A community-based, case-control study evaluating mortality reduction from gastric cancer by endoscopic screening in Japan

Gastric cancer mortality related to direct radiographic and endoscopic screening: A retrospective study

BACKGROUND

Despite its decreased incidence in Japan, gastric cancer continues among the leading causes of cancer-related deaths in both men and women. Accordingly, efforts are still required to lower the mortality rate of gastric cancer in Japan. Maebashi City introduced endoscopic gastric cancer screening in 2004, and participants are able to choose between direct radiography and endoscopy. Hence, we expected to see a decrease in mortality rate from gastric cancer after introducing endoscopic screening and a difference in mortality rate reduction between screening methods.

AIM

To evaluate the impact on gastric cancer mortality rate of two types of gastric cancer screening in Maebashi City, Japan.

METHODS

Participants aged 40 to 79 years of the Maebashi City gastric cancer screening program in 2006 who were screened by direct radiography (n = 11155) or endoscopy (n = 10747) were included. Participants were followed until March 31, 2012, by cross-referencing their data against the Gunma Prefecture cancer registry data. We compared the detection rate of gastric cancers. Then, we compared the mortality rate between the two groups. The Cox proportional hazards model was used to estimate the hazard ratio (HR) of gastric cancer death. Finally, the reduction in gastric cancer mortality rate associated with each screening method was evaluated.

RESULTS

Gastric cancer was detected in 22 participants undergoing direct radiography (detection rate, 0.20%) and in 52 participants undergoing endoscopy (detection rate, 0.48%). However, most gastric cancers detected by endoscopic screening were early cancers that may not have resulted in death. We found no significant difference in gastric cancer mortality rate between participants receiving annual screening and those who do not. When the number of gastric cancer deaths in the direct radiography group was set as 1 in the Cox proportional hazard analysis, the HR of gastric cancer death was 1.368 (95%CI: 0.7308-2.562) in the overall group of participants. The results showed no significant difference between the two screening methods in any of the analysis groups.

CONCLUSION

Although endoscopic screening detected more gastric cancer than direct radiographic screening, no significant difference in the reduction of gastric cancer mortality rate between the two screening methods was found.

Endoscopic Screening and Surveillance for Gastric Cancer

Gastric cancer is one of the most common cancers worldwide. Gastric cancer is a multifactorial disease, and the incidence varies widely by geographic region, with half of new cases occurring in East Asia. Population-based nationwide screening for gastric cancer has been implemented in some Eastern Asian countries such as South Korea and Japan. In these countries, endoscopic screening decreased gastric cancer mortality. Endoscopic screening seems to be a cost-effective modality in countries with high incidence of gastric cancer. However, the usefulness of population-based screening has not yet been proved in countries with low incidence of gastric cancer.

Feasibility of Endoscopic Screening for Upper Gastrointestinal Malignancy in a Comprehensive Health Checkup

Objective In an effort to reduce mortality from gastric cancer, endoscopic screening was introduced in 2016 as a nationwide screening program in Japan. Recent developments in high-definition endoscopic imaging and diagnostic strategies have enabled the simultaneous detection of other upper gastrointestinal (U-GI) malignancies. Therefore, we conducted a study to evaluate the feasibility of endoscopic screening for U-GI malignancy in a comprehensive health checkup. Methods We retrospectively reviewed the data of 13,120 participants who had received a comprehensive health checkup in a single institution between April 2012 and March 2018. Participants were divided into two groups [gastrointestinal endoscopy (GIE) group (n=9,142) and gastrointestinal X-ray (X-ray) group (n=3,978)] and compared with regards to the screening results, adverse events, and detection rate of U-GI malignancies (gastric cancer or other) using a propensity-score matched analysis. Results The gastric cancer detection rate was significantly higher in the GIE group [34/9,142 (0.48%)] than in the X-ray group [3/3,978 (0.08%)] (p=0.003). Other U-GI malignancies were found only in the GIE group and comprised two hypopharyngeal cancers, five esophageal cancers, two duodenal cancers, and one duodenal gastrointestinal stromal tumor. Adverse events occurred in 6/9,142 (0.07%) participants in the GIE group and 18/3,978 (0.45%) participants in the X-ray group (p<0.0001). A propensity-score matched analysis yielded 1,551 matched pairs, and the detection rate of gastric cancer and other U-GI malignancies remained significantly higher in the GIE group than in the X-ray group. Conclusion This study indicated that not only gastric cancer but also other U-GI malignancies can be detected by endoscopic screening.

The risk scoring system for assessing the technical difficulty of endoscopic submucosal dissection in cases of remnant gastric cancer after distal gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for remnant gastric cancer (RGC) after distal gastrectomy (DG) is considered technically challenging due to the narrow working space, and severe fibrosis and staples from the previous surgery. Technical difficulties of ESD for RGC after DG have not been thoroughly investigated. This study aimed to develop and validate a risk-scoring system for assessing the technical difficulty of ESD for RGC after DG in a large multicenter cohort.

METHODS

We investigated patients who underwent ESD for RGC after DG in 10 institutions between April 2008 and March 2018. A difficult case was defined as ESD lasting ≥ 120 min, involving piecemeal resection, or the occurrence of perforation during the procedure. A risk-scoring system for the technical difficulty of the procedure was developed based on multiple logistic regression analyses, and its performance was internally validated using bootstrapping.

RESULTS

A total of 197 consecutive patients with 201 lesions were analyzed. There were 90 and 111 difficult and non-difficult cases, respectively. The scoring model consisted of four independent risk factors and points of risk scores were assigned for each as follows: tumor size > 20 mm: 2 points; anastomosis site: 2 points; suture line: 1 point; and non-expert endoscopist: 2 points. The C-statistics of the scoring system for technical difficulty was 0.72.

CONCLUSIONS

We developed a validated risk-scoring model for predicting the technical difficulty of ESD for RGC after DG that can contribute to its safer and more reliable performance.

A Novel Six-Gene-Based Prognostic Model Predicts Survival and Clinical Risk Score for Gastric Cancer

Background: Autophagy plays a vital role in cancer initiation, malignant progression, and resistance to treatment. However, autophagy-related genes (ARGs) have rarely been analyzed in gastric cancer (GC). The purpose of this study was to analyze ARGs in GC using bioinformatic analysis and to identify new biomarkers for predicting the overall survival (OS) of patients with GC.

Methods: The gene expression profiles and clinical data of patients with GC were obtained from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) datasets, and ARGs were obtained from two other datasets (the Human Autophagy Database and Molecular Signatures Database). Lasso, univariate, and multivariate Cox regression analyses were performed to identify the OS-related ARGs. Finally, a six-ARG model was identified as a prognostic indicator using the risk-score model, and survival and prognostic performance were analyzed based on the Kaplan-Meier test and ROC curve. Estimate calculations were used to assess the immune status of this model, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were employed for investigating the functions and terms associated with the model-related genes in GC.

Results: The six ARGs, DYNLL1, PGK2, HPR, PLOD2, PHYHIP, and CXCR4, were identified using Lasso and Cox regression analyses. Survival analysis revealed that the OS of GC patients in the high-risk group was significantly lower than that of the low-risk group (p < 0.05). The ROC curves revealed that the risk score model exhibited better prognostic performance with respect to OS. Multivariate Cox regression analysis indicated that the model was an independent predictor of OS and was not affected by most of the clinical traits (p < 0.05). The model-related genes were associated with immune suppression and several biological process terms, such as extracellular structure organization and matrix organization. Moreover, the genes were associated with the P13K-Akt signaling pathway, focal adhesion, and MAPK signaling pathway.

Conclusions: This study presents potential prognostic biomarkers for GC patients that would aid in determining the best patient-specific course of treatment.

Prevalence of gastric cancer precursors in gastroscopy-screened adults by family history of gastric cancer and of cancers other than gastric

Background

People are at a high risk of gastric cancer if their first-degree relatives suffered from atrophic gastritis (AG), intestinal metaplasia (IM), intraepithelial neoplasia (IEN), dysplasia (DYS), or gastric cancer (GC). This study was performed to analyse the association between FDR-GC and GC precursors.

Methods

A cross-sectional study was performed to screen the prevalence of GC precursors from November 2016 to September 2019. A total of 1329 participants with FDR-GC, 193 participants with a family history of non-gastric cancer in FDRs (FDR-nGC), and 860 participants without a family history of cancer in FDRs (FDR-nC) were recruited in this study. The logistic regression model was used in this study.

Results

The prevalence of normal, Non-AG, AG/IM, IEN/DYS, and GC was 31.91, 44.21, 13.81, 8.73, and 1.34%, respectively. The prevalence of IEN/DYS was higher in people with FDR-GC and FDR-nGC (FDR-GC: odds ratio (OR) = 1.655; 95%CI, 1.153–2.376; FDR-nGC: OR = 1.984; 95%CI, 1.122–3.506) than those with FDR-nC. The younger the age at which FDRs were diagnosed with GC, the more likely the participants were to develop AG/IM (P_trend = 0.019). The risk of precursors to GC was higher in participants whose FDR-GC was the mother than in those whose FDR-GC was the father or sibling (OR, non-AG: 1.312 vs. 1.007, 1.274; AG/IM: 1.430 vs. 1.296, 1.378; IEN/DYS: 1.988 vs. 1.573, 1.542). There was no statistically significant difference in non-AG (OR = 1.700; 95%CI, 0.940–3.074), AG/IM (OR = 1.291; 95%CI, 0.579–2.877), and IEN/DYS (OR = 1.265; 95%CI, 0.517–3.096) between participants with one or more FDR-GC.

Conclusion

People with FDR-GC and FDR-nGC are at a high risk of IEN/DYS. When an FDR was diagnosed at a younger age, the risk of AG/IM was higher. The risk of GC precursors was higher in people whose FDR-GC was the mother.

Gastric cancer screening in low incidence populations: Position statement of AEG, SEED and SEAP

This positioning document, sponsored by the Asociación Española de Gastroenterología, the Sociedad Española de Endoscopia Digestiva and the Sociedad Española de Anatomía Patológica, aims to establish recommendations for the screening of gastric cancer (GC) in low incidence populations, such as the Spanish. To establish the quality of the evidence and the levels of recommendation, we used the methodology based on the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). We obtained a consensus among experts using a Delphi method. The document evaluates screening in the general population, individuals with relatives with GC and subjects with GC precursor lesions (GCPL). The goal of the interventions should be to reduce GC related mortality. We recommend the use of the OLGIM classification and determine the intestinal metaplasia (IM) subtype in the evaluation of GCPL. We do not recommend to establish endoscopic mass screening for GC or Helicobacter pylori. However, the document strongly recommends to treat H.pylori if the infection is detected, and the investigation and treatment in individuals with a family history of GC or with GCPL. Instead, we recommend against the use of serological tests to detect GCPL. Endoscopic screening is suggested only in individuals that meet familial GC criteria. As for individuals with GCPL, endoscopic surveillance is only suggested in extensive IM associated with additional risk factors (incomplete IM and/or a family history of GC), after resection of dysplastic lesions or in patients with dysplasia without visible lesion after a high quality gastroscopy with chromoendoscopy.

Limited usefulness of serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for gastrointestinal and whole-body cancer screening

The diagnostic performance of serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels for multiple-organ cancer screening has not been fully elucidated. However, they are widely used for real-world opportunistic screening of multiple-organ cancers. This study aimed to examine the diagnostic performance of these serum markers in multiple-organ cancer screening. Data from asymptomatic individuals subjected to opportunistic cancer screening were analyzed. The diagnostic performance of CEA and CA 19-9 was assessed for (A) upper/lower gastrointestinal cancers and (B) whole-body cancers (including both gastrointestinal and other organ cancers) using the results of upper/lower gastrointestinal endoscopy and whole-body imaging as reference. Data from 12,349 and 7616 screened individuals were used to assess the diagnostic performance of CEA and CA 19-9 for (A) and (B), respectively. For (A), the sensitivity and positive predictive value (PPV) of CEA (cut-off: 5 ng/mL) were 7.8% and 3.7%, respectively; those of CA19-9 (cut-off: 37 U/mL) were 7.4% and 2.7%, respectively. For (B), the sensitivity and PPV of CEA were 6.6% and 4.1%, respectively, and those of CA19-9 were 10.8% and 5.8%, respectively. Considering even multiple cancers, the sensitivity and PPV of CEA and CA 19-9 were low, thus confirming their limited usefulness in multiple-organ cancer screening.

Gastric cancer

Gastric cancer is the fifth most common cancer and the third most common cause of cancer death globally. Risk factors for the condition include Helicobacter pylori infection, age, high salt intake, and diets low in fruit and vegetables. Gastric cancer is diagnosed histologically after endoscopic biopsy and staged using CT, endoscopic ultrasound, PET, and laparoscopy. It is a molecularly and phenotypically highly heterogeneous disease. The main treatment for early gastric cancer is endoscopic resection. Non-early operable gastric cancer is treated with surgery, which should include D2 lymphadenectomy (including lymph node stations in the perigastric mesentery and along the celiac arterial branches). Perioperative or adjuvant chemotherapy improves survival in patients with stage 1B or higher cancers. Advanced gastric cancer is treated with sequential lines of chemotherapy, starting with a platinum and fluoropyrimidine doublet in the first line; median survival is less than 1 year. Targeted therapies licensed to treat gastric cancer include trastuzumab (HER2-positive patients first line), ramucirumab (anti-angiogenic second line), and nivolumab or pembrolizumab (anti-PD-1 third line).

A protocol of systematic review and meta-analysis of narrow band imaging endoscopy in detection of early gastric cancer

BACKGROUND

Early gastric cancer is the fifth common malignancy and the third leading cause of cancer death throughout the world. However, it is not clear how endoscopic screening for early gastric cancer affects incidence or mortality. We performed a systematic review and meta-analysis to evaluate the relationship between endoscopic screening for the mortality and incidence of early gastric cancer.

MATERIALS AND METHODS

This protocol established in this study has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Web of Science, PubMed, EMBASE, and the Cochrane Library were searched for cohort and case-control studies in cases without early gastric cancer until March 31, 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the Eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The relative risk and 95% confidence intervals were used as effect estimate. I-square test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide helpful evidence of whether endoscopic screening would reduce the mortality and incidence of early gastric cancer.

PROSPERO REGISTRATION NUMBER

CRD42020171053.

Long-term effectiveness of one-time endoscopic screening for esophageal cancer: A community-based study in rural China

BACKGROUND

Evidence is required to quantify the population-level effects of endoscopic screening for esophageal squamous cell carcinoma (ESCC). The objective of this study was to evaluate the long-term effectiveness of 1-time endoscopic ESCC screening in a Chinese rural population.

METHODS

This community-based cohort study was based on an existing esophageal cancer screening program in Feicheng City, China. The screening group consisted of all permanent residents aged 40 to 69 years in 17 villages who were screened during 2006 through 2009, and the control group consisted of residents in another 43 villages who were not yet covered by the screening program. Residents in the remaining 511 villages were defined as the total population control. The cumulative incidence and mortality of ESCC and the observed and expected numbers of ESCC cases and deaths during the follow-up period (2010-2018) were calculated and compared.

RESULTS

After a 9-year follow-up, the screening group (n = 8460) revealed reductions of 20% (relative risk, 0.80; 95% CI, 0.66-0.97) and 32% (relative risk, 0.68; 95% CI, 0.52-0.89) in ESCC cumulative incidence and mortality, respectively, compared with the control group (n = 20,468). Endoscopic screening prevented 0.41% of the population (attributable risk, 0.41%; 95% CI, 0.07%-0.75%) from ESCC occurrence and 0.38% (attributable risk, 0.38%; 95% CI, 0.14%-0.62%) from ESCC-related death. In the screening group, reductions of 43% (standardized incidence ratio, 0.57; 95% CI, 0.48-0.67) and 45% (standardized mortality ratio, 0.55; 95% CI, 0.44-0.69) were found in the observed cumulative cases and deaths, respectively, compared with the expected cases and deaths.

CONCLUSIONS

One-time endoscopic screening was associated with a significant and consistent reduction in ESCC incidence and mortality among individuals aged 40 to 69 years in high-risk areas.

Guidelines for endoscopic diagnosis of early gastric cancer

The Japan Gastroenterological Endoscopy Society developed the Guideline for Endoscopic Diagnosis of Early Gastric Cancer based on scientific methods. Endoscopy for the diagnosis of early gastric cancer has been acknowledged as a useful and highly precise examination, and its use has become increasingly more common in recent years. However, the level of evidence in this field is low, and it is often necessary to determine recommendations based on expert consensus only. This clinical practice guideline consists of the following sections to provide the current guideline: [I] Risk stratification of gastric cancer before endoscopic examination, [II] Detection of early gastric cancer, [III] Qualitative diagnosis of early gastric cancer, [IV] Diagnosis to choose the therapeutic strategy for gastric cancer, [V] Risk stratification after endoscopic examination, and [VI] Surveillance of early gastric cancer.

Gastric Cancer: Epidemiology, Risk Factors, Classification, Genomic Characteristics and Treatment Strategies

Gastric cancer (GC) is one of the most common malignancies worldwide and it is the fourth leading cause of cancer-related death. GC is a multifactorial disease, where both environmental and genetic factors can have an impact on its occurrence and development. The incidence rate of GC rises progressively with age; the median age at diagnosis is 70 years. However, approximately 10% of gastric carcinomas are detected at the age of 45 or younger. Early-onset gastric cancer is a good model to study genetic alterations related to the carcinogenesis process, as young patients are less exposed to environmental carcinogens. Carcinogenesis is a multistage disease process specified by the progressive development of mutations and epigenetic alterations in the expression of various genes, which are responsible for the occurrence of the disease.

Utilizing Cultural and Ethnic Variables in Screening Models to Identify Individuals at High Risk for Gastric Cancer: A Pilot Study

Identifying persons at high risk for gastric cancer is needed for targeted interventions for prevention and control in low-incidence regions. Combining ethnic/cultural factors with conventional gastric cancer risk factors may enhance identification of high-risk persons. Data from a prior case-control study (40 gastric cancer cases and 100 controls) were used. A "conventional model" using risk factors included in the Harvard Cancer Risk Index's gastric cancer module was compared with a "parsimonious model" created from the most predictive variables of the conventional model as well as ethnic/cultural and socioeconomic variables. Model probability cutoffs aimed to identify a cohort with at least 10 times the baseline risk using Bayes' Theorem applied to baseline U.S. gastric cancer incidence. The parsimonious model included age, U.S. generation, race, cultural food at ages 15-18 years, excessive salt, education, alcohol, and family history. This 11-item model enriched the baseline risk by 10-fold, at the 0.5 probability level cutoff, with an estimated sensitivity of 72% [95% confidence interval (CI), 64-80], specificity of 94% (95% CI, 90-97), and ability to identify a subcohort with gastric cancer prevalence of 128.5 per 100,000. The conventional model was only able to reach a risk level of 9.8 times baseline with a corresponding sensitivity of 31% (95% CI, 23-39) and specificity of 97% (95% CI, 94-99). Cultural and ethnic data may add important information to models for identifying U.S. individuals at high risk for gastric cancer, who then could be targeted for interventions to prevent and control gastric cancer. The findings of this pilot study remain to be validated in an external dataset.

Quality Indicators for the Detection of Helicobacter pylori-Negative Early Gastric Cancer: A Retrospective Observational Study

Background/Aims

While Helicobacter pylori (HP)-negative gastric cancer is frequently reported, little is known about the predictors for detecting HP-negative early gastric cancer (EGC). We aimed to evaluate the predictors for the detection of HP-negative EGC.

Methods

We retrospectively reviewed 13,477 consecutive asymptomatic cases where upper endoscopy was performed by nine physicians from April 2017 to March 2019 and analyzed the detection rate of high-risk lesions (HRLs), including EGC, tubular adenoma, and lymphoma, according to the status of HP infection. The observation time was corrected for multiple regression analyses.

Results

For all physicians, the average observation time for screening HP-eradicated and -naïve patients was shorter than that for screening HP-positive patients (p<0.05). Multiple regression analyses revealed that the observation time in the three groups was an independent predictor for detecting HRLs in HP-eradicated patients (p=0.03106, 0.01263, and 0.02485, respectively), while experience of endoscopy was an independent predictor for detecting HRLs in HP-naïve patients (p=0.02638).

Conclusions

While observation time during screening endoscopy was a quality indicator for detecting HRLs in HP-eradicated patients, experience of endoscopy was a quality indicator for detecting HRLs in HP-naïve patients.

The relative survival and cure fraction of gastric cancer estimated through flexible parametric models using data from population-based cancer registration during 2003-2012 in Linzhou, China

PURPOSE

The proportion of cured gastric cancer patients has drawn the attention of patients, physicians, and healthcare providers after comprehensive prevention and control measures were carried out for several years. Therefore, the relative survival and cure fraction were estimated in our study.

METHODS

Population-based cancer registration data were used to estimate survival and cure fraction. A total of 7585 gastric cancer cases (ICD10:C16.0 ~ C16.9) were extracted and included in the final analysis. Cases were diagnosed in 2003-2012 and followed until the end of 2017. Relative survival was calculated as the ratio between the observed survival through the life-table method. The expected survival was estimated by the Ederer II method. The cure fraction was estimated using flexible parametric cure models stratified by age and calendar period when the cases were diagnosed.

RESULTS

The 5-year relative survival of cardia gastric cancer increased with the calendar period of 2003-2004, 2005-2006, 2007-2008, 2009-2010, and 2011-2012 (27.5%, 28.3%, 33.5%, 38.2%, and 46.8%, respectively). The increasing trend along with the calendar periods was also observed in cure proportion of cardia gastric cancer (24.8%, 25.2%, 31.7%, 36.0%, and 43.1%, respectively). Notable improvement of cure proportion was observed in the period of 2011-2012, compared with the initial period of 2003-2004. There was an improvement of 79.8% among all gastric cancer subjects, and it was 74.1% and 55.7% in cardia gastric and noncardia gastric cancer subjects, respectively. The median survival of "uncured" patients showed no significant improvement along with the calendar periods in all age groups.

CONCLUSIONS

Notable improvement of gastric cancer relative survival and cure proportion was observed in Linzhou during 2003-2012.

Factors associated with technical difficulty of endoscopic submucosal dissection for early gastric cancer that met the expanded indication criteria: post hoc analysis of a multi-institutional prospective confirmatory trial (JCOG0607)

BACKGROUND

There are few reports on the technical difficulty of gastric endoscopic submucosal dissection (ESD). The aim of this study was to investigate the factors associated with the technical difficulty of ESD for early gastric cancer (EGC) using the data from the multicenter non-randomized confirmatory trial of expanded indication criteria of ESD (JCOG0607).

METHODS

The major inclusion criteria were as follows: (1) histologically proven intestinal-type adenocarcinoma; (2) cT1aN0M0; (3) lesion without finding of ulcer (UL-negative) with > 2 cm in size, or UL-positive with ≤ 3 cm; (4) age 20-75 years. The difficult case was defined as ESD taking ≥ 120 min, piecemeal resection, and/or developing perforation during procedure.

RESULTS

Between June 2007 and October 2010, 470 patients were enrolled from 29 institutions. Median procedure time was 79 (range 14-462) min, and it was ≥ 120 min in 127 patients. Twelve patients developed perforation during ESD, and the procedure time was ≥ 120 min in 9 of them. Therefore, 130 patients (27.7%) were identified as difficult cases. Multivariable analysis showed that UL-negative with > 5 cm (vs. UL-negative with ≤ 3 cm, odds ratio, 24.993; 95% CI 6.130-101.897, p < 0.0001) had the largest odds ratio and followed by UL-negative with 3-5 cm upper or middle portion of stomach and age ≤ 60 years were significantly associated with difficulty.

CONCLUSIONS

UL-negative lesion with > 3 cm, upper or middle portion of stomach and age ≤ 60 years were independent factors associated with technical difficulty of ESD for EGC. Trial registered number was UMIN000000737.

Risk of progression to eosinophilic esophagitis in patients with asymptomatic esophageal eosinophilia: A retrospective pilot study

Background and Aim

As the number of patients with eosinophilic esophagitis (EoE) has increased worldwide, the likelihood of diagnosing esophageal eosinophilia (EE) in screening endoscopy has also increased. Many of these EE patients do not display any symptoms (i.e. they display asymptomatic EE: aEE), and the risk of aEE patients developing EoE has yet to be demonstrated.

Methods

A total of 62 250 cases were found in the endoscopic registries of two digestive disease centers in the context of gastric cancer screening from April 2016 to August 2018, and these were reviewed.

Results

Thirty‐seven aEE patients (0.059%) were found in the registries, and the histories of endoscopic findings and symptoms were successfully traced for 29 of them. While 11 aEE (37.9%) patients did not show any change in endoscopic findings, 18 (62.1%) exhibited exacerbation. A comparison of the two groups showed both relative youth and diffuse disease distribution to be independent risk factors for progression (P = 0.0034 and 0.0078, respectively). Of the 18 aEE patients whose findings showed progression, 6 developed EoE (5 (17.2%) developed proton‐pump inhibitor (PPI)‐responsive EoE, and only 1 (3.4%) developed PPI‐resistant EoE). A comparison of the non‐EoE and EoE groups showed relative youth to be an independent risk factor for progression to EoE (P = 0.0146).

Conclusions

While some aEE patients developed symptomatic EE, the existence among them of PPI‐resistant EoE was extremely rare. Younger age and diffuse disease distribution at first detection in endoscopic findings are risk factors for progression to symptomatic EE in aEE patients.

The long-term population impact of endoscopic screening programmes on disease burdens of gastric cancer in China: A mathematical modelling study

BACKGROUND

Gastric cancer (GC) incidence and mortality in China remained high due to delayed diagnosis and accounted for about half of the world's GC cases and deaths. Early detection with endoscopic screening and consequent timely treatment can significantly improve survival. This study aimed to explore the long-term population impact of endoscopic screening on national GC disease burdens in China.

METHODS

Most of previous studies investigated the disease burdens of cancer using Markov model or age-period-cohort (APC) model, which are difficult to estimate the population size of undiagnosed cases. In this paper, we proposed a new dynamic compartmental model based on GC natural history and calibrated model outputs to diagnosed GC cases and GC-related death counts using Markov Chain Monte Carlo methods. We investigated the impact of screening strategies with various coverage (10%, 40%, 70%) and frequency (every 1, 3, 5 years) on disease burdens.

RESULTS

We estimated that 2.22 (95%CI: 1.97-2.47) million Chinese are living with GC in 2019, among which, 42.7% (40.3-45.0%) remained undiagnosed. Without systematic screening, we projected 10.46 (9.07-11.86) million incident cases and 7.35 (6.59-8.11) million GC-related deaths over the next 30 years (2019-2049). Screening with coverage rate at 10%, 40%, 70% every 3 years could prevent 0.85 (0.63-1.06), 2.32 (1.79-2.86), and 3.04 (2.38-3.70) million incident cases, and prevent 1.17 (1.01-1.32), 3.08 (2.70-3.46), and 3.93 (3.46-4.40) million deaths respectively, compared with 'no screening' scenario. Screening would substantially increase the number of diagnosed GC cases within the first three years of program initiation, but this number would quickly reduce below 'no screening' scenario. Three-yearly screening at the above coverage rates would reduce the proportion of undiagnosed GC cases to 38.8% (36.9-40.7%), 25.5% (23.4-27.6%), and 17.8% (16.0-19.6%) by 2049, respectively. Delaying implementation of the screening program would substantially reduce its effectiveness.

CONCLUSIONS

Initiating national endoscopic screening programmes would likely have a major effect on reducing GC incidence and mortality in China. Health resources should be substantially increased and directed to treatment of GC to cope with the initial rise in diagnosed GC cases.

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer-in particular, hereditary diffuse gastric cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.

Evolving Clinical Utility of Liquid Biopsy in Gastrointestinal Cancers

Room for improvement exists regarding recommendations for screening, staging, therapy selection, and frequency of surveillance of gastrointestinal cancers. Screening is costly and invasive, improved staging demands increased sensitivity and specificity to better guide therapy selection. Surveillance requires increased sensitivity for earlier detection and precise management of recurrences. Peripherally collected blood-based liquid biopsies enrich and analyze circulating tumor cells and/or somatic genomic material, including circulating tumor DNA along with various subclasses of RNA. Such assays have the potential to impact clinical practice at multiple stages of management in gastrointestinal cancers. This review summarizes current basic and clinical evidence for the utilization of liquid biopsy in cancers of the esophagus, pancreas, stomach, colon, and rectum. Technical aspects of various liquid biopsy methodologies and targets are reviewed and evidence supporting current commercially available assays is examined. Finally, current clinical applicability, potential future uses, and pitfalls of applying liquid biopsy to the screening, staging and therapeutic management of these diseases are discussed.

Disparities in Epidemiological Profile of Gastric Adenocarcinoma in Selected Cities of Brazil

Background: Despite decreasing global incidence trends, gastric cancer is still among the five most incident cancers in the world and the third cancer-related cause of death. In Brazil, differences in incidence and mortality exist depending on the geographic region studied. Objective: To describe the incidence, mortality, trends and age-period-cohort of gastric cancer in three cities of Brazil (Sao Paulo, Belem and Fortaleza), in the period 1990-2012. Mortality for gastric cancer in Brazil overall and by region was described. Methods: 33,462 incident cases of gastric cancer were identified from the population-based cancer registries and 23,424 deaths from mortality information system in residents of the three cities and in Brazil were included in the study. Data for incident cases were extracted from the Population Based Cancer Registries from the National Cancer Institute (INCA). Mortality data on gastric cancer were extracted from Information Technology Department of Brazilian Public Health Care System/Health Ministry (DATASUS/MS). Mortality and incidence age standardized rates were calculated. For trends analysis the Joinpoint Regression and age-period-cohort model were applied. Results: Belem presented the highest incidence rates for gastric adenocarcinoma. Decreasing incidence trends were identified in Sao Paulo (-7.8% in men; -6.3% in women) and in Fortaleza (-1.2% in men). Increasing incidence trends were observed for women in Belem (1.8%) and Fortaleza (1.1%). In Belem (Amazon area), there was an increased risk for gastric cancer in women born after the 1960s. Overall in Brazil mortality for gastric cancer is decreasing. Mortality trends showed significant reduction, for both sexes, in the three Brazilian cities. Conclusion: Incidence of gastric cancer is increasing in women born in the sixties in Belem (Amazon region) and Fortaleza (Northeast region). In Brazil there was increase in mortality in Northeast region and decrease in others regions. More update data on incidence for Amazon and Northeast region is needed.

Early gastric cancer diagnostic ability of ultrathin endoscope loaded with laser light source

BACKGROUND

Conventionally, the low luminous intensity, low image resolution, and difficulty in operation have been reported with the ultrathin endoscope. However, it has markedly advanced recently. The improvement of the diagnostic ability is expected.

AIM

To compare the early gastric cancer diagnostic ability of an ultrathin endoscope loaded with a laser light source and that of the conventional endoscope.

METHODS

The target subjects were 375 consecutive patients who underwent endoscopy at our hospital for post-endoscopic submucosal dissection follow-up of gastric cancer from January to August 2018. During endoscopy, the ultrathin endoscope was used in 140 patients (37.3%), and the conventional endoscope was used in 235 patients (62.7%). Patient background was adjusted using the propensity score matching method, and gastric cancer detection ability was evaluated in the two groups.

RESULTS

The gastric cancer detection rate was 7.8% in the ultrathin endoscope group and 7.0% in the conventional endoscope group, and the mean intragastric observation time was 4.1 ± 1.7 min in the ultrathin endoscope group and 4.1 ± 1.9 min in the conventional endoscope group, showing no significant differences between the groups. Moreover, the biopsy implementation rate was 31.8% in the ultrathin endoscope group and 41.1% in the conventional endoscope group, and the biopsy prediction rate was 17.9% and 13.2%, respectively, showing no significant differences between the groups.

CONCLUSION

The gastric cancer diagnostic ability of the ultrathin endoscope loaded with a laser light source was comparable to that of the conventional endoscope. The observation time was also comparable. Thus, endoscopy using the ultrathin endoscope loaded with the laser light source would be the first option in screening examinations of gastric cancer due to its low invasion.

Evaluation of serum markers for gastric cancer and its precursor diseases among high incidence and mortality rate of gastric cancer area

BACKGROUND

Mongolia has the highest mortality rate of gastric cancer. The early detection of cancer and down-staging screening for high risk patients are essential. Therefore, we aimed to validate serum markers for stratifying patients for further management.

METHODS

Endoscopy and histological examination were performed to determine high risk and gastric cancer patients. Rapid urease test, culture and histological tests were performed to diagnose Helicobacter pylori infection. Serum pepsinogen (PG) I and II and anti-H. pylori IgG were measured by ELISA. Receiver Operating Characteristic analysis was used to extract the best cut-off point.

RESULTS

Totally 752 non-cancer and 50 consecutive gastric cancer patients were involved. The corpus chronic gastritis (72%: 36/50 vs. 56.4%: 427/752), corpus atrophy (42.0%: 21/50 vs. 18.2%: 137/752) and intestinal metaplasia (IM) (64.0%: 32/50 vs. 21.5%: 162/752) were significantly higher in gastric cancer than non-cancer patients, respectively. Therefore, corpus chronic gastritis, corpus atrophy and IM were considered as high risk disease. The best serum marker to predict the high risk status was PGI/II < 3.1 (sensitivity 67.2%, specificity 61%) and PGI/II further reduced to < 2.2 (sensitivity 66%, specificity 65.1%) together with PGI < 28 ng/mL (sensitivity 70%, specificity 70%) were the best prediction for gastric cancer. The best cut-off point to diagnose H. pylori infection was anti-H. pylori IgG > 8 U/mL. Multivariate analysis showed that anti-H. pylori IgG > 8 U/mL and PGI/II < 3.1 increased risk for high risk status and PGI/II < 3.1 remained to increase risk for gastric cancer.

CONCLUSION

The serum diagnosis using PGI/II < 3.1 cut-off value is valuable marker to predict high risk patients for population based massive screening.

How long should we continue gastric cancer screening? From an epidemiological point of view

BACKGROUND

In Japan, incidence of gastric cancer is expected to follow the current downward trend as the younger generation has lower incidence of Helicobacter pylori infection. In this study we aimed to estimate how long gastric cancer screening is deemed necessary in the future from epidemiologic perspectives.

METHODS

Following the Japanese guidelines for gastric cancer screening 2014, recommendation of providing population-based gastric cancer screening is judged by balancing benefits and harms. Benefits and harms are estimated by number needed to screen (NNS) < 1000 and Number Needed to Recall (NNR) < 100. NNS is the number of people required to participate in a screening to prevent one death and NNR is the number of people required to undergo diagnostic examination to prevent one death. These index are estimated for 2020-2035 using future projections of gastric cancer mortality for the scenarios of relative risk (RR) of 0.5-0.9 for mortality reduction by the screening.

RESULTS

The criteria of both NNS < 1000 and NNR < 100 are fulfilled for the following age groups: when RR is set as 0.6, men ≥ 55 and women ≥ 65; when RR is set as 0.7 and 0.8, men ≥ 65 and women ≥ 75; when RR is set as 0.9, men ≥ 75 only.

CONCLUSIONS

In case of RR of 0.5 and 0.6, the gastric cancer screening are recommended for men ≥ 55 and women ≥ 65 until 2035, while it is not recommended for men and women in the 45-54 even in 2010 and 2015.

Risk factors for development of gastric cancer in chronic atrophic gastritis: A long-term follow-up study

AIM

To identify the risk factors for the development of gastric cancer (GC) in atrophic gastritis patients during a long-term follow-up.

METHODS

This study enrolled 522 chronic atrophic gastritis patients who underwent gastroscopy and pathological diagnosis and completed endoscopic follow-up for more than 5 years in the Affiliated Hospital of Qingdao University from 2003 to 2007. The following parameters were collected: age, gender, degree of gastric mucosal lesions, survival time, and survival status. Baseline clinical and histological features are analyzed as potential risk factors for the development of GC by Cox regression analysis.

RESULTS

After an average follow-up period of 7.57 years ± 1.74 years, 23 of 522 patients with chronic atrophic gastritis were diagnosed with GC, with an incidence of 4.41% (23/522), of whom 11 had poorly differentiated adenocarcinomas, 7 had moderately differentiated adenocarcinomas, 2 had well differentiated adeno-carcinomas, 2 had neuroendocrine carcinoma, and 1 had malignant lymphoma. Male gender (P = 0.030, HR = 2.464), age > 55 years (P = 0.021, HR = 2.584), CAG with intestinal metaplasia (P = 0.014, HR = 6.261), CAG with mild to moderate atypical hyperplasia (P = 0.020, HR = 6.504), and CAG with severe atypical hyperplasia (P = 0.015, HR = 22.314) were identified to be risk factors for the development of GC in patients with chronic atrophic gastritis.

CONCLUSION

Male gender, age > 55 years, and the degree of gastric mucosal lesions are risk factors for GC in underlying mucosal atrophy. Patients with chronic atrophic gastritis with severe dysplasia are at the highest risk, and early endoscopic treatment is recommended after diagnosis.

Occurrence of gastric cancer in patients with atrophic gastritis during long-term follow-up

BACKGROUND

Additional data on the incidence of gastric neoplasia in the Chinese atrophic gastritis (AG) population during long-term follow-up are needed and the influence of the endoscopic surveillance interval on gastric neoplasia occurrence remains unknown.

AIMS

Retrospectively investigated the occurrence of gastric cancer (GC) and precancerous lesions in AG patients during long-term follow-up and assessed risk factors, such as the endoscopic surveillance interval for the development of gastric neoplasia.

METHODS

This study enrolled 332 AG patients who underwent initial gastroscopy from 2002 to 2005. Following parameters were collected: age, gender, smoking history, H. pylori infection, location of atrophy and intestinal metaplasia (IM), surveillance interval, follow-up duration, and neoplasia occurrence.

RESULTS

Gastric neoplasia was diagnosed in 16 patients. The annual incidence rates per person-year of total gastric neoplasia, gastric high-grade intraepithelial neoplasia (HGIN), early GC and advanced GC were 0.53%, 0.07%, 0.20% and 0.33%, respectively. A multivariate Cox analysis not accounting for the extent of AG and/or IM showed that the risk factors for GC development among AG patients included the presence of AG and/or IM involving both antral and corporal (p<.001, HR 2.898) and H. pylori infection (p=.018, HR 3.946). In the extensive AG and/or IM group, a 2- to 3-year surveillance interval might be instructive in early detection of GC (p=.008, HR 0.015).

CONCLUSIONS

Our data reveal an annual incidence rate of 0.53% per person-year for GC and HGIN in AG patients. A 2- to 3-year surveillance interval may be suitable for patients with extensive AG and/or IM.

Differences in upper gastrointestinal neoplasm detection rates based on inspection time and esophagogastroduodenoscopy training

Background and study aims  Esophagogastroduodenoscopy (EGD) has utility in early detection of upper gastrointestinal (UGI) neoplasms. However, previous studies report shorter inspection times and inexperienced endoscopists contribute to overlooking gastric neoplasms. We investigated neoplasm detection rates according to inspection time and extent of EGD training. Patients and methods  In this retrospective observational study, we reviewed routine EGDs for 3,925 consecutive cases between October 2014 and March 2015. We divided the endoscopists into three groups based on median inspection time during EGD without undergoing biopsy. Using cut-off median inspection times of 7 and 10 minutes, three, five, and eight endoscopists were classified into the fast, moderate, and slow groups, respectively. We compared detection rates according to inspection time and the extent of EGD training. Results  The median inspection time among all endoscopists was 9.3 minutes (range, 6.6 - 12.0 min). The detection rate for UGI neoplasms was as follows: fast group, 3.6%; moderate group, 3.3 %; and slow group, 3.1 % ( P  = 0.807). The median inspection time was significantly shorter among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: median 6.3 min; range 8.2 - 13.9 min, ≥ 1-year: median 8.9 min; range 6.4 - 11.4 min, P  < 0.001). The detection rate for UGI neoplasms was significantly higher among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: 2.2 %; ≥ 1-year: 3.7 %, OR = 1.65, 95 % CI: 1.02 - 2.68, P  = 0.041). Conclusions  There was no association between inspection times and neoplasm detection rates. The quality of EGD, as measured by neoplasm detection rates, may be improved by ≥ 1-year of intensive training.

Endoscopic Screening in Asian Countries Is Associated With Reduced Gastric Cancer Mortality: A Meta-analysis and Systematic Review

BACKGROUND & AIMS

It is not clear how endoscopic screening for gastric cancer affects incidence or mortality. We performed a systematic review and meta-analysis to evaluate the relationship between endoscopic screening for gastric cancer and mortality and incidence.

METHODS

We conducted a systematic search of PubMed and EMBASE for published cohort and case-control studies of adults without gastric cancer who underwent endoscopic screening at least once that included a comparator and reported outcomes of mortality or incidence through March 8, 2018. Two investigators independently reviewed the included studies and extracted relevant data. The effect estimate of interest was the relative risk (RR). We used a random effects model to combine RRs and 95% confidence intervals (Cis).

RESULTS

Our final analysis included 6 cohort studies and 4 nested case-control studies comprising 342,013 individuals, all from Asia. The combined result (RR, 0.60; 95% CI, 0.49-0.73) indicated that endoscopic screening was associated with a 40% RR reduction in gastric cancer mortality. We did not observe an association between endoscopic screening and incidence (RR, 1.14; 95% CI, 0.93-1.40). Subgroup analysis showed significant reductions in gastric cancer mortality after endoscopic screening compared with no screening (RR, 0.58; 95% CI, 0.48-0.70) or radiographic screening (RR, 0.33; 95% CI, 0.12-0.91). However, endoscopic screening did not significantly reduce mortality compared with expected deaths (RR, 0.67; 95% CI, 0.38-1.16).

CONCLUSIONS

In a systematic review and meta-analysis, we found that endoscopic screening may reduce the risk of death from gastric cancer and not affect incidence in Asian countries. Population-based prospective cohort studies are warranted to confirm our findings.

Update version of the Japanese Guidelines for Gastric Cancer Screening

Background

Although the incidence and mortality of gastric cancer have gradually decreased, its burden remains in East Asian countries. Gastric cancer screening has been performed in Japan since 1983, and the introduction of new screening techniques has been eagerly anticipated.

Objective

To promote evidence-based screening, the Japanese guidelines for gastric cancer screening have been revised based on the new studies.

Methods

The guidelines for gastric cancer screening have been developed according to a previously established method. To assess evidence regarding the effectiveness of the screening methods, a systematic review was conducted based on an analytic framework including clinical questions aiming at reducing mortality from gastric cancer. The following methods were assessed for gastric cancer screening: upper gastrointestinal series (radiographic screening), gastrointestinal endoscopy (endoscopic screening), Helicobacter pylori antibody test and serum pepsinogen tests. Based on the balance of the benefits and harms of each screening method, recommendations for population-based and opportunistic screenings were formulated.

Findings

After the Japanese guidelines for gastric cancer screening were published in 2005, several observational studies on radiographic and endoscopic screenings have been reported. Three case-control studies have evaluated mortality reduction from gastric cancer by endoscopic screening. Notably, evidence of the H. pylori antibody and serum pepsinogen tests was insufficient. Although false-positive results, false-negative results, and complications were observed in endoscopic and radiographic screenings, the complication rates were higher in endoscopic screening than in radiographic screening. Overdiagnosis was not estimated directly in both methods.

Recommendations

Radiographic and endoscopic screenings for gastric cancer are recommended for population-based and opportunistic screenings. The H. pylori antibody and serum pepsinogen tests are not recommended for population-based screening because of insufficient evidence.

Three-year interval for endoscopic screening may reduce the mortality in patients with gastric cancer

BACKGROUND

Endoscopic screening has been adopted in South Korea for the national screening of gastric cancer (GC). This study aimed to assess the effect on overall survival of GC patients and determine the optimal endoscopic screening interval.

METHODS

The baseline characteristics and overall survival of GC patients treated at the National Cancer Center, Korea, between 2010 and 2016 were compared between those without a history of endoscopic evaluation (group N) and those in whom the interval between the last endoscopic evaluations and diagnosis of GC was ≤ 1, 1-2, 2-3, 3-4, or > 4 years (groups 1-5, respectively).

RESULTS

A total of 2362 patients met the criteria for the study (1060 in group N and 1302 in groups 1-5). More patients in groups 1-5 were diagnosed with stage I GC (83.7, 83.7, 71.8, 78.2, and 71.6%, respectively) than in group N (62.4%, P < 0.001) and were treated endoscopically (38.8, 33.8, 24.7, 21.8, and 15.5%, respectively, vs. 13.5%; P < 0.001). Group 2 had less-advanced tumor stages (P = 0.001) and was more likely to have received endoscopic treatments (P = 0.026) than group 3. Hazard ratios for death were significantly lower in groups 2 (0.45; 95% confidence interval [CI], 0.32-0.64) and 3 (0.57; 95% CI, 0.33-0.98) than in group N; the decrease was not significant in group 4 (0.49, 95% CI, 0.20-1.20).

CONCLUSIONS

Endoscopic screening every 3 years may reduce the mortality of GC patients, though screenings at least every 2 years may benefit patients with less-advanced stages.

Higher risk of gastric cancer among immigrants to Ontario: a population-based matched cohort study with over 2 million individuals

BACKGROUND

The risk of gastric carcinoma (GC) varies around the world and between females and males. We aimed to compare the risk of GC among immigrants to Ontario, Canada, to the risk of GC in its general population.

METHODS

This was a retrospective population-based matched cohort study from 1991 to 2014. We identified immigrants who were first eligible for the Ontario Health Insurance Plan at age 40 years or older, and matched 5 controls by year of birth and sex. We calculated crude rates and relative rates of GC stratified by sex. We modeled GC hazard using multivariable Cox proportional hazards regression, where a time-varying coefficient was incorporated to examine changes in the association of immigrant status with GC hazard over time.

RESULTS

Among females, 415 GC cases were identified among 209,843 immigrants and 1872 among 1,049,215 controls. Among males, 596 GC cases were identified among 191,792 immigrants and 2998 among 958,960 controls. Comparing immigrants from East Asia and Pacific with the controls, the crude relative rate of GC was 1.54 for females and 1.32 for males. The adjusted hazard ratio (HR) for GC among female immigrants was 1.29 [95% confidence interval (CI) 1.12, 1.48] within 10 years and 1.19 (1.01, 1.40) beyond 10 years; for males, the HR was 1.17 (1.04, 1.31) within 10 years and 1.00 (0.87, 1.15) beyond 10 years.

CONCLUSION

The risk of GC among immigrants is elevated. Although high-risk immigrant populations in Ontario have been identified, further knowledge is required before a program of GC prevention that is targeted to them can be planned.

Factors Affecting Endoscopic Curative Resection of Gastric Cancer in the Population-Based Screening Era

Background/Aims

Since population-based screening for gastric cancer in Korea was implemented, endoscopic treatment of early gastric cancer has become increasingly popular. This study investigates factors affecting endoscopic curative resection of early gastric cancer in population-based screening for gastric cancer.

Methods

We retrospectively reviewed data of patients with newly diagnosed gastric cancer who underwent treatment at Seoul St. Mary’s Hospital. All patients completed questionnaires about clinical information, including interval between surveillance tests for gastric cancer.

Results

Of 469 gastric cancer patients, 147 (31.3%) had undergone curative endoscopic resection, 260 (55.4%) had undergone curative surgical resection, and 62 (13.3%) underwent non-curative resection or were in an inoperable state. Patients with curative endoscopic resection had fewer alarm symptoms/signs than other groups. In multivariate analysis, regular surveillance endoscopy was the only factor predicting curative endoscopic resection (odds ratio [OR], 6.099; 95% confidence interval [CI], 2.532–14.933). In addition, patients undergoing gastric cancer screening had a significantly higher rate of endoscopic curative resection compared with subjects who had never been screened. (1-year interval: OR, 49.969; 95% CI, 6.340–393.827, 2-year interval: OR, 15.283; 95% CI, 1.833–127.406, over 2-year interval: OR, 10.651; 95% CI, 1.248–90.871). Shorter screening test intervals were associated with higher rates of endoscopic curative resection.

Conclusions

Regular surveillance testing was the independent factor predicting curative endoscopic resection of gastric cancer.

Cost-effectiveness of combined serum anti-Helicobacter pylori IgG antibody and serum pepsinogen concentrations for screening for gastric cancer risk in Japan

BACKGROUND

A combination of assays for the presence of serum anti-Helicobacter pylori IgG antibody (HPA) and serum pepsinogen (PG) concentrations can be used to screen for gastric cancer risk. In Japan, this "ABC method" is considered an effective means of stratifying gastric cancer risk. This study aimed to ascertain its cost-effectiveness for assessing gastric cancer risk.

METHODS

A Markov model was constructed to compare the cost-effectiveness of two strategies for gastric cancer-risk screening over a 30-year period: the ABC method, which uses a combination of assessing the presence of HPA and measuring serum PG concentrations and scheduling endoscopies accordingly, and annual endoscopic screening. Clinical and epidemiological data on variables in the model were obtained from published reports. Analyses were made from the perspective of the Japanese health care payer.

RESULTS

According to base-case analysis, the ABC method cost less than annual endoscopic screening (64,489 vs. 64,074 USD) and saved more lives (18.16 vs. 18.30 quality-adjusted life years). One-way analyses confirmed the robustness of the cost-effectiveness results. The probability that the ABC method is cost-effective in Japanese individuals aged 50 years was 0.997.

CONCLUSIONS

A combination of HPA and serum PG assays, plus scheduling endoscopy accordingly, is a cost-effective method of screening for gastric cancer risk in Japan.

Can a gastric cancer risk survey identify high-risk patients for endoscopic screening? A pilot study

BACKGROUND

A questionnaire that distinguishes how variability in gastric cancer prevalence is associated with ethnicity/birth country/immigration/cultural diet along with known risk factors may improve targeting populations for gastric cancer screening in the United States.

METHODS

Existing literature was used to identify the item pool. Cluster analysis, focus groups, and cognitive interviewing were used to reduce collinear items and refine the questionnaire. Logistic regression analysis was used to determine which items distinguished gastric cancer cases from the primary care and community controls.

RESULTS

The results of analysis of data from 40 cases and 100 controls (primary care = 47; community = 53) were used to reduce the 227 item pool to 12 items. After ranking these variables using model bootstrapping, a logistic regression model using the highest ranked eight variables was chosen as the final model. Older age, foreign nativity, daily consumption of cultural food at ages 15-18, less than high-school education, and greater acculturation were significantly associated with being a gastric cancer case compared with the controls.

CONCLUSIONS

An eight-item survey that addresses gastric cancer risk factors, ethnicity, cultural habits, and immigration patterns has potential to identify high-risk persons from multicultural areas within the US, who might benefit from endoscopic screening for gastric cancer.

Association of gastric intestinal metaplasia and East Asian ethnicity with the risk of gastric adenocarcinoma in a U.S. population

BACKGROUND AND AIMS

Although the incidence of gastric cancer is higher than that of esophageal cancer in the United States, no screening or surveillance guidelines exist. The aim of this study is to evaluate the association between gastric intestinal metaplasia and the risk of gastric cancer in a U.S. tertiary care system with a large immigrant population.

METHODS

This is a retrospective case-control study with cases of biopsy-proven gastric cancer matched (by age and gender) to controls without gastric cancer who had undergone EGD. The presence of gastric intestinal metaplasia was ascertained from pathology reports. Other potential risk factors for gastric cancer were abstracted from medical records as follows: country of origin, Helicobacter pylori infection, family history of gastric cancer, alcohol consumption, smoking, and history of partial gastrectomy (Billroth I or II). Conditional logistic regression was used to identify independent risk factors for gastric cancer.

RESULTS

One hundred fifty-two cases of gastric cancer were compared with 456 age- and gender-matched controls. The mean age was 66 years, and 57% were male. Multivariable analysis identified 2 significant predictors of gastric cancer: the presence of gastric intestinal metaplasia (odds ratio [OR], 9.3; 95% confidence interval [CI], 4.5-18.9; P < .001) and East Asian ethnicity (OR, 15.9; 95% CI, 5.8-43.6; P < .001).

CONCLUSION

The presence of gastric intestinal metaplasia on endoscopy and East Asian ethnicity were significant risk factors for gastric cancer. Screening East Asian immigrants and surveying patients with gastric intestinal metaplasia may improve the rates of early detection of gastric cancer in the United States.

Diagnostic performance of routine esophagogastroduodenoscopy using magnifying endoscope with narrow-band imaging for gastric cancer

BACKGROUND AND AIM

In Japan, an increase in the number of routine esophagogastroduodenoscopy procedures is expected because several studies have reported that endoscopy screening has reduced gastric cancer mortality. Magnifying narrow-band imaging has been reported to be effective for accurate diagnosis of gastric abnormalities such as cancers, adenomas, and intestinal metaplasia. However, the efficacy of this method in routine esophagogastroduodenoscopy has not been clarified.

METHODS

We divided 3763 patients into two groups. The non-magnification group included 1842 patients who underwent endoscopy screening using GIF-H260/LUCERA-SPECTRUM between October 2014 and February 2015, whereas the magnification group included 1921 patients who underwent screening using GIF-H290Z/LUCERA-ELITE between March 2015 and May 2015. In the magnification group, diagnosis of cancer was conducted using the VS classification system. We did not carry out a biopsy when results were confirmed as non-cancer using magnifying narrow-band imaging. If cancer was diagnosed, or when a cancer or non-cancer diagnosis was difficult, we carried out a biopsy. We analyzed and compared the diagnostic performance between the two groups.

RESULTS

Gastric biopsy rate was significantly lower in the magnification group (29%) than in the non-magnification group (41%) (P < 0.001). Positive predictive value (PPV) for gastric cancer was significantly higher in the magnification group (5.5%) than in the non-magnification group (2.5%) (P < 0.001). Furthermore, PPV for gastric epithelial neoplasia was significantly higher in the magnification group (7.9%) than in the non-magnification group (3.2%) (P < 0.001).

CONCLUSION

Magnifying narrow-band imaging improves the diagnostic performance of routine esophagogastroduodenoscopy.

Optimal interval of endoscopic screening based on stage distributions of detected gastric cancers

BACKGROUND

Although Korea and Japan have a national gastric cancer screening program, their screening intervals are different. The optimal screening interval of endoscopic screening in Japan was investigated based on the stage distributions of screen-detected gastric cancers.

METHODS

Patients with gastric cancer detected by endoscopic and radiographic screenings were selected from the Niigata City Medical Association database. The stage distributions of the detected gastric cancers were compared among patients with different screening histories in both groups. Gastric cancer specific survival rates were analyzed using the Kaplan-Meier method with the log-rank test.

RESULTS

There were 1585 and 462 subjects in the endoscopic and radiographic screening groups, respectively. In the endoscopic screening group, the stage IV proportion was lower in patients with screening history 1 and 2 years before diagnosis than in patients without screening history. Stage IV development was significantly related to the absence of screening history (p < 0.001); however, there were no differences between patients who had endoscopic screening history 2 and 3 years before diagnosis. The survival rates were not significantly different between patients with endoscopic screening 1 and 2 years previously (p = 0.7763). The survival rates were significantly higher in patients with endoscopic screening history 1 and 2 years before diagnosis than in patients without screening history (p < 0.001), and in patients with endoscopic screaming 3 years before diagnosis (P < 0.0069).

CONCLUSION

The endoscopic screening interval for gastric cancer can be expanded to at least 2 years based on the stage distributions of detected cancers and the patient survival rates.

Examination time as a quality indicator of screening upper gastrointestinal endoscopy for asymptomatic examinees

BACKGROUND AND AIM

The significance of examination time of esophagogastroduodenoscopy (EGD) for asymptomatic examinees is yet to be established. We aimed to clarify whether endoscopists who allot more examination time can detect higher numbers of neoplastic lesions among asymptomatic examinees.

METHODS

We reviewed a database of consecutive examinees who underwent EGD in our hospital from April 2010 to September 2015. Staff endoscopists were classified into fast, moderate, and slow groups based on the mean examination time of EGD without a biopsy. Neoplastic lesion detection rate among these groups was compared using multiple logistic regression.

RESULTS

Of the 55 786 consecutive examinees who underwent EGD, 15 763 asymptomatic examinees who were screened by staff doctors were analyzed. Mean examination time of 13 661 EGD without biopsy was 6.2 min (range, 2-18 min). When cut-off times of 5 and 7 min were used, four endoscopists were classified into the fast (mean duration, 4.4 ± 1.0 min), 12 into the moderate (6.1 ± 1.4 min), and four into the slow (7.8 ± 1.9 min) groups. Neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2288), 0.97% (99/10 180), and 0.94% (31/3295), respectively. Compared with that in the fast group, odds ratios for the neoplastic lesion detection rate in the moderate and slow groups were 1.90 (95% confidence interval [CI], 1.06-3.40) and 1.89 (95% CI, 0.98-3.64), respectively.

CONCLUSION

Endoscopists who do not allot adequate examination time may overlook neoplastic lesions in the upper gastrointestinal tract.

Effectiveness of Gastric Cancer Screening on Gastric Cancer Incidence and Mortality in a Community-Based Prospective Cohort

Purpose

This study was performed to investigate the effectiveness of gastric cancer (GC) screening methods in a community-based prospective cohort of the Korean Multi-center Cancer Cohort (KMCC) with over a 10-year follow-up.

Materials and Methods

A total 10,909 and 4,773 subjects from the KMCC with information on gastroendoscopy (GE) and upper gastrointestinal series (UGIS) were included in this study. Cox proportional hazard model adjusted for age, sex, Helicobacter pylori infection, cigarette smoking, and alcohol drinking was used to estimate the hazard ratios (HRs) and 95% confidence interval (CI).

Results

The GE screened subjects had almost half the risk of GC-specific death than that of unscreened subjects (HR, 0.58; 95% CI, 0.36 to 0.94). Among the GC patients, GE screenees had a 2.24-fold higher survival rate than that of the non-screenees (95% CI, 1.61 to 3.11). In particular, GE screenees who underwent two or more screening episodes had a higher survival rate than that of the non-screenees (HR, 13.11; 95% CI, 7.38 to 23.30). The effectiveness of GE screening on reduced GC mortality and increased survival rate of GC patients was better in elderly subjects (≥ 65 years old) (HR, 0.47; 95% CI, 0.24 to 0.95 and HR, 8.84; 95% CI, 3.63 to 21.57, respectively) than that in younger subjects (< 65 years old) (HR, 0.66; 95% CI, 0.34 to 1.29 and HR, 1.83; 95% CI, 1.24 to 2.68, respectively). In contrast, UGIS screening had no significant relation to GC mortality and survival.

Conclusion

The findings of this study suggest that a decreased GC-specific mortality and improved survival rate in GC patients can be achieved through GE screening.

Cancer survival in Qidong between 1972 and 2011: A population-based analysis

Population-based cancer survival is an improved index for evaluating the overall efficiency of cancer health services in a given region. The current study analysed the observed survival and relative survival of leading cancer sites from a population-based cancer registry between 1972 and 2011 in Qidong, China. A total of 92,780 incident cases with cancer were registered and followed-up for survival status. The main sites of the cancer types, based on the rank order of incidence, were the liver, stomach, lung, colon and rectum, oesophagus, breast, pancreas, leukaemia, brain and central nervous system (B and CNS), bladder, blood [non-Hodgkin's lymphoma (NHL)] and cervix. For all malignancies combined, the 5-year observed survival was 13.18% and the relative survival was 15.80%. Females had higher observed survival and relative survival (19.32 and 22.71%, respectively) compared with males (9.63 and 11.68%, respectively). The cancer sites with the highest five-year relative survival rates were the female breast, bladder, cervix and colon and rectum; followed by NHL, stomach, B and CNS cancer and leukaemia. The poorest survival rates were cancers of oesophagus, lung, pancreas and liver. Higher survival rates were observed in younger patients compared with older patients. Cancers of the oesophagus, female breast and bladder were associated with higher survival in middle-aged groups. Improved survival rates in the most recent two 5-year calendar periods were identified for stomach, lung, colon and rectum, oesophagus, female breast and bladder cancer, as well as leukaemia and NHL. The observations of the current study provide the opportunity for evaluation of the survival outcomes of frequent cancer sites that reflects the changes and improvement in a rural area in China.

Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality

BACKGROUND & AIMS

It is not clear whether screening for gastric cancer by upper endoscopy or upper gastrointestinal (UGI) series examinations (looking at the upper and middle sections of the gastrointestinal tract by imaging techniques) reduces mortality. Nevertheless, the Korean National Cancer Screening Program for gastric cancer was launched in 1999 to screen individuals 40 years and older for gastric cancer using these techniques. We evaluated the effectiveness of these techniques in gastric cancer detection and compared their effects on mortality in the Korean population.

METHODS

We performed a nested case-control study using data from the Korean National Cancer Screening Program for gastric cancer since 2002. A total of 16,584,283 Korean men and women, aged 40 years and older, comprised the cancer-free cohort. Case subjects (n = 54,418) were defined as individuals newly diagnosed with gastric cancer from January 2004 through December 2009 and who died before December 2012. Cases were matched with controls (subjects who were alive on the date of death of the corresponding case subject, n = 217,672) for year of entry into the study cohort, age, sex, and socioeconomic status. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained via conditional logistic regression analysis.

RESULTS

Compared with subjects who had never been screened, the overall OR for dying from gastric cancer among ever-screened subjects was 0.79 (95% CI, 0.77-0.81). According to screening modality, the ORs of death from gastric cancer were 0.53 (95% CI, 0.51-0.56) for upper endoscopy and 0.98 (95% CI, 0.95-1.01) for UGI series. As the number of endoscopic screening tests performed per subject increased, the ORs of death from gastric cancer decreased: 0.60 (95% CI, 0.57-0.63), 0.32 (95% CI, 0.28-0.37), and 0.19 (95% CI, 0.14-0.26) for once, twice, and 3 or more times, respectively.

CONCLUSIONS

Within the Korean National Cancer Screening Program, patients who received an upper endoscopy were less likely to die from gastric cancer; no associations were found for UGI series.

The diagnostic value of confocal laser endomicroscopy for gastric cancer and precancerous lesions among Asian population: a system review and meta-analysis

OBJECTIVE

The objective of this study is to evaluate the diagnostic value of confocal laser endomicroscopy (CLE) in detection of gastric cancer (GC), gastric intraepithelial metaplasia (GIM), and gastric intraepithelial neoplasia (GIN) lesions.

METHOD

PubMed, the Cochrane Library, and Wangfang databases were searched to include eligible articles about CLE in detection of gastric lesions. After study selection, quality assessment and data extraction conducted by two reviewers independently, meta-analysis was performed by Meta-Disc 1.4. The pooled sensitivity and specificity was calculated, receiver operating characteristic (ROC) curve was constructed, and the area under ROC curve (AUC) was calculated.

RESULTS

Twenty-three studies evaluating the diagnostic value of CLE were included. For the diagnosis of GC lesions, the pooled sensitivity, specificity, and AUC were 91% (88-94%), 99% (99-99%), and 0.9513, respectively. For the diagnosis of lesions, the pooled sensitivity, specificity, and AUC were 92% (90-94%), 97% (96-98%), and 0.9774, respectively. For the diagnosis of GIN lesions, the pooled sensitivity, specificity and AUC were 81% (75-85%), 98% (97-98%), and 0.9204, respectively.

CONCLUSIONS

CLE can provide an accurate diagnosis with high sensitivity and specificity for GC, GIM, and GIN lesions. The results should be confirmed by well-designed, multi-centered, randomized controlled, and double blinded trials with large samples.

Stomach Cancer Disparity among Korean Americans by Tumor Characteristics: Comparison with Non-Hispanic Whites, Japanese Americans, South Koreans, and Japanese

Background: Stomach cancer incidence shows substantial racial-ethnic disparity in the United States, with Korean Americans experiencing by far the highest incidence. We examined stomach cancer incidence trends in Korean Americans by tumor subsite, histology, and stage and compared them with incidence rates in racial-ethnic groups with the second highest rate (Japanese Americans) and the lowest rate (non-Hispanic whites; NHWs) as well as populations in South Korea and Japan.Methods: We calculated age-adjusted incidence rates by racial-ethnic groups, sex, and tumor characteristics, using the 1988-2012 California Cancer Registry data. Data on South Korea and Japan were obtained from the literature and other resources.Results: Between 1988 and 2012 in California, Korean Americans had about five times greater incidence than NHWs and twice that of Japanese Americans. Tumor characteristics differed by ethnic group and gender. The incidence in Korean Americans has declined during recent years, for both cardia and noncardia sites and for both intestinal- and diffuse-type histology. Although Korean Americans were diagnosed at an earlier stage than other Californians, the proportion with localized disease (43%) was much smaller than in South Korea (57%), where population-based screening is available.Conclusions: Stomach cancer incidence declined in the highest risk ethnic groups. However, the persistent disparity between Korean Americans and other racial-ethnic groups warrants additional strategies for prevention and earlier diagnosis.Impact: Analysis of California Cancer Registry data identified a racial-ethnic subgroup with stomach cancer disparity that may benefit from targeted prevention and screening efforts. Cancer Epidemiol Biomarkers Prev; 26(4); 587-96. ©2016 AACR.

Overdiagnosis of gastric cancer by endoscopic screening

Gastric cancer screening using endoscopy has recently spread in Eastern Asian countries showing increasing evidence of its effectiveness. However, despite the benefits of endoscopic screening for gastric cancer, its major harms include infection, complications, false-negative results, false-positive results, and overdiagnosis. The most serious harm of endoscopic screening is overdiagnosis and this can occur in any cancer screening programs. Overdiagnosis is defined as the detection of cancers that would never have been found if there is no cancer screening. Overdiagnosis has been estimated from randomized controlled trials, observational studies, and modeling. It can be calculated on the basis of a comparison of the incidence of cancer between screened and unscreened individuals after the follow-up. Although the estimation method for overdiagnosis has not yet been standardized, estimation of overdiagnosis is needed in endoscopic screening for gastric cancer. To minimize overdiagnosis, the target age group and screening interval should be appropriately defined. Moreover, the balance of benefits and harms must be carefully considered to effectively introduce endoscopic screening in communities. Further research regarding overdiagnosis is warranted when evaluating the effectiveness of endoscopic screening.

Surveillance of patients with gastric precancerous conditions

Intestinal-type gastric adenocarcinoma arises from a multistep process starting with Helicobacter pylori infection followed by gastric atrophy, gastric intestinal metaplasia and dysplasia. Indeed, patients with gastric precancerous conditions or lesions (GPC) are at increased risk to develop gastric cancer even in regions with low incidence. Thus, the identification and surveillance of a high risk subgroup could lead to the diagnosis of cancer at early stage and improve survival. However, both endoscopic and histological accuracy and interobserver agreement in the diagnosis of GPC are still far from optimal. Also, there are conceptual differences between the West and the East in the diagnosis and surveillance of patients. In the former, multiple gastric biopsies are still recommended but Eastern gastroenterologists select patients to surveillance according to the results of endoscopy or serology. In this literature review we describe the cascade of GPC and we highlight the differences between eastern and western clinical practice.

Effectiveness evaluation of organized screening for esophageal cancer: a case-control study in Linzhou city, China

In China, esophageal cancer has remained a large burden, and endoscopic screening is expected to reduce esophageal cancer mortality. Therefore, a population-based case-control study was conducted to evaluate the effect of screening. Cases were defined as individuals who had died of esophageal cancer, and controls were residents from the same area (three per case) who had not died of esophageal cancer, matched by gender and birth year. The exposure status (whether cases and controls had ever attended the screening or not) was acquired by inspecting the well documented screening records. A conditional logistic regression model was used to estimate the odds ratios (OR) and their 95% confidence intervals (95% CI). There were 253 cases and 759 controls. The reduction in risk of esophageal cancer mortality in individuals who had ever attended screening was 47% (OR: 0.53, 95% CI: 0.37–0.77). Compared with never-screened subjects, the ORs for screened subjects within 36 and 48 months before the reference date were 0.59(0.39–0.89) and 0.59(0.40–0.87); the ORs for 50–59 year old subjects were 0.48(0.28–0.85). The results suggest a 47% reduction in esophageal cancer mortality risk due to endoscopic screening, which may have significant implications for esophageal cancer screening in China, especially in rural areas.