic breath test after a 250-kcal meal.

RESULTS

In the patients, both fasting fundus tone (BII 7.0 +/- 0.5, controls 8.4 +/- 2.4 mm Hg) and volume (BII 108 +/- 11, controls 119 +/- 29 ml) were not different from controls. Fasting fundus tone was lower in asymptomatic patients than in symptomatic patients (6.5 +/- 0.4 vs 8.1 +/- 0.5 mm Hg, p < 0.04). Gastric relaxation was observed immediately after the meal in all asymptomatic patients as well as in controls. In contrast, gastric relaxation occurred in only two of six symptomatic patients (p < 0.01); when it occurred it was delayed by the meal and was observed only 23 +/- 1 min after food intake. When a relaxation occurred, its amplitude was higher than that observed in controls both in asymptomatic and symptomatic patients (294 +/- 21 vs 179 +/- 53 ml, p < 0.02).

CONCLUSIONS

After distal gastrectomy, gastric accommodation is impaired (i.e., absent or delayed) in symptomatic patients. When relaxation exists in these patients, its amplitude is higher than in control subjects.

Expression level of valosin-containing protein is strongly associated with progression and prognosis of gastric carcinoma

PURPOSE

Valosin-containing protein (VCP; also known as p97) was shown to be associated with antiapoptotic function and metastasis via activation of nuclear factor kappa-B signaling pathway. In this study, association of VCP expression with recurrence of gastric carcinoma (GC), in which lymphatic vessels are the main route of spread, was examined.

PATIENTS AND METHODS

VCP expression in 330 patients with GC (242 males and 88 females) with ages ranging from 26 to 81 years (median, 60 years) was analyzed by immunohistochemistry, in which staining intensity in tumor cells was categorized as weaker (level 1) or equal to or stronger (level 2) than that in endothelial cells.

RESULTS

Ninety-four (28.7%) patient cases showed level 1 and 233 patient cases (71.3%) showed level 2 VCP expression. Patients with level 2 expression showed higher rates of large tumor size (P <.0001), undifferentiated histologic subtype (P <.05), presence of vascular and lymphatic invasion (P <.0001 for both), presence of lymph node metastasis (P <.0001), deep tumor invasion (P <.0001), and poorer disease-free and overall survivals (P <.0001 for both) compared with those with level 1 VCP expression. Multivariate analysis revealed VCP expression level as an independent prognosticator for disease-free and overall survival. VCP level was an indicator for disease-free and overall survival in the early (pT1; P <.01 and P <.05, respectively) and advanced (pT2-4; P <.05 for both) group of pathologic tumor-node-metastasis system classification.

CONCLUSION

The prognostic significance of VCP expression level in GC was demonstrated.