Unchanged survival of gastric cancer in the southeastern Netherlands since 1982: result of differential trends in incidence according to Laurén type and subsite

Development and validation of a nomogram to individually predict survival of young patients with nonmetastatic gastric cancer: A retrospective cohort study

BACKGROUND/AIMS

Evidence regarding gastric cancer (GC) patients <40 years old is limited. The aim of the study was to identify risk factors affecting overall survival (OS) of young patients with nonmetastatic GC and to establish a nomogram for prognostic prediction using data from the Surveillance, Epidemiology and End Results (SEER) database. Furthermore, this study sought to externally validate this nomogram in an independent patient cohort.

PATIENTS AND METHODS

In this retrospective cohort study, the records of patients aged <40 years with nonmetastatic GC (n = 559), from the SEER database, between 2006 and 2015, were examined. The nomogram was established based on the Cox proportional hazards regression model using the SEER dataset. Patients with nonmetastatic GC (n = 201) in our department between 2009 and 2015 were selected as an external validation set. Discrimination and calibration were performed in both cohorts.

RESULTS

The multivariate Cox model identified race, tumor subsites, tumor size, depth of invasion, lymph node metastasis, number of examined lymph nodes, and surgery as independent covariates associated with OS. The nomogram exhibited superior discriminative power than the eighth tumor, node, metastasis (TNM) staging system in both the training set [Harrell's concordance index (C index): 0.762 vs. 0.635,P < 0.001] and validation set (C index: 0.805 vs. 0.712,P= 0.176). Calibration of the nomogram was good in both cohorts.

CONCLUSIONS

We developed a nomogram predicting 3- and 5-year OS rates in young patients with nonmetastatic GC. Both the training set and validation set showed good discrimination and calibration, suggesting good clinical applicability.

Examining the gastric cancer survival gap between Asians and whites in the United States

BACKGROUND

Globally, Asian countries bear a disproportionate gastric cancer burden. Asian Americans, the fastest growing minority population in the US, have higher gastric cancer survival than non-Hispanic whites (NHWs) despite higher incidence. Benefitting from uniform cancer registry standards within the US, we examine for the first time the heterogeneity in the Asian American population, which may elucidate the causes of these disparities.

METHODS

SEER gastric cancer data from 2000 to 2012 were used to calculate 5-year survival estimates for NHWs and the six largest Asian ethnicities. Multivariate analyses were performed to identify critical prognostic factors and survival disparities between Asian groups and NHWs.

RESULTS

We analyzed 33,313 NHW and 8473 Asian gastric cancer cases. All Asian groups had significantly higher 5-year survival than NHWs, at 29.8%. Among Asians, Koreans and Vietnamese had the highest and lowest survival, at 45.4% and 35.7%, respectively. The Korean survival advantage was largely attributable to relatively high proportions of localized stage and low proportions of cardia tumors. After adjusting for major prognostic factors, the survival disadvantage of NHWs, while attenuated, remained significant in comparison to all Asian groups (HR: 1.33, 95% CI: 1.24-1.43; reference: Korean). The survival disparities within the Asian groups vanished with adjustment.

CONCLUSIONS

This study characterizes distinctive gastric cancer survival patterns among the six major Asian groups and NHWs in the US. The favorable survival for Koreans is largely attributable to specific clinical factors, particularly stage at diagnosis. The causes of the survival disadvantage for NHWs remain elusive.

Prognostic value of diffuse versus intestinal histotype in patients with gastric cancer: a systematic review and meta-analysis

BACKGROUND

There are two distinct types of gastric carcinoma (GC), intestinal, more frequently sporadic and linked to environmental factors, and diffuse (undifferentiated) that is highly metastatic and characterized by rapid disease progression and a poor prognosis. However, there are many conflicting data in the literature concerning the association between histology and prognosis in GC. This meta-analysis was performed to provide demonstration if histology according to Lauren classification is associated with different prognosis in patients with GC.

METHODS

We searched PubMed, the Cochrane Library, SCOPUS, Web of Science, CINAHL, and EMBASE for all eligible studies. The combined hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) in terms of overall survival (OS) were evaluated.

RESULTS

A total of 73 published studies including 61,468 patients with GC were included in this meta-analysis. Our analysis indicates that GC patients with diffuse-type histology have a worst prognosis than those with intestinal subgroup in all studies (HR 1.23; 95% CI, 1.17-1.29; P<0.0001), in both loco-regional confined (HR 1.21; 95% CI, 1.12-1.30; P<0.0001) and advanced disease (HR 1.25; 95% CI, 1.046-1.50; P=0.014), in Asiatic (HR 1.2; 95% CI, 1.14-1.27; P<0.0001) and Western patients (HR 1.3; 95% CI, 1.19-1.41; P<0.0001), and in those not exposed (HR 1.15; 95% CI, 1.07-1.24; P<0.0001) or exposed (HR 1.27; 95% CI, 1.17-1.37; P<0.0001) to (neo)adjuvant therapy.

CONCLUSIONS

Our results indicated that histology might be a useful prognostic marker for both early and advanced GC patients, with intestinal-type associated with a better outcome. This information could be used for stratification purpose in future clinical trials.

Survival from common and rare cancers in Germany in the early 21st century

BACKGROUND

Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States.

PATIENTS AND METHODS

Cancer patients diagnosed in 1997-2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002-2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database.

RESULTS

Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin's lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin's lymphoma.

CONCLUSIONS

German cancer survival estimates are mostly higher than the 2000-2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

Prognostic factors and survival in stomach cancer - analysis of 15 years of data from a referral hospital in iran and evaluation of international variation

BACKGROUND

Stomach cancer is the most common cancer among Iranian men. We studied survival rates and prognostic factors of stomach cancer in a referral hospital in Tehran, Iran.

PATIENTS AND METHODS

We followed 367 stomach cancer patients hospitalized between 1991 and 2007 in the Baqyiatallah Hospital. We estimated survival rates overall and among operable patients exclusively. Hazard ratios (HR) for the different prognostic factors were estimated with the Cox regression model. Furthermore, we studied international variations in stage distribution and 5 year survival for stomach cancer.

RESULTS

Overall, 5 year survival of stomach cancer was low (14%), and the majority of patients (53%) were diagnosed at stage IV. Stage, tumor size, age, and gender were statistically significant prognostic factors. Relative risk of mortality in stage IV compared to stage IA was 9.9 (95% confidence interval 5.8-16.9). The highest 5 year survival was reported from Japan, particularly among screening detected patients (89.4%). Among operable patients, 5 year survival was 32.6% in France, 26% in the USA, and 30.5% in China, which was close to the rates estimated in our study (24%).

CONCLUSIONS

Due to stomach cancer being frequently diagnosed in advanced stages, its prognosis is poor in Iran. Early diagnosis and downstaging strategies need to be prioritized to improve the prognosis of stomach cancer.

Bax predicts outcome in gastric cancer patients treated with 5-fluorouracil, leucovorin, and oxaliplatin palliative chemotherapy

BACKGROUND

Platinum and 5-fluorouracil (5-FU)-based regimens have been used the most frequently in palliative chemotherapy for gastric cancer. The present study evaluated the prognostic significance of Bax, excision repair cross-complementation group 1 (ERCC1), and thymidylate synthase (TS) in advanced gastric cancer patients treated with 5-FU, leucovorin, and oxaliplatin (FOLFOX) palliative chemotherapy.

METHODS

Seventy-two patients with metastatic or recurrent gastric cancer were treated with FOLFOX regimen. Pretreatment tumor biopsy specimens were analyzed for Bax, ERCC1, and TS expression by immunohistochemistry.

RESULTS

High expression of Bax, ERCC1, and TS was observed in 31 (43%), 33 (46%), and 35 (49%) patients, respectively. The median overall survival (OS) of patients was 12 months. Low expression of Bax was associated with poor OS (median, 9 months vs. 18 months; 2-year, 10% vs. 48%; p=0.0005) in univariate analysis, while expression of ERCC1 and TS was not correlated with patient outcome. In multivariate analysis, low expression of Bax was a significant independent predictor of poor OS (p=0.028). Low expression of Bax was significantly associated with poor survival of patients with metastatic or recurrent gastric cancer treated with FOLFOX chemotherapy.

CONCLUSIONS

Immunohistochemical staining for Bax with pretreatment biopsy specimen may be useful in selecting FOLFOX regimen as a treatment option for advanced gastric cancer patients.

Trends in survival of patients diagnosed with cancer of the digestive organs in the Nordic countries 1964-2003 followed up to the end of 2006

Cancers of the digestive organs (including the oesophagus, stomach, small intestine, colon, rectum and anus, liver, gallbladder, and pancreas) constitute one-fifth of all cancer cases in the Nordic countries and is a group of diseases with diverse time trends and varying consequences for public health. In this study we examine trends in relative survival in relation to the corresponding incidence and mortality rates in the Nordic countries during the period 1964-2003.

MATERIAL AND METHODS

Data were retrieved from the NORDCAN database for the period 1964 to 2003, grouped into eight 5-year periods of diagnosis. The patients were followed up until the end of 2006. Analysis comprised trends in 5-year relative survival, excess mortality and age-specific relative survival.

RESULTS

Survival following cancers of the colon and rectum has increased continuously over the observed period, yet Danish patients fall behind those in the other Nordic countries. The largest inter-country variation is seen for the rare cancers in the small intestine. There has been little increase in prognosis for patients diagnosed with cancers of the liver, gallbladder or pancreas; 5-year survival is generally below 15%. Survival also remains consistently low for patients with oesophageal cancer, while minor increases in survival are seen among stomach cancer patients in all countries except Denmark. The concomitant incidence and mortality rates of stomach cancer have steadily decreased in each Nordic country at least since 1964.

CONCLUSION

While the site-specific variations in mortality and survival largely reflect the extent of changing and improving diagnostic and clinical practices, the incidence trends highlight the importance of risk factor modification. Alongside the ongoing clinical advances, effective primary prevention measures, including the control of alcohol and tobacco consumption as well as changing dietary pattern, will reduce the incidence and mortality burden of digestive cancers in the Nordic countries.

Trends in incidence, treatment and survival of gastric adenocarcinoma between 1990 and 2007: a population-based study in the Netherlands

BACKGROUND

Survival of gastric cancer in the Western world remains poor. We conducted a retrospective population-based study to evaluate trends in incidence, treatment and outcome of gastric adenocarcinoma.

METHODS

All patients diagnosed with gastric adenocarcinoma during 1990-2007 in the Dutch Eindhoven Cancer Registry area were included (n=4,797). Trend analyses were conducted for incidence, mortality, tumour and patient characteristics, treatment and crude overall survival, according to tumour location (cardia versus non-cardia). Temporal changes in the odds of undergoing surgery and the risk of death were analysed by means of multivariable regression methods.

RESULTS

Age-standardised incidence decreased among males (24-12 per 100,000 inhabitants) and females (10-6); mortality rates decreased at a similar pace. The proportion of cardia tumours remained stable. Stage distribution worsened over time among patients with cardia (stages I and II: 32% in 1990-1993 and 22% in 2006-2007, p=0.005) and non-cardia (stage IV: 33% in 1990-1993 and 40% in 2006-2007, p=0.0003) cancer. Chemotherapy rates increased in all settings. Five-year survival worsened over time for patients with non-cardia tumours. Age and stage had significant influence on survival after stratification for tumour localisation. After adjustments for relevant factors (i.e. stage), the risk of death decreased since the late 90s for patients with a cardia tumour (hazard ratio 0.8, p=0.01).

CONCLUSION

The absence of improvement in survival rates indicates the need for earlier detection and prospective studies to evaluate new therapy regimens with standardised surgery and pathology.

What reasons lie behind long-term survival differences for gastric cancer within Europe?

BACKGROUND

Wide geographic variations in survival for gastric cancer in Europe have been reported. The aim of this study was to analyse the effect of stage at diagnosis, treatment and cancer characteristics on long-term survival for gastric cancer in populations covered by cancer registries.

METHODS

We analysed survival in 4620 cases of gastric cancer from 17 European population-based cancer registries from 8 countries. Univariate and multivariate regression of relative survival were performed.

RESULTS

Five-year relative survival varied between 10.6% and 24.0%, while 10-year survival ranged from 7.7% to 23.0%. After adjustment for age and sex, the regional excess hazard ratio (EHR) of death was significantly higher in Ragusa, Granada, Yorkshire, Slovakia, Slovenia and Poland than in France, Northern Italy, The Netherlands and the Basque Country. After further adjustment for surgical resection versus no resection (a proxy of stage), the EHR of death remained significantly higher only in Granada and Yorkshire than in the reference country (France). After adjustment for stage, the EHR was significantly higher only in Yorkshire (EHR: 1.51; 95% confidence interval (CI): 1.29-1.77). The EHR in this area was limited to the first year following diagnosis.

CONCLUSION

Differences across Europe in gastric cancer survival depend to a large extent on differences in stage at diagnosis. However they do not explain all variations. Quality of management and treatment can explain some differences.

Long-term survival expectations of cancer patients in Europe in 2000-2002

Period analysis has been shown to provide more up-to-date estimates of long-term cancer survival rates than traditional cohort-based analysis. Here, we provide detailed period estimates of 5- and 10-year relative survival by cancer site, country, sex and age for calendar years 2000-2002. In addition, pan-European estimates of 1-, 5- and 10-year relative survival are provided. Overall, survival estimates were mostly higher than previously available cohort estimates. For most cancer sites, survival in countries from Northern Europe, Central Europe and Southern Europe was substantially higher than in the United Kingdom and Ireland and in countries from Eastern Europe. Furthermore, relative survival was also better in female than in male patients and decreased with age for most cancer sites.

Differences in the histological findings, phenotypic marker expressions and genetic alterations between adenocarcinoma of the gastric cardia and distal stomach

Adenocarcinoma of the gastric cardia (C-Ca) is possibly a specific subtype of gastric carcinoma. The purpose of this study was to clarify the differences in the clinicopathological characteristics between C-Ca and adenocarcinoma of the distal stomach (D-Ca), and also the differences in the expressions of gastric and intestinal phenotypic markers and genetic alterations between the two. The clinicopathological findings in 72 cases with C-Ca were examined and compared with those in 170 cases with D-Ca. The phenotypic marker expressions examined were those of human gastric mucin (HGM), MUC6, MUC2 and CD10. Furthermore, the presence of mutations in the APC, K-ras and p53 genes and the microsatellite instability status of the tumour were also determined. C-Ca was associated with a significantly higher incidence of differentiated-type tumours and lymphatic vessel invasion (LVI) as compared with D-Ca (72.2 vs 48.2%, P=0.0006 and 72.2 vs 55.3%, P=0.0232, respectively). Oesophageal invasion by the tumour beyond the oesophago-gastric junction (OGJ) was found in 56.9% of cases with C-Ca; LVI in the area of oesophageal invasion was demonstrated in 61% of these cases. Also, LVI was found more frequently in cases of C-Ca with oesophageal invasion than in those without oesophageal invasion (82.9 vs 58.1%, P=0.0197). The incidence of undifferentiated-type tumours was significantly higher in cases with advanced-stage C-Ca than in those with early-stage C-Ca (5 vs 36.5%, P=0.0076). A significantly greater frequency of HGM expression in early-stage C-Ca and significantly lower frequency of MUC2 expression in advanced-stage C-Ca was observed as compared with the corresponding values in cases of D-Ca (78.9 vs 52.2%, P=0.0402 and 51.5 vs 84.6%, P=0.0247, respectively). Mutation of the APC gene was found in only one of all cases of C-Ca, and the frequency of mutation of the APC gene was significantly lower in cases of C-Ca than in those of D-Ca (2.4 vs 20.0%, P=0.0108). The observations in this study suggest that C-Ca is a more aggressive tumour than D-Ca. The differences in biological behavior between C-Ca and D-Ca may result from the different histological findings in the wall of the OGJ and the different genetic pathways involved in the carcinogenesis.

Cancer survival in the elderly: Effects of socio-economic factors and health care system features (ELDCARE project)

The purpose of the ELDCARE project is to study differences in cancer survival for elderly patients by country, taking into account the socio-economic conditions and the characteristics of health care systems at the ecological level. Fifty-three European cancer registries, from 19 countries, participating in the EUROCARE 3 programme, collected information to compute relative survival on patients aged 65-84 years, diagnosed over the period 1990-1994. National statistics offices provided the macro-economic and labour force indicators (gross domestic product, total health expenditure, and proportion of people employed in the agriculture sector) as well as the features of national health care systems. Survival for several of the cancer sites had high positive Pearson's correlations (r) with the affluence indicators (usually r>0.7), but survival for the poor prognosis cancers (lung, ovary, stomach) and for cervix uteri was not so well correlated. Among the medical resources considered, the number of computed tomography scanners was the variable most related to survival in the elderly; the number of total health practitioners in the country did not show any relationship. Survival was related to the marital status of elderly women more strongly than for men and younger people. The highest correlations of survival with the percentage of married elderly women in the population were for cancers of the rectum (r=0.79) and breast (r=0.66), while survival correlated negatively with the proportion of widows for most cancers. Being married or widowed is for elderly people, in particular elderly women, an important factor influencing psychological status, life habits and social relationships. Social conditions could play a major role in determining health outcomes, particularly in the elderly, by affecting access to health care and delay in diagnosis.

Clinicopathologic and protein expression differences between cardia carcinoma and noncardia carcinoma of the stomach

BACKGROUND

Although the incidence of adenocarcinoma of the stomach has decreased over the past several decades, gastric cardia carcinoma has increased over the same period.

METHODS

The clinicopathologic characteristics and immunohistochemical staining results of 21 proteins were investigated in 165 patients with cardia carcinoma, including 74 patients with true cardia carcinoma and 91 patients with subcardia carcinoma, and the results were compared with the results from 564 patients with noncardia carcinoma.

RESULTS

In the clinicopathologic analysis, patients who had cardia carcinoma tended to have tumors with poorly differentiated histology according to the World Health Organization classification system (P = 0.012), diffuse type according to the Lauren classification system (P = 0.049), and advanced pathologic TNM stage (P < 0.001). On immunohistochemical staining, loss of the p16 (P = 0.038) and smad4 (P < 0.001) tumor suppressor genes was more frequent in cardia carcinoma than in noncardia carcinoma. Carcinoembryonic antigen and CD44 overexpression were more frequent in patients with cardia carcinoma (P < 0.05). Conversely, patients who had cardia carcinoma exhibited less frequent expression of MUC1 (P = 0.008) and MUC5AC (P = 0.006) compared with patients who had noncardia carcinoma. Epstein-Barr virus infection was more common in patients with cardia carcinoma (P < 0.001). In the survival analysis, the patients with cardia carcinoma had a poorer prognosis. In the multivariate analysis, tumor location in the cardia was confirmed as an independent, poor prognostic factor in patients with gastric carcinoma.

CONCLUSION

Cardia carcinoma and noncardia carcinoma differed in their clinicopathologic characteristics and in their alterations of gene expression, as evaluated by immunohistochemistry. The current results support the hypothesis that cardia carcinoma forms a specific category of gastric carcinoma that is distinct from noncardia carcinoma.

Prognostic indicators in locally advanced gastric cancer (LAGC) treated with preoperative chemotherapy and D2-gastrectomy

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients.

METHODS

Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression.

RESULTS

Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor.

CONCLUSIONS

In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

Mutations of mitochondrial 12S rRNA in gastric carcinoma and their significance

AIM: To detect the variations of mitochondrial 12S rRNA in patients with gastric carcinoma, and to study their significance and the relationship between these variations and the genesis of gastric carcinoma.

METHODS: PCR amplified mitochondrial 12S rRNA of 44 samples including 22 from gastric carcinoma tissues and 22 from adjacent normal tissues, was detected by direct DNA sequencing. Then laser capture microdissection technique (LCM) was used to separate the cancerous cells and dysplasia cells with specific mutations. Denaturing high performance liquid chromatography (DHPLC) plus allele-specific PCR (AS-PCR), nest-PCR and polyacrylamide gel electrophoresis (PAGE) were used to further evaluate this mutant property and quantitative difference of mutant type between cancerous and dysplasia cells. Finally, RNAdraw biosoft was used to analyze the RNA secondary structure of mutant-type 12S rRNA.

RESULTS: Compared with Mitomap database, some new variations were found, among which np652 G insertion and np716 T-G transversion were found only in cancerous tissues. There was a statistic difference in the frequency of 12S rRNA variation between intestinal type (12/17, 70.59%) and diffusive type (5/17, 29.41%) of gastric carcinoma (P<0.05). DHPLC analysis showed that 12S rRNA np652 G insertion and np716 T-G transversion were heteroplasmic mutations. The frequency of 12S rRNA variation in cancerous cells was higher than that in dysplasia cells (P<0.01). 12S rRNA np652 G insertion showed obviously negative effects on the stability of 12S rRNA secondary structure, while others such as T-G transversion did not.

CONCLUSION: The mutations of mitochondrial 12S rRNA may be associated with the occurrence of intestinal-type gastric carcinoma. Most variations exist both in gastric carcinomas and in normal tissues, and they might not be the characteristics of tumors. However, np652 G insertion and np716 T-G transversion may possess some molecular significance in gastric carcinogenesis. During the process from normality to dysplasia, then to carcinoma, 12S rRNA tends to convert from homoplasmy (wild type) to heteroplasmy, then to homoplasmy (mutant type, np717 T-G).

The correlation between gastric cancer screening method and the clinicopathologic features of gastric cancer

BACKGROUND

A gastric cancer (GC) screening program using gastrofiberscopy (GFS) or double contrast upper gastrointestinal series (UGIS), as a public policy, has been used in Korea since 1996. The aim of this study was to assess whether there have been major changes in clinicopathologic features of GC by introducing GC screening.

METHOD

We reviewed the medical records of 1478 consecutive patients with GC who underwent gastrectomy between 1989 and 1999. Patients were divided into two groups: group I (before GC screening), 1989-1995 (n = 840), and group II (after GC screening), 1996-1999 (n = 638).

RESULTS

After employment of GC screening, the incidence of early cancer was significantly increased (21% vs 13%, p < 0.0001). During these years, the proportion of patients using GFS as the first diagnostic procedure and the relative frequency of intestinal-type GC increased significantly (63% vs 84%, 0.6 vs 1.2, respectively, p < 0.0001).

CONCLUSIONS

These results suggest that GC screening is effective for early detection of GC. Furthermore, the preferred screening method of GC can attribute the clinicopathologic features of GC.</p>

Comparison of stomach cancer incidence and survival in four continents

The aim of this study was to compare stomach cancer incidence and survival rates between four very distinct areas: Campinas (Brasil), Latin America, Iowa (USA), Northern America, Varese (Italy), Europe and Osaka (Japan) in Asia, and determine which of the differences are due to variations in the case mix and which are due to the care received. A proportional hazards regression method was applied to the relative survival rates to obtain geographical differences that were adjusted for age, gender, period of diagnosis, sub-site and stage. Age, gender, period and stage explained most of the variability between the areas (50-100% excess risk of death with respect to Osaka) in the survival rates for stomach cancer patients. In Iowa and Varese, information on the sub-site fully explained the remaining variability. The large survival differences between the four areas were almost totally due to the different case mixes of the stomach cancer patients. The importance of stage indicates that diagnostic delay may be a major clinical factor affecting survival.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.

Prognostic value of Goseki histological classification in adenocarcinoma of the cardia

Various histologic classification systems have been proposed as prognostic factors for gastric cancer. We assessed the prognostic value of Goseki classification as well as the TNM staging system, histological tumour grading, Lauren, WHO, Goseki and Siewert classifications in 100 patients with cardia carcinoma undergoing curative surgery. Two patients were lost at follow-up. The median time of follow-up in the remaining patients was 32.9 months after surgery (range: 0.1-142.1 months). No differences in survival rates were observed according to tumour grading, Lauren or WHO histologic or Siewert topographical classification. No differences were found according to Goseki classes, when considering either the mucin content of the carcinoma (types I and III vs II and IV) or the differentiation grade (types I and II vs III and IV). Multivariate analysis showed that the only lymph node positivity was a significant predictor of survival: 7.2% of patients with, but 41.5% of those without nodal involvement were alive after five years (P=0.0001). In conclusion, we found no prognostic role for Goseki or the traditional histological indexes, while the TNM staging system and particularly lymph node positivity were the main predictors of survival in patients with cardia adenocarcinoma.

Increased incidence of adenocarcinomas at the gastro-oesophageal junction in Dutch males since the 1990s

BACKGROUND

Worldwide population-based studies suggest that the incidence of oesophageal and gastric cardia adenocarcinomas has increased since the 1970s.

OBJECTIVE AND METHODS

We studied time trends in mortality and incidence rates of oesophageal and gastric carcinomas according to subsite and histology in the south-east Netherlands since 1978.

RESULTS

The age-adjusted mortality and incidence rates for oesophageal cancer doubled in males over the entire 19-year study period from 2.7 to 5.6 and from 2.4 to 4.8 per 100,000 person years, respectively. In females, a similar trend for the mortality and incidence rates was seen, but at a lower level. The age-adjusted mortality and incidence rates for gastric cancer decreased with time from 20.7 to 12.8 and from 21.6 to 15.9 per 100,000 person years in males, respectively. In females, age-adjusted mortality and incidence rates for gastric cancer also decreased. Analysis of incidence rates by subsite and subtype showed an increase in adenocarcinomas of the oesophagus and gastric cardia, largely restricted to males. In females, the rise in incidence of squamous cell carcinoma of the oesophagus appeared to be more marked than the rise in adenocarcinomas, whereas the incidence of gastric cardia carcinomas has remained stable over the last 10 years. Neither the decrease in the number of unspecified tumours with time, nor the increase in the use of diagnostic endoscopy and imaging techniques, is likely to explain completely the observed increases.

CONCLUSION

The increase in incidence of adenocarcinomas at the gastro-oesophageal junction in the south-eastern Netherlands seems, at least in part, to represent a true underlying increase that is restricted largely to males.

Long-term prognosis of gastric cancer in a European country: a population-based study in Florence (Italy). 10-year survival of cases diagnosed in 1985-1987

This paper analysed, in a population-based series of 1976 gastric cancers diagnosed in Florence (Italy), from 1985 to 1987, the relationship between prognostic variables (demographic, clinical and pathological) and 10-year survival rates. Gastric cancer was mostly detected in elderly patients (mean age: 70.5 years) and at advanced stages (i.e. approximately 50% of the patients could not undergo radical surgery). Ten-year observed survival was 12.1% (95% confidence interval (CI): 10.6-13.6%) for the whole series and 20.8% (95% CI: 18.3-23.3%) for resected cases; relative survival was, respectively, 20.9% (95% CI: 18.4-23.4%) and 32.0% (95% CI: 28.1-35.9%). Ten-year relative survival was 86% for stage IA (95% CI: 73-99%) and 67% for stage IB (95% CI: 52-82%). Multivariate analysis showed a significantly better prognosis in females and a significantly worse prognosis in patients aged 65 years or more (reference: < or = 59 years). In addition, an independent prognostic effect was observed for pT in the resected cases (reference: pT3; pT1: RR = 0.47, 95% CI: 0.34-0.64; pT2 = 0.71, 95% CI: 0.58-0.87; pT4: RR = 2.02, 95% CI: 1.49-2.75), pN (reference: pN0; pN1: RR = 2.13, 95% CI: 1.70-2.68; pN2-3: RR = 3.14, 95% CI: 2.42-4.07; pN+ no. nodes involved unspecified: RR = 4.26, 95% CI: 3.11-5.83) and surgical margin involvement (reference: not involved; involved: RR = 1.36, 95% CI: 1.08-1.72). In addition, the stage, after adjustment for age, gender and surgical margin involvement, showed a strong independent prognostic value (reference: stage II; IA: RR=0.37, 95% CI: 0.25-0.57; IB: RR=0.70, 95% CI: 0.50-0.98; IIIA: RR = 1.80, 95% CI: 1.40-2.33; IIIB: RR = 2.82, 95% CI: 2.14-3.72; IV: RR = 3.29, 95% CI: 2.36-4.59). In conclusion, on the basis of a large population-based series, our results confirm the prognostic effect on long-term gastric cancer survival of pathological and demographic variables. In addition, the study shows that Italy had a relatively good, long-term survival when diagnosis was performed at early stages. However, only a few cases were diagnosed at stages when cure by radical surgery is more likely (i.e. stage I accounted for approximately 20% of the resected cases and less than 10% of all incident cases).

Epidemiologic panorama of stomach cancer mortality in Mexico

BACKGROUND

Annually, there are more than 6 million deaths from a type of malignant neoplasia worldwide. In developing countries, the highest rates of incidence of malignant neoplasias are uterine cervical cancer, stomach, lung, esophagus, pharynx, and liver cancers. Recent estimates on the incidence of cancer worldwide show that, in 1990, stomach cancer (SC) was the second most frequent type of cancer (900,000 new cases annually). Rates of incidence have decreased consistently in nearly all areas of the world. In Mexico, however, rates of incidence and mortality have increased gradually between 1980 and 1997; in 1995, 4,685 people died of SC in Mexico. This report presents a descriptive analysis of SC mortality in Mexico.

METHODS

A mortality database edited from the electronic files of the National Institute of Informatics, Statistics and Geography (INEGI) in Mexico was used; population denominators were edited by the Mexican National Population Council (Conapo). Adjusted mortality rates, taking as standard of reference the population of Mexico City by sex, year, and 10-year age groups were calculated as well as the sex ratio for the 1980-1997 period. To evaluate the magnitude of risks by state, the standardized mortality ratio (SMR) was calculated; prematurity was evaluated through the potential lost-life years index (PLLYI). The analysis was carried out using the Excel and Stata 5.0 software programs.

RESULTS

During the years from 1980 to 1997, in Mexico the total number of deaths from SC was 76,315. The male:female ratio was 1.2:1.0. SMR by state showed that the states of Yucatán, Sonora, Zacatecas, Michoacán, and Chiapas had higher mortality rates. The PLLYI was higher for males in the states of Chiapas, Sonora, Chihuahua, Zacatecas, and Southern Baja California, and higher for females in Chiapas, Oaxaca, Yucatán, Puebla, and Campeche.

CONCLUSIONS

World statistics on mortality caused by SC suggest a decreasing trend. Findings for this study show an increase in the adjusted mortality rates by SC during the 1980-1997 period in Mexico. However, when analyzing the different indicators that reveal risks, magnitude, and prematurity of mortality, there is a differential trend in mortality by sex that includes regional patterns probably related to different socioeconomic levels.

Prognostic factors after curative resection for gastric cancer. A population-based study

The aim of this study was to document patterns of survival after resection for cure for gastric cancer in a well-defined population. A population-based series of 649 gastric cancers resected for cure between 1976 and 1995 in a 494000 population, was used. Resection for cure was performed in 44.4% of the diagnosed cases. This proportion increased from 36.8% (1976-1979) to 45.0% (1992-1995) (P=0.03) whilst operative mortality decreased from 18.3 to 12.7% (P=0.003). The overall crude 5-year survival rate (excluding operative mortality) was 32.6% (95% confidence interval (CI) 28.7-36. 5) and the corresponding relative survival rate was 40.9%. Prognosis did not improve during the study period. Stage at diagnosis was the most important prognostic factor, the 5-year relative survival rate being 81.2% (+/-5.9) in TNM stage IA, 76.9% (+/-8.0) in stage IB, 50. 4% (+/-4.6) in stage II, 24.4% (+/-3.7) in stage IIIA, 5.6% (+/-3.2) in stage IIIB and 5.2% (+/- 2.2) in stage IV. Stage at diagnosis, age, subsite and macroscopic type of growth were independent prognostic factors, in a multivariate relative survival model. Earlier detection or development of an effective adjuvant therapy could contribute to improvement in prognosis.

Surgical intervention and understanding of diseases of the stomach and duodenum

The stomach and duodenum are organs of complex physiology and cell biology. Neoplastic disease of these organs represents a difficult surgical challenge, and gastric and duodenal cancer mortality rates remain high despite advances in surgical technique, perioperative care, and adjuvant therapy. True "cures" elude the surgeon all too often. Fortunately, our understanding of the genetics and molecular biology of upper gastrointestinal neoplasms is increasing and is now significantly affecting the clinical management of these tumors as surgical therapies continue to improve. The care of benign disease of the stomach and duodenum is also evolving as medical therapy and surgical technology improve to lessen the morbidity associated with peptic ulcer disease and other benign conditions. The event that may have the greatest effect on surgical intervention in peptic ulcer disease is the Centers for Disease Control and Prevention launching of an educational campaign to promote treatment of Helicobacter pylori. This article reviews the most significant advances published in the past year on surgical intervention of the stomach and duodenum.

[Treatment of gastric cancer]

Gastric cancer (GC) still remains a major cancer problem in the world. Its prognosis is poor with an overall 5-year survival rate less than 20%. Surgical resection is still the only curative treatment of GC. Curative resection depends on tumoral location and extension, particularly lymph node involvement. Proximal GC (fundus, body) are treated by total gastrectomy (TG). For distal GC (antrum, pylorus), the TG is no more the recommended treatment and distal sub-total gastrectomy can safely be performed when carcinologic rules are respected: 5-6 cm free margin for the remnant stomach and at least 2 cm resection of the proximal duodenum. Cardia cancers, upon to their tumoral extension toward the esophagus, can require either TG or proximal esophagogastrectomy by combined thoracic and abdominal approach. As demonstrated in the last controlled studies, D2 extensive lymphadenectomy, in spite of its contribution to a better prognostic staging, does not improve long term survival after curative surgery. TG extended to the spleen or to the pancreas should not be performed in curative surgery because of a high rate of postoperative complications. Limited gastric resections for superficial GC have to be evaluated in Western countries. Palliative exploratory laparotomies should be avoided by better preoperative explorations. Laparoscopic staging in GC could be indicated when palliative resection or bypass are possible. The results of adjuvant chemotherapy is still disappointing and new protocols have to be evaluated. Intraperitoneal chemotherapy with or without hyperthermia represents a serious hope in the treatment of GC, but its significative action on the survival is not well demonstrated, while its morbidity and mortality rate is high.

Survival of patients with oesophageal and gastric cancers in Europe. EUROCARE Working Group

The EUROCARE study is a European Union project to collect survival data from population-based cancer registries and analyse them according to standardised procedures. We investigated and compared oesophageal and gastric cancer survival in 17 countries between 1985 and 1989. Time trends in survival over the 1978-1989 period were also investigated in 13 countries. The overall European 1-year relative survival rates were 33% for oesophageal cancer and 40% for gastric cancer. The corresponding 5-year relative survival rates were 10 and 21%, respectively. Important intercountry survival differences exist within Europe for oesophageal and gastric cancer. Taking the European average as the reference, the relative risk (RR) of death at 5 years was at least 30% higher in Denmark, Poland, Estonia and Slovenia for oesophageal cancer and in Denmark, England, Scotland and Poland for gastric cancer. In the other countries survival figures were close to the European average. Gender had little influence on survival, whilst age at diagnosis was inversely related to prognosis. There was a slight improvement between 1978 and 1989 in 5-year overall relative survival rates for both oesophageal cancer (RR = 0.80, 95% confidence interval (CI) 0.72-0.90) and gastric cancer (RR = 0.88, 95% CI 0.82-0.94). Differences in quality of care and stage at diagnosis can explain in part the differences in survival found in the EUROCARE countries. Significant improvement in prognosis has still to be achieved.