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Hu Z, Liu Z, Li W, You W, Pan K. Health economic evaluation on population-based Helicobacter pylori eradication and endoscopic screening for gastric cancer prevention. Chin J Cancer Res 2023; 35:595-605. [PMID: 38204445 PMCID: PMC10774135 DOI: 10.21147/j.issn.1000-9604.2023.06.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/21/2023] [Indexed: 01/12/2024] Open
Abstract
Gastric cancer is a global public health burden, nearly one million new cases are diagnosed per year worldwide, of which 44% of cases occur in China. The prognosis of gastric cancer varies remarkably by the stage of cancer, and most of the patients in China are diagnosed at advanced stages, resulting in poor prognoses. Effective strategies to reduce the burden of gastric cancer include primary prevention through testing and treatment of Helicobacter pylori (H. pylori) and secondary prevention by screening and early detection. Although many countries have issued management guidelines and consensus reports concerning these strategies, the limited availability of healthcare resources often precludes their widespread implementation. Therefore, assessing the costs, benefits, and harms of population-based intervention measures through health economic evaluation is necessary for informed health policy decisions. Accordingly, we synthesize management approaches from different countries on H. pylori eradication and endoscopic screening, and also summarize recent advancements in health economic evaluations on population-based preventive strategies. The goal of the review is to provide empirical evidence supporting optimal resource allocation, maximizing benefits for the population, and ultimately reducing the burden of gastric cancer.
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Affiliation(s)
- Zhiqiang Hu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Cancer Epidemiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zongchao Liu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Cancer Epidemiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Wenqing Li
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Cancer Epidemiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Weicheng You
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Cancer Epidemiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Kaifeng Pan
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Cancer Epidemiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
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2
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Huang RJ, Epplein M, Hamashima C, Choi IJ, Lee E, Deapen D, Woo Y, Tran T, Shah SC, Inadomi JM, Greenwald DA, Hwang JH. An Approach to the Primary and Secondary Prevention of Gastric Cancer in the United States. Clin Gastroenterol Hepatol 2022; 20:2218-2228.e2. [PMID: 34624563 PMCID: PMC8983795 DOI: 10.1016/j.cgh.2021.09.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Gastric cancer (GC) remains a leading cause of mortality among certain racial, ethnic, and immigrant groups in the United States (US). The majority of GCs are diagnosed at advanced stages, and overall survival remains poor. There exist no structured national strategies for GC prevention in the US. METHODS On March 5-6, 2020 a summit of researchers, policy makers, public funders, and advocacy leaders was convened at Stanford University to address this critical healthcare disparity. After this summit, a writing group was formed to critically evaluate the effectiveness, potential benefits, and potential harms of methods of primary and secondary prevention through structured literature review. This article represents a consensus statement prepared by the writing group. RESULTS The burden of GC is highly inequitably distributed in the US and disproportionately falls on Asian, African American, Hispanic, and American Indian/Alaskan Native populations. In randomized controlled trials, strategies of Helicobacter pylori testing and treatment have been demonstrated to reduce GC-specific mortality. In well-conducted observational and ecologic studies, strategies of endoscopic screening have been associated with reduced GC-specific mortality. Notably however, all randomized controlled trial data (for primary prevention) and the majority of observational data (for secondary prevention) are derived from non-US sources. CONCLUSIONS There exist substantial, high-quality data supporting GC prevention derived from international studies. There is an urgent need for cancer prevention trials focused on high-risk immigrant and minority populations in the US. The authors offer recommendations on how strategies of primary and secondary prevention can be applied to the heterogeneous US population.
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Affiliation(s)
- Robert J Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California
| | - Meira Epplein
- Department of Population Health Sciences, Duke University, and Cancer Risk, Detection, and Interception Program, Duke Cancer Institute, Durham, North Carolina
| | | | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, South Korea
| | - Eunjung Lee
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Yanghee Woo
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, California
| | - Thuy Tran
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, California
| | - Shailja C Shah
- Gastroenterology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California; Division of Gastroenterology and Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - John M Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - David A Greenwald
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
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Qin S, Wang X, Li S, Tan C, Zeng X, Wu M, Peng Y, Wang L, Wan X. Benefit-to-harm ratio and cost-effectiveness of government-recommended gastric cancer screening in China: A modeling study. Front Public Health 2022; 10:955120. [PMID: 36033760 PMCID: PMC9399635 DOI: 10.3389/fpubh.2022.955120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/18/2022] [Indexed: 01/24/2023] Open
Abstract
Objective Current guidelines recommend the gastric cancer risk score scale (GCRSS) for screening in gastric cancer (GC) high-risk populations in China. This study aimed to estimate the clinical benefits, harms, cost, and cost-effectiveness of the GCRSS screening strategy from a Chinese healthcare system perspective. Materials and methods Using a microsimulation model, we evaluated 7 screening scenarios of the GCRSS with varying starting ages. We simulated 100,000 individuals from the age of 20 for each screening scenario. The main outcomes included GC incidence reduction, number of cause-specific deaths, costs, quality-adjusted life year (QALY), incremental cost-effectiveness ratio (ICER), and benefit-to-harm ratio. Deterministic and probabilistic sensitivity analyses were done to explore the robustness of model findings. Results Screening with the GCRSS strategy at the age of 40 years (40-GCRSS) provided the greatest reduction of GC incidence by 70.6%, with 7,374 GC deaths averted per 100,000 individuals and the lowest benefit-to-harm ratio of 0.392. Compared with no screening or previous less costly strategy, at a willingness-to-pay (WTP) threshold of $37,655 per QALY, the 40-GCRSS strategy was cost-effective, with ICERs of $12,586 and $29,115 per QALY, respectively. Results were robust across univariate and probabilistic sensitivity analyses. The 40-GCRSS strategy showed a 0.856 probability of being cost-effective at a $37,655 per QALY WTP threshold. Conclusions The findings suggest that the GCRSS strategy is effective and cost-effective in reducing the GC disease burden in China from a Chinese healthcare system perspective. Screening from the age of 40 would be the optimal strategy.
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Affiliation(s)
- Shuxia Qin
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Sini Li
- Xiangya Nursing School, Central South University, Changsha, China,School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, United Kingdom
| | - Chongqing Tan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaohui Zeng
- PET-CT Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Meiyu Wu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ye Peng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Liting Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaomin Wan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Xiaomin Wan
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Qin S, Wang X, Li S, Tan C, Zeng X, Luo X, Yi L, Peng L, Wu M, Peng Y, Wang L, Wan X. Clinical Benefit and Cost Effectiveness of Risk-Stratified Gastric Cancer Screening Strategies in China: A Modeling Study. PHARMACOECONOMICS 2022; 40:725-737. [PMID: 35701687 DOI: 10.1007/s40273-022-01160-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE A new gastric cancer screening scoring system (NGCS) strategy was recommended for the early gastric cancer (GC) screening process in China. The current study aimed to assess the clinical benefits and the cost effectiveness of the NGCS strategy in GC high-risk areas of China from a societal perspective. METHODS A Markov microsimulation model was developed to evaluate 30 alternative screening strategies with varying initiation age, including the NGCS strategy, the modified NGCS strategy, and the endoscopic screening strategy with various screening intervals. The primary outcomes included GC mortality, number of endoscopies, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Cost estimates were reported in 2021 USD (US$) and both costs and benefits were discounted at 5% annually. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. RESULTS Screening with the NGCS strategy from age 40 years (40-NGCS) reduced the GC incidence by 86.4%, which provided the greatest benefit across strategies. Compared with all strategies, at a willingness-to pay threshold of US$17,922 per QALY, the 40-NGCS strategy was a leading cost-effective strategy, with an ICER of US$15,668 per QALY. Results were robust in univariate and probabilistic sensitivity analyses. The probability of the 40-NGCS strategy being cost effective was 0.863. CONCLUSIONS The 40-NGCS strategy was an effective and cost-effective strategy to reduce GC incidence and mortality in China. The findings provide important evidence for decision makers to formulate and optimize targeted approaches for GC prevention and control policies in China.
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Affiliation(s)
- Shuxia Qin
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Sini Li
- Xiangya Nursing School, Central South University, Changsha, 410013, Hunan, China
- Faculty of Medicine, Dentistry and Health, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Chongqing Tan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xiaohui Zeng
- PET-CT Center, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xia Luo
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Lidan Yi
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Liubao Peng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Meiyu Wu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Ye Peng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Liting Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xiaomin Wan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
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Kowada A. Endoscopy Is Cost-Effective for Gastric Cancer Screening After Successful Helicobacter pylori Eradication. Dig Dis Sci 2021; 66:4220-4226. [PMID: 33417196 DOI: 10.1007/s10620-020-06813-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND After successful Helicobacter pylori eradication, patients with gastric mucosal atrophy are at high risk of gastric cancer. Endoscopy can detect early gastric cancer with high sensitivity. AIMS This study aimed to assess the cost-effectiveness of annual endoscopy versus biennial endoscopy versus no screening for gastric cancer screening in patients after successful Helicobacter pylori eradication. METHODS We developed decision trees with Markov models for a hypothetical cohort of patients aged 50 years after successful Helicobacter pylori eradication over a lifetime horizon from a healthcare payer perspective. Main outcomes were costs, quality-adjusted life-years (QALYs), life expectancy life-years (LYs) with discounting at a fixed annual rate of 3%, and incremental cost-effectiveness ratios (ICERs). RESULTS In a base-case analysis, biennial endoscopy (US$4305, 19.785QALYs, 19.938LYs) was more cost-effective than annual endoscopy (US$7516, 19.808QALYs, 19.958LYs, ICER; US$135,566/QALY gained) and no screening (US$14,326, 19.704QALYs, 19.873LYs). In scenario analyses, biennial endoscopy for patients with mild-to-moderate gastric mucosal atrophy and annual endoscopy for patients with severe gastric mucosal atrophy were the most cost-effective. Cost-effectiveness was sensitive to incidence of gastric cancer and the proportion of stage I. Probabilistic sensitivity analyses using Monte Carlo simulation demonstrated that at a willingness-to-pay level of US$100,000/QALY gained, biennial endoscopy was optimal 99.9% for patients with mild-to-moderate gastric mucosal atrophy, and that annual endoscopy was optimal 98.4% for patients with severe gastric mucosal atrophy. CONCLUSIONS Based on cancer risk assessment of gastric mucosal atrophy and cost-effectiveness results, annual or biennial endoscopic surveillance could be established for patients after successful Helicobacter pylori eradication.
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Affiliation(s)
- Akiko Kowada
- Department of Occupational Health, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.
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Al Hennawi H, Khedr A, Maan RK, Albarazi M, Atluri P. Gastric Intestinal Metaplasia and Its Rapid Progression Toward Gastric Adenocarcinoma: A Call for Clear Patient Management and Awareness. Cureus 2021; 13:e18751. [PMID: 34796052 PMCID: PMC8589342 DOI: 10.7759/cureus.18751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/05/2022] Open
Abstract
Gastric cancer is one of the leading causes of cancer-related death worldwide. Helicobacter pylori (H. pylori) infection is known to cause gastric adenocarcinoma in a stepwise fashion. Gastric intestinal metaplasia is a known premalignant stage. We report a case of a 70-year-old male patient with active chronic H. pylori-associated gastritis and focal intestinal metaplasia on the initial presentation, who rapidly developed diffuse, poorly differentiated gastric adenocarcinoma 20 months after the loss to follow-up. Our case highlights the premalignant nature of gastric intestinal metaplasia (GIM) and the extreme importance of early eradication of H. pylori. We also address the lack of definitive GIM surveillance guidelines.
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Affiliation(s)
- Hussam Al Hennawi
- Internal Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | - Anwar Khedr
- Internal Medicine, Tanta University Faculty of Medicine, Tanta, EGY
| | | | | | - Purna Atluri
- Gastroenterology, University Hospital of Brooklyn, State University of New York Downstate Medical Center, Brooklyn, USA
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7
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Zhang Y, Zhang PS, Rong ZY, Huang C. One stomach, two subtypes of carcinoma—the differences between distal and proximal gastric cancer. Gastroenterol Rep (Oxf) 2021; 9:489-504. [PMID: 34925847 PMCID: PMC8677565 DOI: 10.1093/gastro/goab050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/13/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022] Open
Abstract
Abstract
Gastric cancer (GC) is one of the most common malignant tumors of the digestive tract, posing a significant risk to human health. Over the past 10 years, the pathological characteristics and the prognosis of GC have been determined based on the locations of the tumors that were then classified into two types—proximal and distal GC. This review focuses on the differences in epidemiology, etiology, cell source, pathological characteristics, gene expression, molecular markers, manifestations, treatment, prognosis, and prevention between proximal and distal GC to provide guidance and a basis for clinical diagnosis and treatment.
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Affiliation(s)
- Yuan Zhang
- Department of Gastrointestinal Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, P. R. China
| | - Peng-Shan Zhang
- Department of Gastrointestinal Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, P. R. China
| | - Ze-Yin Rong
- Department of Gastrointestinal Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, P. R. China
| | - Chen Huang
- Department of Gastrointestinal Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, P. R. China
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Enríquez-Sánchez LB, Gallegos-Portillo LG, Camarillo-Cisneros J, Cisneros-Castolo M, Montelongo-Santiesteban JJ, Aguirre-Baca DA, Pérez-Echavarría AI, Contreras-Pacheco AE. Cost-benefit of serum pepsinogen screening for gastric adenocarcinoma in the Mexican population. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021; 87:285-291. [PMID: 34794924 DOI: 10.1016/j.rgmxen.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/19/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND AIM Helicobacter pylori (H. pylori) is known to be capable of causing chronic inflammation of the gastric mucosa that slowly progresses through the premalignant stages, reaching localized gastric adenocarcinoma (GAC). Its outcome is closely related to the stage at which diagnosis is made. The aim of the present study was to determine cost-benefit by comparing esophagogastroduodenoscopy, serum pepsinogen detection, and no screening at all. MATERIAL AND METHODS Utilizing Markov chains and Monte Carlo simulation, the costs and effects of various detection modalities were simulated to analyze the cost-benefit of each strategy. For our population, we used the published data of patients with gastric cancer, applicable to the Mexican population. RESULTS The results were reported as incremental cost-effectiveness ratios. The best strategy was serum pepsinogen determination, followed by the strategy of endoscopic examination with continued monitoring every 3 years. CONCLUSIONS The performance of serum pepsinogen serology and directed endoscopic examination (and continued monitoring, if necessary) for GAC screening could be a cost-effective intervention in Mexico, despite the low-to-moderate general prevalence of the disease.
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Affiliation(s)
- L B Enríquez-Sánchez
- Servicio de Cirugía, Departamento de Cirugía General, Hospital Central Universitario del Estado, Chihuahua, Mexico.
| | - L G Gallegos-Portillo
- Servicio de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico
| | - J Camarillo-Cisneros
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - M Cisneros-Castolo
- Unidad de Vigilancia Epidemiológica, Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | - J J Montelongo-Santiesteban
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - D A Aguirre-Baca
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - A I Pérez-Echavarría
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - A E Contreras-Pacheco
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, Mexico
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9
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Enríquez-Sánchez LB, Gallegos-Portillo LG, Camarillo-Cisneros J, Cisneros-Castolo M, Montelongo-Santiesteban JJ, Aguirre-Baca DA, Pérez-Echavarría AI, Contreras-Pacheco AE. Cost-benefit of serum pepsinogen screening for gastric adenocarcinoma in the Mexican population. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 87:S0375-0906(21)00041-0. [PMID: 34052055 DOI: 10.1016/j.rgmx.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/13/2020] [Accepted: 01/19/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND AIM Helicobacter pylori (H. pylori) is known to be capable of causing chronic inflammation of the gastric mucosa that slowly progresses through the premalignant stages, reaching localized gastric adenocarcinoma (GAC). Its outcome is closely related to the stage at which diagnosis is made. The aim of the present study was to determine cost-benefit by comparing esophagogastroduodenoscopy, serum pepsinogen detection, and no screening at all. MATERIAL AND METHODS Utilizing Markov chains and Monte Carlo simulation, the costs and effects of various detection modalities were simulated to analyze the cost-benefit of each strategy. For our population, we used the published data of patients with gastric cancer, applicable to the Mexican population. RESULTS The results were reported as incremental cost-effectiveness ratios. The best strategy was serum pepsinogen determination, followed by the strategy of endoscopic examination with continued monitoring every 3 years. CONCLUSIONS The performance of serum pepsinogen serology and directed endoscopic examination (and continued monitoring, if necessary) for GAC screening could be a cost-effective intervention in Mexico, despite the low-to-moderate general prevalence of the disease.
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Affiliation(s)
- L B Enríquez-Sánchez
- Servicio de Cirugía, Departamento de Cirugía General, Hospital Central Universitario del Estado , Chihuahua, México.
| | - L G Gallegos-Portillo
- Servicio de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de MéxicoMéxico
| | - J Camarillo-Cisneros
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, México
| | - M Cisneros-Castolo
- Unidad de Vigilancia Epidemiológica, Hospital Infantil de Especialidades de Chihuahua, Chihuahua, México
| | - J J Montelongo-Santiesteban
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, México
| | - D A Aguirre-Baca
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, México
| | - A I Pérez-Echavarría
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, México
| | - A E Contreras-Pacheco
- Departamento de Investigación, Facultad de Medicina y Ciencias Biomédicas, Universidad Autónoma de Chihuahua, Chihuahua, México
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10
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Lansdorp-Vogelaar I, Meester RGS, Laszkowska M, Escudero FA, Ward ZJ, Yeh JM. Cost-effectiveness of prevention and early detection of gastric cancer in Western countries. Best Pract Res Clin Gastroenterol 2021; 50-51:101735. [PMID: 33975689 DOI: 10.1016/j.bpg.2021.101735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 02/08/2023]
Abstract
Gastric cancer (GC) is a significant global health problem, with Helicobacter pylori infection estimated to be responsible for 89% of non-cardiac GC cases, or 78% of all GC cases. The International Agency for Research on Cancer has called for Helicobacter pylori test-and-treat strategies in countries with high rates of GC. However, for countries with low rates of GC, such as most Western countries, the balance between benefits, harms and costs of screening is less clear-cut. GC is a disease with a well-characterized precancerous process, providing the basis for primary and secondary prevention efforts. However, rigorous data assessing the impact of such interventions in Western countries are lacking. In the absence of clinical trials, modelling offers a unique approach to evaluate the potential impact of various screening and surveillance interventions. In this paper, we provide an overview of modelling studies evaluating the cost-effectiveness of GC screening and surveillance in Western countries.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - Monika Laszkowska
- Gastroenterology, Hepatology, and Nutrition Service, Memorial-Sloan Kettering Cancer Research Center New York, NY, USA.
| | | | - Zachary J Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Jennifer M Yeh
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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11
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Canakis A, Pani E, Saumoy M, Shah SC. Decision model analyses of upper endoscopy for gastric cancer screening and preneoplasia surveillance: a systematic review. Therap Adv Gastroenterol 2020; 13:1756284820941662. [PMID: 32728390 PMCID: PMC7366398 DOI: 10.1177/1756284820941662] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Gastric cancer (GC) is the third leading cause of cancer death worldwide, but the burden of disease is not distributed evenly. GC screening routinely occurs in some high-incidence regions/countries and is generally cost-effective, which is attributed largely to the associated GC mortality reduction. In regions of low-intermediate incidence, less is known about the outcomes of GC screening and gastric precancer surveillance, including cost-effectiveness, since there are no comparative clinical studies. Decision analytic studies are informative in such instances where logistical limitations preclude "gold standard" study designs. We therefore aimed to conduct a systematic review of decision model analyses focused on endoscopic GC screening or precancer surveillance. METHODS We identified decision model analyses, including cost effectiveness and cost utility studies, of GC screening or preneoplasia surveillance. At minimum, articles were evaluated for: study country; analytic design; population and health states; time horizon; model assumptions; outcomes; threshold value(s) for "cost-effective" determination; and sensitivity analyses. Quality appraisal was performed using a modified Drummond's analytic scoring system. Data sources were PubMed, Web of Science, Embase, and the Cochrane Library. RESULTS We identified 17 studies (8 screening, 4 surveillance, and 5 screening and surveillance) that met full inclusion criteria. Endoscopic screening in countries of high GC incidence was cost-effective across all studies; targeted screening of high-risk populations within otherwise low-intermediate incidence countries was also generally cost-effective. Surveillance of gastric precancer, including atrophic gastritis or gastric intestinal metaplasia, was generally cost-effective. Most studies had high appraisal scores, with 4 (24%) studies achieving perfect scores on the Drummond scale. CONCLUSION Decision model analyses offer a unique mechanism with which to efficiently explore the cost benefit of various prevention and early detection strategies. Based on this comprehensive systematic review, upper endoscopy for GC screening and gastric precancer surveillance might be cost-effective depending on the population and protocol. Focused efforts are especially needed not only to define the optimal approach, but also to define the populations within otherwise low-intermediate regions/countries who might benefit most.
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Affiliation(s)
- Andrew Canakis
- Department of Medicine, Boston University
Medical Center, Boston, Massachusetts, USA
| | - Ethan Pani
- Department of Medicine, University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Monica Saumoy
- Division of Gastroenterology and Hepatology,
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,
USA
| | - Shailja C. Shah
- Division of Gastroenterology, Hepatology, and
Nutrition, Vanderbilt University Medical Center, 2215 Garland Avenue,
Medical Research Building IV, Room 1030-C (mail), Nashville, TN 37232-0252,
USA
- Section of Gastroenterology, Veterans Affairs
Tennessee Valley Health System, Nashville, TN, USA
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12
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Suh Y, Lee J, Woo H, Shin D, Kong S, Lee H, Shin A, Yang H. National cancer screening program for gastric cancer in Korea: Nationwide treatment benefit and cost. Cancer 2020; 126:1929-1939. [DOI: 10.1002/cncr.32753] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/25/2019] [Accepted: 12/28/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Yun‐Suhk Suh
- Department of Surgery Seoul National University College of Medicine Seoul Korea
- Department of Surgery Seoul National University Hospital Seoul Korea
- Department of Surgery Seoul National University Bundang Hospital Seongnam Korea
| | - Joonki Lee
- Department of Preventive Medicine Seoul National University College of Medicine Seoul Korea
| | - Hyeongtaek Woo
- Department of Preventive Medicine Seoul National University College of Medicine Seoul Korea
| | - Dongwook Shin
- Department of Family Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seong‐Ho Kong
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Hyuk‐Joon Lee
- Department of Surgery Seoul National University College of Medicine Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
| | - Aesun Shin
- Department of Preventive Medicine Seoul National University College of Medicine Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
| | - Han‐Kwang Yang
- Department of Surgery Seoul National University College of Medicine Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
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13
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Incidence Rate of Gastric Cancer Adenocarcinoma in Patients With Gastric Dysplasia: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019; 53:703-710. [PMID: 31415022 DOI: 10.1097/mcg.0000000000001257] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several studies have reported the risk of progression to gastric adenocarcinoma (GAC) in patients with gastric dysplasia (GD); however, the findings are controversial. We performed a systematic review and meta-analysis to study the incidence rate of GAC among patients with GD. Using a comprehensive search strategy, we systematically searched online databases including PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science databases for identifying all relevant original articles through inception until July 2018. Cochran Q and I tests were used to assess heterogeneities between included studies. The incidence rates of GAC and their corresponding 95% confidence intervals (CIs) were pooled using random-effect or fixed-effect models. Of the 1980 retrieved records, 30 eligible articles (61 studies) were included. The overall pooled incidence rate of GAC was 40.36 (95% CI, 27.08-55.71; I, 96.0%) cases per 1000 person-years in patients with GD. Subgroup analysis according to the type of GD indicated the highest incidence rate of GAC was 186.40 (95% CI, 106.63-285.60; I, 94.6%) per 1000 person-years among patients with high-grade dysplasia (HGD) lesions. Although the incidence rates of GAC in low-grade dysplasia (LGD) lesions and in nonclassified lesions were 11.25 (95% CI, 3.91-21.22; I, 89.3%), and 1.40 (95% CI, 0.00-9.71; I, 78.8%), respectively. Compared with patients with LGD lesions, progression rate from GD to GAC was roughly 16 times greater in patients with HGD lesions. As the majority of patients with GAC are diagnosed in an advanced stage our study suggests strict management of HGD lesions to prevent GAC.
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14
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The long-term population impact of endoscopic screening programmes on disease burdens of gastric cancer in China: A mathematical modelling study. J Theor Biol 2019; 484:109996. [PMID: 31491497 DOI: 10.1016/j.jtbi.2019.109996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/03/2019] [Accepted: 09/03/2019] [Indexed: 12/24/2022]
Abstract
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.
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15
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Banks M, Graham D, Jansen M, Gotoda T, Coda S, di Pietro M, Uedo N, Bhandari P, Pritchard DM, Kuipers EJ, Rodriguez-Justo M, Novelli MR, Ragunath K, Shepherd N, Dinis-Ribeiro M. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut 2019; 68:1545-1575. [PMID: 31278206 PMCID: PMC6709778 DOI: 10.1136/gutjnl-2018-318126] [Citation(s) in RCA: 314] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 05/06/2019] [Accepted: 05/17/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Matthew Banks
- University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK.,Research Department of Targeted Intervention, University College London, London, UK
| | - David Graham
- University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK.,Division of Surgery and Interventional Science, University College London Division of Biosciences, London, UK
| | - Marnix Jansen
- Department of Histopathology, University College London, London, UK
| | - Takuji Gotoda
- Gastroenterology, Nihon University School of Medicine Graduate School of Medicine, Itabashi-ku, Tokyo, Japan
| | | | - Massimiliano di Pietro
- MRC Cancer Unit, University of Cambridge, Cambridge, UK.,Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Endoscopic Training and Learning Center, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | | | - D Mark Pritchard
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | | | - Marco R Novelli
- Department of Histopathology, University College London, London, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, Nottingham University Hospital, Nottingham, UK
| | - Neil Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, Gloucestershire, UK
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16
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Trieu JA, Bilal M, Saraireh H, Wang AY. Update on the Diagnosis and Management of Gastric Intestinal Metaplasia in the USA. Dig Dis Sci 2019; 64:1079-1088. [PMID: 30771043 DOI: 10.1007/s10620-019-05526-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Gastric intestinal metaplasia (GIM) is a premalignant condition that can lead to intestinal-type gastric adenocarcinoma. It is characterized by a change in the gastric mucosa to a small-intestinal phenotype. Infection with Helicobacter pylori is the most common factor associated with GIM. Although GIM is typically a histologic diagnosis, various techniques have been developed to enable the endoscopic identification of GIM. There are presently no widely accepted guidelines on screening and surveillance strategies in patients with GIM in the USA. The aim of this review is to provide an update regarding the problem, diagnosis, and management of GIM in the USA.
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Affiliation(s)
- Judy A Trieu
- Department of Internal Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
| | - Hamzeh Saraireh
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, 1200 East Broad Street, P.O. Box 98034, Richmond, VA, 23298, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, P.O. Box 800708, Charlottesville, VA, 22908, USA
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17
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Da B, Jani N, Gupta N, Jayaram P, Kankotia R, Yao Yu C, Dinis-Ribeiro M, Buxbaum J. High-risk symptoms do not predict gastric cancer precursors. Helicobacter 2019; 24:e12548. [PMID: 30412322 DOI: 10.1111/hel.12548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/06/2018] [Accepted: 09/07/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND & STUDY AIMS Gastric intestinal metaplasia (GIM) is the most common precursor of gastric cancer. Our aim is to determine if presenting symptoms predict gastric cancer precursor lesions in a high-risk population. PATIENT AND METHODS Consecutive unique patients evaluated by endoscopy for upper gastrointestinal symptoms at the Los Angeles County Hospital between 2010 and 2014 were evaluated. Presenting symptoms were classified as low- or high-risk depending on the procedure indication as coded using the Clinical Outcomes Research Initiative (CORI) system. Endoscopy and histology results were used to classify findings as benign, GIM, high-risk GIM, or malignant. The primary outcome was the proportion of patients with premalignant or malignant gastric findings who had high-risk clinical indications for endoscopy relative to those with benign results. RESULTS A total of 3699 patients underwent endoscopy to evaluate upper gastrointestinal symptoms. There were 373 (10.1%) patients with GIM of which 278 had high-risk GIM. One hundred and sixty (4.3%) patients were diagnosed with gastric cancer. High-risk indications for upper endoscopy predicted gastric cancer (OR 1.8 [95% CI 1.3-2.6]) but not GIM (OR 1.0 [0.8-1.3]) or high-risk GIM (OR 0.9 [0.7-1.2]). Hispanic or Asian patients and patients >50 years old were more likely to have GIM, high-risk GIM, and cancer. CONCLUSIONS Performance of upper endoscopy for high-risk indications is inadequate to detect GIM and marginal for malignancy. At risk patients should undergo upper endoscopy for both low- and high-risk symptoms. Screening certain populations deserve additional study and may, in fact, be cost-effective.
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Affiliation(s)
- Ben Da
- Digestive Disease Branch, National Institutes of Health, Bethesda, Maryland
| | - Niraj Jani
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nikhil Gupta
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Preeth Jayaram
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ravi Kankotia
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Chung Yao Yu
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute, Porto, Portugal
| | - James Buxbaum
- Division of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, California
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18
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Matsuda A, Saika K, Tanaka R, Ito Y, Fukui K, Kamo KI. Simulation Models in Gastric Cancer Screening: A Systematic Review. Asian Pac J Cancer Prev 2018; 19:3321-3334. [PMID: 30583337 PMCID: PMC6428531 DOI: 10.31557/apjcp.2018.19.12.3321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 03/04/2018] [Indexed: 12/24/2022] Open
Abstract
Background: Together with such high-quality approaches as randomized controlled trials and large-scale cohort studies, simulation models are often employed to evaluate the effect of cancer screening methods and decide on their appropriateness. This study aimed to evaluate all effects of gastric cancer screening that have been assessed using simulation models, including cost-effectiveness, mortality reduction, and early-stage detection. Methods: We performed a systematic review using PubMed and Web of Science. We evaluated the effect of screening related to cost, such as incremental cost-effectiveness and incremental cost-effectiveness ratios; we also separately assessed effects other than cost, such as quality-adjusted life-years, number of deaths prevented, life-years saved, relative risk of mortality from gastric cancer, life expectancy, and incidence reduction. The methods targeted for evaluation were Helicobacter pylori testing or endoscopy. Results: We identified 19 studies dealing with simulation models in gastric cancer screenings: 14 examined H. pylori screening and 7 focused on endoscopy. Among those studies, two assessed both H. pylori and endoscopy screening. Most of the studies adopted a Markov model, and all the studies evaluated cost-effectiveness. Of the 14 H. pylori screening studies, 13 demonstrated cost-effectiveness and 11 also showed good results other than cost-effectiveness, such as extension of life-years and increase in early-stage detection. In three of the five endoscopy studies, the target population was patients; all five studies obtained good results for cost-effectiveness and four observed good results other than for cost-effectiveness. Conclusions: In this study, we showed that the H. pylori screening test was cost-effective in terms of simulation model investigations. However, the H. pylori screening test should not ordinarily be recommended since there is insufficient evidence that it reduces gastric cancer mortality. In Japan, simulation modeling should be employed to plan for cancer control, and the appropriate use of simulation models should be examined for future use.
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Affiliation(s)
- Ayako Matsuda
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.
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19
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Zhang X, Li M, Chen S, Hu J, Guo Q, Liu R, Zheng H, Jin Z, Yuan Y, Xi Y, Hua B. Endoscopic Screening in Asian Countries Is Associated With Reduced Gastric Cancer Mortality: A Meta-analysis and Systematic Review. Gastroenterology 2018; 155:347-354.e9. [PMID: 29723507 DOI: 10.1053/j.gastro.2018.04.026] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Xing Zhang
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Meng Li
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Shuntai Chen
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Jiaqi Hu
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Qiujun Guo
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Rui Liu
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Honggang Zheng
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhichao Jin
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yuan Yuan
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yupeng Xi
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Baojin Hua
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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20
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Comparison of endoscopic ultrasonography and magnifying endoscopy for assessment of the invasion depth of shallow gastrointestinal neoplasms: a systematic review and meta-analysis. Surg Endosc 2017; 31:4923-4933. [PMID: 28547665 DOI: 10.1007/s00464-017-5596-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/11/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To conduct a meta-analysis to provide accurate evidence regarding the preferred diagnostic method, magnifying endoscopy (ME) or endoscopic ultrasonography (EUS), for assessment of the depth of invasion of the gastrointestinal neoplasms. METHODS PubMed, EMBASE, Ovid Medline, and the Cochrane Library databases were searched for studies published between January 1946 and October 2016, regarding the use of EUS and ME to assess the invasion depth of gastrointestinal cancers. The quality of diagnostic studies was evaluated using the QUADAS2 instrument. The Meta-DiSc software (version 1.4) was used for meta-analysis of the pooled data regarding the diagnostic accuracy of EUS and ME of the invasion depth of gastrointestinal neoplasms. RESULTS Our meta-analysis included the data of 754 patients with gastrointestinal cancers contributed by seven prospective studies. All studies were of high quality (QUADAS2). The receiver operating characteristic (ROC) planes were not observed in shoulder and arm forms for either EUS or ME, with Spearman's correlation coefficients of -0.821 and 0.234 for EUS and ME, respectively. The p values of the diagnostic odds ratio for EUS and ME were 0.0038 and 0.0131, respectively. The sensitivity and specificity of EUS for the diagnosis of the depth of invasion of gastrointestinal cancers were 0.75 (95% CI 0.69-0.81) and 0.84 (95% CI 0.79-0.88), respectively. In comparison, the sensitivity and specificity for ME were 0.74 (95% CI 0.67-0.69) and 0.85 (95% CI 0.80-0.89), respectively. The values of area under the summary ROC (SROC) curves for EUS and ME were 0.8499 and 0.8757, respectively, with a non-significant Z value between EUS and MR (0.296 < 1.96). CONCLUSIONS Both EUS and ME provide a comparable performance for judging the depth of invasion of gastrointestinal neoplasms. However, there is heterogeneity between studies contributed by non-threshold effects.
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21
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Woo Y, Behrendt CE, Trapp G, Hyun JG, Gonda T, Fong Y, Wang T. Screening endoscopy finds high prevalence of Helicobacter pylori and intestinal metaplasia in Korean American with limited access to health care. J Surg Oncol 2017; 116:172-176. [PMID: 28445591 DOI: 10.1002/jso.24622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/09/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastric cancer (GC) is the leading cause of cancer death among Korean Americans. Prevention and early detection is improved by screening. METHODS Between September 2013 and March 2015, ethnic Koreans age 40 or older without history or symptoms of GC and without upper endoscopy (UE) during previous 3 years were enrolled. Participants were offered screening with GC risk assessment followed by UE with biopsies. RESULTS Risk assessment was provided to 146 participants (age 55.6 ± 8.3 years; 52.1% female; 92.5% uninsured), of whom 99 (67.8%) returned for UE. Undergoing UE was independently associated with family history of GC (OR 12.33, 95% CI:1.52-100.17), being a former smoker (6.68,1.42-31.32), and Hp-negative status (0.25,0.11-0.57). Among UE recipients, half (49.5%) had intestinal metaplasia (IM) only (n = 24), Hp only (n = 12), or both (n = 13). No case of GC was found. Adjusted for age, IM was independently associated with male sex (2.89,1.12-7.42), current Hp (2.90,0.99-8.51), unmarried status (single or divorced) (4.23,1.23-14.56). CONCLUSIONS High prevalence of risk factors associated with gastric carcinogenesis including Hp infection and IM exists in Korean Americans who underwent upper endoscopic screening. Acceptance of GC screening is informed by personal risk factors. These findings support the need to improve access to screening UE among KAs.
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Affiliation(s)
- Yanghee Woo
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California.,Department of Surgery, Columbia University Medical Cancer, Duarte, California
| | - Carolyn E Behrendt
- Department of Biostatistics, City of Hope National Medical Center, Duarte, California
| | - Garrick Trapp
- Department of Surgery, Columbia University Medical Cancer, Duarte, California
| | | | - Tamas Gonda
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Timothy Wang
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
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Abstract
With the increasing popularity of sleeve gastrectomy, many stomach specimens are being evaluated. Understanding the significance and treatment for unexpected pathology is important. This study examines the incidence of relevant histopathology of sleeve gastrectomy specimens. It evaluates previous data for each histopathology and provides recommendations for treatment. In this study, a retrospective review was performed for 241 patients who underwent sleeve gastrectomy from 2009 to 2014 at a single institution. Of the specimens, 122 had no significant histopathology, 91 had gastritis, 13 had lymphoid aggregates, 5 had hyperplasia, 3 had intestinal metaplasia, 3 had gastrointestinal stromal tumors (GISTs), and 3 had gastric polyps. Of the GISTs all had a low mitotic rate and the size of the tumor ranged from 1.5 to 4.5 cm. The findings of metaplasia may be a marker for increased risk of malignancy and may require additional surveillance. The findings of GIST may warrant interval imaging to survey for recurrence, though the likelihood of recurrence for the tumors in this study is less than 2 per cent based on previous studies.
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Risk of Gastric Cancer Among Patients With Intestinal Metaplasia of the Stomach in a US Integrated Health Care System. Clin Gastroenterol Hepatol 2016; 14:1420-5. [PMID: 27317852 DOI: 10.1016/j.cgh.2016.05.045] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastric intestinal metaplasia (GIM) is a common finding from routine endoscopies. Although GIM is an early step in gastric carcinogenesis, there is controversy regarding routine surveillance of patients with GIM in regions with a low prevalence of gastric cancer. We aimed to determine the incidence of gastric cancer among patients with GIM and risk factors for gastric cancer. METHODS We performed a retrospective cohort study of patients from the Kaiser Permanente Southern California region diagnosed with GIM from 2000 through 2011. GIM was identified by a keyword search of pathology reports; gastric cancer cases were identified by cross-reference with an internal cancer registry. The incidence of gastric cancer in patients with GIM (n = 923; median age at diagnosis, 68 y) was compared with that of an age- and sex-matched reference population (controls). Risk factors such as ethnicity, smoking status, history of Helicobacter pylori infection, and family history of gastric cancer were evaluated by individual Cox proportional hazards regression. We then performed a second case-cohort study to evaluate the risk of gastric cancer based on the location and extent of GIM. The median duration of follow-up evaluation was 4.6 years (interquartile range, 3.0-6.7 y). RESULTS We identified 25 patients with GIM who developed gastric cancers. Seventeen cases of cancer were diagnosed at the same time as the diagnosis of GIM. Eight cases of cancer were identified within a median time period of 4.6 years after a diagnosis of GIM (interquartile range, 2-5.7 y). The overall incidence rate for the cohort was 1.72 (95% confidence interval, 0.74-3.39). Among the risk factors evaluated, only family history (hazard ratio, 3.8; 95% confidence interval, 1.5-9.7; P = .012) and extent of GIM (odds ratio, 9.4; 95% confidence interval, 1.8-50.4) increased the risk for gastric cancer. The incidence rate for gastric cancer in patients with a positive family history was 8.12 (95% confidence interval, 1.67-23.73). CONCLUSIONS In an analysis of patients with GIM listed in the Kaiser Permanente Southern California database, 2.7% were diagnosed with gastric cancer; almost 70% of cases of gastric cancer were detected at the time of GIM diagnosis. Family history and extensive metaplasia were associated with an increased risk of subsequent gastric cancer. Targeted surveillance of patients with these criteria could increase early detection of gastric cancer.
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Yeh JM, Hur C, Ward Z, Schrag D, Goldie SJ. Gastric adenocarcinoma screening and prevention in the era of new biomarker and endoscopic technologies: a cost-effectiveness analysis. Gut 2016; 65:563-74. [PMID: 25779597 PMCID: PMC4573370 DOI: 10.1136/gutjnl-2014-308588] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/21/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of noncardia gastric adenocarcinoma (NCGA) screening strategies based on new biomarker and endoscopic technologies. DESIGN Using an intestinal-type NCGA microsimulation model, we evaluated the following one-time screening strategies for US men: (1) serum pepsinogen to detect gastric atrophy (with endoscopic follow-up of positive screen results), (2) endoscopic screening to detect dysplasia and asymptomatic cancer (with endoscopic mucosal resection (EMR) treatment for detected lesions) and (3) Helicobacter pylori screening and treatment. Screening performance, treatment effectiveness, cancer and cost data were based on published literature and databases. Subgroups included current, former and never smokers. Outcomes included lifetime cancer risk and incremental cost-effectiveness ratios (ICERs), expressed as cost per quality-adjusted-life-year (QALY) gained. RESULTS Screening the general population at age 50 years reduced the lifetime intestinal-type NCGA risk (0.24%) by 26.4% with serum pepsinogen screening, 21.2% with endoscopy and EMR and 0.2% with H. pylori screening/treatment. Targeting current smokers reduced the lifetime risk (0.35%) by 30.8%, 25.5%, and 0.1%, respectively. For all subgroups, serum pepsinogen screening was more effective and more cost-effective than all other strategies, although its ICER varied from $76,000/QALY (current smokers) to $105,400/QALY (general population). Results were sensitive to H. pylori prevalence, screen age and serum pepsinogen test sensitivity. Probabilistic sensitivity analysis found that at a $100,000/QALY willingness-to-pay threshold, the probability that serum pepsinogen screening was preferred was 0.97 for current smokers. CONCLUSIONS Although not warranted for the general population, targeting high-risk smokers for serum pepsinogen screening may be a cost-effective strategy to reduce intestinal-type NCGA mortality.
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Affiliation(s)
- Jennifer M. Yeh
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | - Chin Hur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA, USA
| | - Zachary Ward
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | - Deborah Schrag
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Sue J. Goldie
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
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The Influence of Gastric Cancer Screening on the Stage at Diagnosis and Survival: A Meta-Analysis of Comparative Studies in the Far East. J Clin Gastroenterol 2016; 50:190-7. [PMID: 26844858 DOI: 10.1097/mcg.0000000000000466] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastric cancer is the fifth most common cancer and the second most common cause of cancer-related death worldwide. The aim of this review was to evaluate the effect of gastric cancer screening on the stage at diagnosis and survival from disease. A systematic review of the literature between January 1995 and December 2014 was performed. Studies that compared screened versus nonscreened populations for the diagnosis of gastric cancer and included the stage at diagnosis were analyzed. The QUADAS-2 and the ROBANS tools were used to assess the quality of the studies. A total of 11 studies from the Far East comprising 4039 participants in the screened and 6635 in the nonscreened groups were included. Screening was associated with a significant increase in the detection of early gastric cancer (EGC) [pooled odds ratio (POR)=3.90; 95% confidence interval (CI), 3.01-5.06; P<0.0001] and reduction in the incidence of advanced gastric cancer (POR=0.27; 95% CI, 0.20-0.35; P<0.0001). Furthermore, screening improved the 5-year survival significantly (hazard ratio=0.56; 95% CI, 0.48-0.66; P<0.0001). About 73% of the screened patients were found to have EGC compared with 43% of the nonscreened patients. About 8% of the screened patients were found to have advanced gastric cancer compared with 54% of the nonscreened patients. Screening for gastric cancer is useful in detecting asymptomatic patients with EGC in high-prevalence areas. This in turn increases the number of treatable cancers and improves the 5-year survival. There is a need for the development and the validation of alternative risk-stratification tools in low-incidence areas to allow for similar benefits.
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Liu KSH, Wong IOL, Leung WK. Helicobacter pylori associated gastric intestinal metaplasia: Treatment and surveillance. World J Gastroenterol 2016; 22:1311-1320. [PMID: 26811668 PMCID: PMC4716041 DOI: 10.3748/wjg.v22.i3.1311] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer (GC) is one of the leading causes of cancer related death in the world, particularly in East Asia. According to the Correa’s cancer cascade, non-cardia GC is usually developed through a series of mucosal changes from non-atrophic gastritis to atrophic gastritis (AG), intestinal metaplasia (IM), dysplasia and adenocarcinoma. Atrophic gastritis and IM are therefore generally considered to be pre-neoplastic gastric lesions. Helicobacter pylori (H. pylori) infection is an important initiating and promoting step of this gastric carcinogenesis cascade. Emerging long-term data showed that eradication of H. pylori reduced the risk of subsequent cancer development. It however remains confusing whether eradication of the bacterium in individuals with pre-neoplastic gastric lesions could regress these changes as well as in preventing cancer. Whilst H. pylori eradication could likely regress AG, the presence of IM may be a point of no return in this cascade. Hence, surveillance by endoscopy may be indicated in those with extensive IM or those with incomplete IM, particularly in populations with high GC risk. The optimal interval and the best tool of surveillance endoscopy remains to be determined in future studies.
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Boklage SH, Mangel AW, Ramamohan V, Mladsi D, Wang T. Impact of patient adherence on the cost-effectiveness of noninvasive tests for the initial diagnosis of Helicobacter pylori infection in the United States. Patient Prefer Adherence 2016; 10:45-55. [PMID: 26855566 PMCID: PMC4727507 DOI: 10.2147/ppa.s93320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Previous US-based economic models of noninvasive tests for diagnosis of Helicobacter pylori infection did not consider patient adherence or downstream costs of continuing infection. This analysis evaluated the long-term cost-effectiveness of the urea breath test (UBT), fecal antigen test (FAT), and serology for diagnosis of H. pylori infection after incorporating information regarding test adherence. MATERIALS AND METHODS A decision-analytic model incorporating adherence information evaluated the cost-effectiveness of the UBT, FAT, and serology for diagnosis of H. pylori infection. Positive test results led to first-line triple therapy; no further action was taken for nonadherence or negative results. Excess lifetime costs and reduced quality-adjusted life-years (QALYs) were estimated for patients with continuing H. pylori infection. RESULTS In the base-case scenario with estimated adherence rates of 86%, 48%, and 86% for the UBT, monoclonal FAT, and serology, respectively, corresponding expected total costs were US$424.99, $466.41, and $404.98/patient. Test costs were higher for the UBT, but were fully or partially offset by higher excess lifetime costs for the monoclonal FAT and serology. The QALYs gained/patient with the UBT vs monoclonal FAT and serology were 0.86 and 0.27, respectively. The UBT was dominant vs the monoclonal FAT, leading to lower costs and higher QALYs; the UBT was cost-effective vs serology (incremental cost/QALY gained $74). CONCLUSION Based on a comprehensive modeled analysis that included consideration of patient test adherence and long-term consequences resulting from continuing H. pylori infection, the UBT provided the greatest economic value among noninvasive tests for diagnosis of H. pylori infection, because of high patient adherence and excellent test performance.
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Affiliation(s)
| | | | | | | | - Tao Wang
- Otsuka America Pharmaceutical Inc, Princeton, NJ
- Correspondence: Tao Wang, Otsuka America Pharmaceutical Inc, 2440 Research Boulevard, Rockville, MD 20850, USA, Tel +1 240 683 3213, Fax +1 301 721 7213, Email
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Boklage SH, Mangel AW, Ramamohan V, Mladsi D, Wang T. Cost-effectiveness analysis of universal noninvasive testing for post-treatment confirmation of Helicobacter pylori eradication and the impact of patient adherence. Patient Prefer Adherence 2016; 10:1025-35. [PMID: 27354772 PMCID: PMC4908940 DOI: 10.2147/ppa.s102760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The treatment failure rate for Helicobacter pylori eradication therapy is ~20% due to poor patient compliance and increased antibiotic resistance. This analysis assessed the cost-effectiveness of universal post-treatment testing to confirm eradication of H. pylori infection in adults. METHODS Decision-analytic models evaluated the cost-effectiveness of universal post-treatment testing (urea breath test [UBT] or monoclonal fecal antigen test [mFAT]) vs no testing (Model 1), and UBT vs mFAT after adjusting for patient adherence to testing (Model 2) in adults who previously received first-line antimicrobial therapy. Patients testing positive received second-line quadruple therapy; no further action was taken for those testing negative or with no testing (Model 1) or for those nonadherent to testing (Model 2). In addition to testing costs, excess lifetime costs and reduced quality-adjusted life-years (QALYs) due to continuing H. pylori infection were considered in the model. RESULTS Expected total costs per patient were higher for post-treatment testing (UBT: US$325.76; mFAT: US$242.12) vs no testing (US$182.41) in Model 1 and for UBT (US$336.75) vs mFAT (US$326.24) in Model 2. Expected QALYs gained per patient were 0.71 and 0.72 for UBT and mFAT, respectively, vs no testing (Model 1), and the same was 0.37 for UBT vs mFAT (Model 2). The estimated incremental costs per QALY gained for post-treatment testing vs no testing were US$82.90-US$202.45 and, after adjusting for adherence, US$28.13 for UBT vs mFAT. CONCLUSION Universal post-treatment testing was found to be cost-effective for confirming eradication of H. pylori infection following first-line therapy. Better adherence to UBT relative to mFAT was the key to its cost-effectiveness.
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Affiliation(s)
| | | | | | | | - Tao Wang
- Otsuka America Pharmaceutical, Inc, Princeton, NJ, USA
- Correspondence: Tao Wang, Department of Medical Affairs, Otsuka America Pharmaceutical, Inc, 2440 Research Boulevard, Rockville, MD 20850, USA, Tel +1 240 683 3213, Fax +1 301 721 7213, Email
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Kim GH, Bang SJ, Ende AR, Hwang JH. Is screening and surveillance for early detection of gastric cancer needed in Korean Americans? Korean J Intern Med 2015; 30:747-58. [PMID: 26552450 PMCID: PMC4642004 DOI: 10.3904/kjim.2015.30.6.747] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 12/16/2022] Open
Abstract
The incidence rate of gastric cancer in Korean Americans is over five times higher than that in non-Hispanic whites, and is similar to the incidence of colorectal cancer in the overall United States population. In Korea, the National Cancer Screening Program recommends endoscopy or upper gastrointestinal series for people aged 40 years and older every 2 years. However, the benefit of gastric cancer screening in Korean Americans has not been evaluated. Based on epidemiologic studies, Korean Americans appear to have more similar gastric cancer risk factors to Koreans as opposed to Americans of European descent, though the risk of gastric cancer appears to decrease for subsequent generations. Therefore, in accordance with recent recommendations regarding screening for gastric cancer in Korea, endoscopic screening for gastric cancer in Korean Americans should be considered, especially in those with known atrophic gastritis/intestinal metaplasia or a family history of gastric cancer. In the future, additional studies will needed to assess whether a screening program for gastric cancer in Korean Americans will result in a survival benefit.
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Affiliation(s)
- Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sung Jo Bang
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Alexander R. Ende
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
- Correspondence to Joo Ha Hwang, M.D. Division of Gastroenterology, Department of Medicine, University of Washington 325 Ninth Avenue, Seattle, WA 98104, USA Tel: +1-206-744-7050 Fax: +1-206-744-8698 E-mail:
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Ro TH, Mathew MA, Misra S. Value of screening endoscopy in evaluation of esophageal, gastric and colon cancers. World J Gastroenterol 2015; 21:9693-9706. [PMID: 26361416 PMCID: PMC4562953 DOI: 10.3748/wjg.v21.i33.9693] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
Esophageal, gastric, and colorectal cancers are deadly diseases that continue to plague our world today. The value of screening endoscopy in evaluating these types of cancers is a critical area of discussion due to a potential reduction in morbidity and mortality. This article describes how to identify a good screening test and explains what are important criteria in the field of screening endoscopy. Furthermore, the current status and progress of screening endoscopy for esophageal, gastric, and colorectal cancer will be evaluated and discussed. Mass screening programs have not been implemented for esophageal and gastric carcinomas in those with average or low risk populations. However, studies of high-risk populations have found value and a cost-benefit in conducting screening endoscopy. Colorectal cancer, on the other hand, has had mass screening programs in place for many years due to the clear evidence of improved outcomes. As the role of endoscopy as a screening tool has continued to develop, newer technology and techniques have emerged to improve its utility. Many new image enhancement techniques and computer processing programs have shown promise and may have a significant role in the future of endoscopic screening. These developments are paving the way for improving the diagnostic and therapeutic capability of endoscopy in the field of gastroenterology.
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Zhao G, Xue M, Hu Y, Lai S, Chen S, Wang L. How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis. PLoS One 2015; 10:e0132699. [PMID: 26182344 PMCID: PMC4504521 DOI: 10.1371/journal.pone.0132699] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/18/2015] [Indexed: 02/07/2023] Open
Abstract
Gastric dysplasia is a well-known precancerous lesion. Though the diagnosis of gastric low grade dysplasia (LGD) is generally made from endoscopic forceps biopsy (EFB), the accuracy is doubtful after numerous EFB-proven gastric LGD were upgraded to gastric high grade dysplasia (HGD) or even carcinoma (CA) by further diagnostic test with the procedure of endoscopic resection (ER). We aimed to evaluate the upgraded diagnosis rate (UDR) and the risk factors by ER in EFB-proven gastric LGD lesions. Two investigators independently searched studies reporting the UDR by ER in EFB-proven gastric LGD lesions from databases and analyzed the overall UDR, HGD-UDR and CA-UDR. The pooled UDR by ER in EFB-proven gastric LGD lesions was 25.0% (95% CI, 20.2%-29.8%), made up of HGD-UDR and CA-UDR by rates of 16.7% (95% CI, 12.8%-20.6%) and 6.9% (95% CI, 4.2%-9.6%) respectively. Lesion size larger than 2 cm, surface with depression and nodularity under endoscopic examinations were the major risk factors associated with UDR. In conclusion, one quarter of EFB-proven gastric LGD lesions will be diagnosed as advanced lesions, including gastric HGD (16.7%) and gastric CA (6.9%) by ER. The diagnosis of those LGD lesions with an endoscopic diameter larger than 2cm, and depressed or nodular surface are more likely to be upgraded after ER.
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Affiliation(s)
- Guangfeng Zhao
- Department of Emergency, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Meng Xue
- Department of Gastroenterology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yingying Hu
- Department of Gastroenterology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Sanchuan Lai
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Gastroenterology, Sir Runrun Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shujie Chen
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Gastroenterology, Sir Runrun Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Liangjing Wang
- Department of Gastroenterology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou, Zhejiang, China
- * E-mail:
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Kim JW, Jang JY. Optimal management of biopsy-proven low-grade gastric dysplasia. World J Gastrointest Endosc 2015; 7:396-402. [PMID: 25901219 PMCID: PMC4400629 DOI: 10.4253/wjge.v7.i4.396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/22/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023] Open
Abstract
Gastric adenocarcinoma generally culminates via the inflammation-metaplasia-dysplasia-carcinoma sequence progression. The prevalence of gastric adenomas shows marked geographic variation. Recently, the rate of diagnosis of low-grade dysplasia (LGD) has increased due to increased use of upper endoscopy. Many investigators have reported that gastric high-grade dysplasia has high potential for malignancy and should be removed; however, the treatment for gastric LGD remains controversial. Although the risk of LGD progression to invasive carcinoma has been reported to be inconsistent, progression has been observed during follow-up. Additionally, the rate of upgraded diagnosis in biopsy-proven LGD is high. Therefore, endoscopic resection (ER) may be useful in the treatment and diagnosis of LGD, especially if lesions are found to have risk factors for upgraded histology after ER, such as large size, surface erythema or depressed morphology. Fatal complications in endoscopic submucosal dissection (ESD) are extremely low and its therapeutic and diagnostic outcomes are excellent. Therefore, ESD should be applied preferentially instead of endoscopic mucosal resection.
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Sonnenberg A. Modeling lengthy work-ups in gastrointestinal bleeding. Clin Gastroenterol Hepatol 2015; 13:433-9. [PMID: 24440338 DOI: 10.1016/j.cgh.2014.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 12/21/2022]
Abstract
Multiple procedures and medical devices are being used in a complex interplay to diagnose and treat gastrointestinal bleeding. The aim of the study was to develop a mathematical model that helps in estimating the average number of procedures to be expected in the general management of gastrointestinal bleeding. The modeling process serves as an example of how mathematical analysis in general can be used to answer unresolved clinical questions, lead to a better understanding of the underlying influences in a disease process, and provide a starting point for future clinical trials. The analysis uses a Markov chain to model the transition probabilities among consecutive interventions used to find and treat a bleeding site. The results show that starting a work-up of gastrointestinal bleeding with an esophagogastroduodenoscopy will lead on average to 2.69 procedures per patient. Of these expected procedures, 1.46 will be esophagogastroduodenoscopies, 0.69 colonoscopies, 0.25 video capsule endoscopies, 0.14 double-balloon enteroscopies, and 0.14 procedures from interventional radiology. Management chains initiated with a colonoscopy result in similar outcomes. Among 10,000 simulated individual patients, the number of procedures varies between 1 and 16 consecutive procedures, with 95% of all patients undergoing 6 procedures or less. The outcomes of the model suggest that the published success rates of endoscopic and radiographic procedures are overly optimistic. The results also point to the need to generate clinical data through future studies that more reliably account for treatment failures and the interchange among various complementary diagnostic modalities.
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Affiliation(s)
- Amnon Sonnenberg
- Portland VA Medical Center and Oregon Health and Science University, Portland, Oregon.
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Areia M, Dinis-Ribeiro M, Rocha Gonçalves F. Cost-utility analysis of endoscopic surveillance of patients with gastric premalignant conditions. Helicobacter 2014; 19:425-36. [PMID: 25164596 DOI: 10.1111/hel.12150] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Progression of extensive gastric premalignant conditions to cancer might warrant surveillance programms. Recent guidelines suggest a 3-yearly endoscopic follow-up for these patients. Our aim was to determine the cost utility of endoscopic surveillance of patients with extensive gastric premalignant conditions such as extensive atrophy or intestinal metaplasia. MATERIALS AND METHODS A cost-utility economic analysis was performed from a societal perspective in Portugal using a Markov model to compare two strategies: surveillance versus no surveillance. Clinical data were collected from a systematic review of the literature, costs from published national data, and community utilities derived from a population study by the EuroQol questionnaire in terms of quality-adjusted life years (QALY). Population started at age 50, for a time horizon of 25 years and an annual discount rate of 3% was used for cost and effectiveness. Primary outcome was the incremental cost-effectiveness ratio (ICER) of a 3-yearly endoscopic surveillance versus no surveillance for a base case scenario and in deterministic and probabilistic sensitivity analysis. Secondary outcomes were ICER of 5- and 10-yearly endoscopic surveillance versus no surveillance. RESULTS Endoscopic surveillance every 3 years provided an ICER of € 18,336, below the adopted threshold of € 36,575 which corresponds to the proposed guideline limit of USD 50,000 and this strategy dominated surveillance every 5 or 10 years. Utilities for endoscopic treatment were relevant in deterministic analysis, while probabilistic analysis showed that in 78% of cases the model was cost-effective. CONCLUSIONS Endoscopic surveillance every 3 years of patients with premalignant conditions is cost-effective.
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Affiliation(s)
- Miguel Areia
- CINTESIS - Center for Research in Health Technologies and Information Systems, Faculty of Medicine, Porto University, Porto, Portugal; Gastroenterology Department, Portuguese Oncology Institute - Coimbra, Coimbra, Portugal
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Choi KS, Suh M. Screening for gastric cancer: the usefulness of endoscopy. Clin Endosc 2014; 47:490-6. [PMID: 25505713 PMCID: PMC4260095 DOI: 10.5946/ce.2014.47.6.490] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 07/18/2014] [Accepted: 07/23/2014] [Indexed: 12/12/2022] Open
Abstract
Gastric cancer screening is common in countries with high prevalence rates of gastric cancer. However, data supporting the effectiveness of gastric cancer screening are lacking. Thus, the aim of this review was to examine the current evidence on gastric cancer screening. Herein, we reviewed radiographic and endoscopic tests as methods of gastric cancer screening. Previous cohort studies and case-control studies have demonstrated reduced gastric cancer mortality in study populations that had undergone gastric cancer screening with radiographic tests. Recently, a case-control study in Japan reported a 30% reduction in gastric cancer mortality when screening was undertaken via endoscopy. Also, endoscopic screening for gastric cancer exhibited higher sensitivity and specificity than radiographic screening. Moreover, most cost-effectiveness analyses on the best strategy for detecting early gastric cancer have generally concluded that endoscopy is more cost-effective than radiographic testing. Although data on the impact of endoscopy screening programs on gastric cancer mortality are limited, recent study results suggest that gastric cancer screening by endoscopy in average-risk populations performs better than radiography screening. Further evaluation of the impact of these screening methods should take into account cost and any associated reduction in gastric cancer mortality.
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Affiliation(s)
- Kui Son Choi
- Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Mina Suh
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
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Oh S, Kim N, Yoon H, Choi YJ, Lee JY, Park KJ, Kim HJ, Kang KK, Oh DH, Seo AY, Lee JW, Shin CM, Park YS, Oh JC, Lee DH, Jung HC. Risk factors of atrophic gastritis and intestinal metaplasia in first-degree relatives of gastric cancer patients compared with age-sex matched controls. J Cancer Prev 2014; 18:149-60. [PMID: 25337541 PMCID: PMC4189453 DOI: 10.15430/jcp.2013.18.2.149] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 06/19/2013] [Accepted: 06/20/2013] [Indexed: 01/14/2023] Open
Abstract
Background: To identify whether first-degree relatives (FDRs) of gastric cancer (GC) patients have increased risk for atrophic gastritis (AG) and intestinal metaplasia (IM) in relation to other risk factors of GC. Methods: The study cohort consisted of 224 pairs of age-sex matched controls and FDRs. AG and IM in the gastric mucosa were scored histologically using the updated Sydney classification. Risk of having AG and IM was studied by comparing FDRs to controls. Impacts of age, H. pylori infection, smoking, dietary and socioeconomic factors on the presence of AG and IM were studied. Results: In multivariate regression analysis, FDRs had adjusted OR of 2.69 (95% CI 1.06–6.80, P=0.037) for antral IM in male population. Adjusted OR for antral AG and IM were 9.28 (95% CI 4.73–18.18, P<0.001) and 7.81 (95% CI 3.72–16.40, P<0.001) for the H. pylori infected subjects in total population. Getting old by 5 years increased the ORs of having AG and IM by approximately 1.25 fold (P<0.001). Spicy food increased the OR of antral IM by 2.28 fold (95% CI 1.36–3.84, P=0.002). Conclusions: Family history of GC was an independent risk factor for antral IM in male in our study, which could be one reason for the increase of gastric cancer in the family member of gastric cancer. It could be an evidence for the necessity of frequent endoscopy in the presence of family history of GC compared to general population in male.
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Affiliation(s)
- Sooyeon Oh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Nayoung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul ; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yun Jin Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Yup Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyoung Jun Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee Jin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyu Keun Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Hyun Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - A Young Seo
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Woo Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | - Dong Ho Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul ; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
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Compare D, Rocco A, Nardone G. Screening for and surveillance of gastric cancer. World J Gastroenterol 2014; 20:13681-91. [PMID: 25320506 PMCID: PMC4194552 DOI: 10.3748/wjg.v20.i38.13681] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/06/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Although the prevalence of gastric cancer (GC) progressively decreased during the last decades, due to improved dietary habit, introduction of food refrigeration and recovered socio-economic level, it still accounts for 10% of the total cancer-related deaths. The best strategy to reduce the mortality for GC is to schedule appropriate screening and surveillance programs, that rises many relevant concerns taking into account its worldwide variability, natural history, diagnostic tools, therapeutic strategies, and cost-effectiveness. Intestinal-type, the most frequent GC histotype, develops through a multistep process triggered by Helicobacter pylori (H. pylori) and progressing from gastritis to atrophy, intestinal metaplasia (IM), and dysplasia. However, the majority of patients infected with H. pylori and carrying premalignant lesions do not develop GC. Therefore, it remains unclear who should be screened, when the screening should be started and how the screening should be performed. It seems reasonable that screening programs should target the general population in eastern countries, at high prevalence of GC and the high-risk subjects in western countries, at low prevalence of GC. As far as concern surveillance, currently, we are lacking of standardized international recommendations and many features have to be defined regarding the optimal diagnostic approach, the patients at higher risk, the best timing and the cost-effectiveness. Anyway, patients with corpus atrophic gastritis, extensive incomplete IM and dysplasia should enter a surveillance program. At present, screening and surveillance programs need further studies to draw worldwide reliable recommendations and evaluate the impact on mortality for GC.
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Li J, Wang JC, Ma B, Gao W, Chen P, Sun R, Yang KH. Shenqi Fuzheng Injection for advanced gastric cancer: a systematic review of randomized controlled trials. Chin J Integr Med 2014; 21:71-9. [PMID: 25246138 DOI: 10.1007/s11655-014-1768-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of Shenqi Fuzheng Injection (, SFI) combined with chemotherapy for advanced gastric cancer. METHODS Randomized controlled trials (RCTs) from 10 databases were searched for this meta-analysis till December 31, 2012 without language restriction. Grey literature and potential unpublished literature was also searched. The key search terms were "chemotherapy", "Shenqi Fuzheng Injection" and "advanced gastric cancer". Criteria were built to select these clinical trials, in which SFI combined with chemotherapy was compared with chemotherapy alone for advanced gastric cancer. The methodological quality of each RCT was assessed using the Cochrane risk of bias tool. RevMan 5.1 software was applied for data analyses. RESULTS Thirteen RCTs involving 860 patients met the selection criteria (all articles were from Chinese databases). The meta-analysis showed positive results for the use of SFI combined with chemotherapy according to quality of life in terms of the scores when compared with chemotherapy alone. Positive results were also obtained for the combination treatment, in terms of complete remission and partial remission efficacy rate, body weight and decreased adverse events including nausea and vomiting at grade 3-4, oral mucositis at grade 1-2, leucopenia at grade 3-4, and myelo-suppression at grade 1-2. CONCLUSIONS This systematic review found encouraging albeit limited evidence for SFI combined with chemotherapy. However, to obtain stronger evidence without the drawbacks of trial design and the quality of studies, we recommend comparative effectiveness researches to test the effectiveness of combination treatment.
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Affiliation(s)
- Jiang Li
- Evidence-Based Medicine Center, College of Basic Medicine, Lanzhou University, Lanzhou, 730000, China
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39
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Is lesion size an independent indication for endoscopic resection of biopsy-proven low-grade gastric dysplasia? Dig Dis Sci 2014; 59:428-35. [PMID: 23912249 DOI: 10.1007/s10620-013-2805-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIM The standard treatment for patients with gastric low-grade dysplasia (LGD) remains controversial, even though diagnosis of LGD is increasingly common as esophagogastrodeuodenoscopy becomes more available. The aim of this study was to identify a lesion size cut-off as an indication for endoscopic resection (ER) for patients with LGD. RESULTS We retrospectively reviewed 285 lesions initially diagnosed as LGD by endoscopic forceps biopsies (EFB) from 2007 to 2010 in Kyung Hee University Hospital, Seoul, Korea. All patients underwent ER. A total of 285 lesions from 257 patients were assessed. After ER, 239 LGD (83.9 %) showed histological concordance and the remaining 46 (16.1 %) cases revealed an upgraded histology [22 high-grade dysplasia (7.7 %), and 24 differentiated adenocarcinoma (8.4 %)]. Univariate analyses demonstrated that lesion size, erythema, depression, and erosion were significant predictors of upgraded LGD (P < 0.001). Multivariate analysis showed that a lesion size ≥2 cm, erythema, and a depressed-type lesion were independent predictors of upgraded histology (P = 0.014, odds ratio 3.27, 95 % confidence interval 1.28-8.39). CONCLUSIONS Our data suggest that a substantial number of LGD diagnoses based on EFB were not representative of the entire lesion. We recommend ER if gastric LGD has at least one of the following risk factors: surface erythema and a depressed type regardless of size, or ≥2 cm size regardless of abnormal surface configuration.
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40
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Zhou HJ, Dan YY, Naidoo N, Li SC, Yeoh KG. A cost-effectiveness analysis evaluating endoscopic surveillance for gastric cancer for populations with low to intermediate risk. PLoS One 2013; 8:e83959. [PMID: 24386314 PMCID: PMC3873968 DOI: 10.1371/journal.pone.0083959] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/10/2013] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) surveillance based on oesophagogastroduodenoscopy (OGD) appears to be a promising strategy for GC prevention. By evaluating the cost-effectiveness of endoscopic surveillance in Singaporean Chinese, this study aimed to inform the implementation of such a program in a population with a low to intermediate GC risk. METHODS USING A REFERENCE STRATEGY OF NO OGD INTERVENTION, WE EVALUATED FOUR STRATEGIES: 2-yearly OGD surveillance, annual OGD surveillance, 2-yearly OGD screening and 2-yearly screening plus annual surveillance in Singaporean Chinese aged 50-69 years. From a perspective of the healthcare system, Markov models were built to simulate the life experience of the target population. The models projected discounted lifetime costs ($), quality adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) indicating the cost-effectiveness of each strategy against a Singapore willingness-to-pay of $46,200/QALY. Deterministic and probabilistic sensitivity analyses were used to identify the influential variables and their associated thresholds, and to quantify the influence of parameter uncertainties respectively. RESULTS With an ICER of $44,098/QALY, the annual OGD surveillance was the optimal strategy while the 2-yearly surveillance was the most cost-effective strategy (ICER = $25,949/QALY). The screening-based strategies were either extendedly dominated or cost-ineffective. The cost-effectiveness heterogeneity of the four strategies was observed across age-gender subgroups. Eight influential parameters were identified each with their specific thresholds to define the choice of optimal strategy. Accounting for the model uncertainties, the probability that the annual surveillance is the optimal strategy in Singapore was 44.5%. CONCLUSION Endoscopic surveillance is potentially cost-effective in the prevention of GC for populations at low to intermediate risk. Regarding program implementation, a detailed analysis of influential factors and their associated thresholds is necessary. Multiple strategies should be considered in order to recommend the right strategy for the right population.
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Affiliation(s)
- Hui Jun Zhou
- School of Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yock Young Dan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nasheen Naidoo
- School of Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shu Chuen Li
- Discipline of Pharmacy & Experimental Pharmacology, School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
| | - Khay Guan Yeoh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- * E-mail:
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Abstract
Helicobacter pylori-associated gastric cancer is a major cause of morbidity and mortality worldwide, and is predicted to become even more common in developing countries as the population ages. Since gastric cancer develops slowly over years to decades, and typically progresses though a series of well-defined histologic stages, cancer biomarkers have potential to identify asymptomatic individuals in whom surgery might be curative, or even those for whom antibiotics to eradicate H. pylori could prevent neoplastic transformation. Here we describe some of the challenges of biomarker discovery, summarize current approaches to biomarkers of gastric cancer, and explore some recent novel strategies.
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Affiliation(s)
- Cara L Cooke
- Departments of Medicine and Microbiology & Immunology; University of California; Davis School of Medicine; Davis, CA USA,Center for Comparative Medicine; University of California; Davis School of Medicine; Davis, CA USA
| | - Javier Torres
- Infectious Diseases Research Unit; Instituto Mexicano del Seguro Social; Mexico City, Mexico
| | - Jay V Solnick
- Departments of Medicine and Microbiology & Immunology; University of California; Davis School of Medicine; Davis, CA USA,Center for Comparative Medicine; University of California; Davis School of Medicine; Davis, CA USA,California National Primate Research Center; University of California; Davis School of Medicine; Davis, CA USA,Correspondence to: Jay V Solnick,
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42
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Areia M, Carvalho R, Cadime AT, Rocha Gonçalves F, Dinis-Ribeiro M. Screening for gastric cancer and surveillance of premalignant lesions: a systematic review of cost-effectiveness studies. Helicobacter 2013; 18:325-37. [PMID: 23566268 DOI: 10.1111/hel.12050] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cost-effectiveness studies are highly dependent on the models, settings, and variables used and should be based on systematic reviews. We systematically reviewed cost-effectiveness studies that address screening for gastric cancer and/or surveillance of precancerous conditions and lesions. MATERIALS AND METHODS A systematic review of cost-effectiveness studies was performed by conducting a sensitive search in seven databases (PubMed, Scopus, Web of Science, Current Contents Connect, Centre for Reviews and Dissemination, Academic Search Complete, and CINAHL Plus), independently evaluated by two investigators. Articles were evaluated for type of study, perspective, model, intervention, incremental cost-effectiveness ratio, clinical or cost variables, and quality, according to published guidelines. RESULTS From 2395 abstracts, 23 articles were included: 19 concerning population screening and 4 on following up premalignant lesions. Studies on Helicobacter pylori screening concluded that serology was cost-effective, depending on cancer incidence and endoscopy cost (incremental cost-effectiveness ratio: 6264-25,881), and eradication after endoscopic resection was also cost-effective (dominant) based on one study. Studies on imaging screening concluded that endoscopy was more cost-effective than no screening (incremental cost-effectiveness ratio: 3376-26,836). Articles on follow-up of premalignant lesions reported conflicting results (incremental cost-effectiveness ratio: 1868-72,519 for intestinal metaplasia; 18,600-39,800 for dysplasia). Quality assessment revealed a unanimous lack of a detailed systematic review and fulfillment of a median number of 23 items (20-26) of 35 possible ones. CONCLUSIONS The available evidence shows that Helicobacter pylori serology or endoscopic population screening is cost-effective, while endoscopic surveillance of premalignant gastric lesions presents conflicting results. Better implementation of published guidelines and accomplishment of systematic detailed reviews are needed.
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Affiliation(s)
- Miguel Areia
- CINTESIS - Center for Research in Health Technologies and Information Systems, Faculty of Medicine, Porto University, Porto, Portugal.
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Tänzer M, Liebl M, Quante M. Molecular biomarkers in esophageal, gastric, and colorectal adenocarcinoma. Pharmacol Ther 2013; 140:133-47. [PMID: 23791941 DOI: 10.1016/j.pharmthera.2013.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/06/2013] [Indexed: 02/06/2023]
Abstract
Cancers of the esophagus, stomach and colon contribute to a major health burden worldwide and over 20% of all cancer deaths. Biomarkers that should indicate pathogenic process and are measureable in an objective manner for these tumors are rare and not established in the clinical setting. In general biomarkers can be very useful for cancer management as they can improve clinical decision-making regarding diagnosis, surveillance, and therapy. Biomarkers can be different types of molecular entities (such as DNA, RNA or proteins), which can be detected, in different tissues or body fluids. However, more important is the type of biomarker itself, which allows diagnostic, prognostic or predictive analyses for different clinical problems. This review aims to systematically summarize the recent findings of genetic and epigenetic markers for gastrointestinal tumors within the last decade. While many biomarkers seem to be very promising, especially if used as panels, further development is urgently needed to address practical considerations of biomarkers in cancer treatment.
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Affiliation(s)
- Marc Tänzer
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
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Zullo A, Hassan C, Repici A, Annibale B. Intestinal metaplasia surveillance: Searching for the road-map. World J Gastroenterol 2013; 19:1523-1526. [PMID: 23539645 PMCID: PMC3602469 DOI: 10.3748/wjg.v19.i10.1523] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 02/02/2013] [Accepted: 02/08/2013] [Indexed: 02/06/2023] Open
Abstract
Atrophic gastritis and intestinal metaplasia (IM) of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, a pragmatic management has been performed in Western countries in patients with these premalignant conditions. Recently, formal European guidelines have been delivered on this topic. Basically, it has been recommended that patients with extensive atrophic gastritis (AG) and/or extensive IM should be offered endoscopic surveillance every 3 years. On the contrary, no scheduled endoscopic/histological control has been advised for those patients with precancerous conditions confined to the antrum. In this commentary, we highlighted some potential weaknesses in the management formally recommended by the new guidelines. In detail, we discussed that AG and IM patients do not share the same gastric cancer risk, at least in Western countries, deserving a different approach. Some factors significantly associated with gastric cancer risk, such as IM type, first-degree family history of gastric cancer, and smoking habit have not been considered in tailoring the endoscopic follow-up. Finally, some data would suggest that a 3-year follow-up in patients with extensive gastric precancerous conditions could result in an inadequate secondary prevention.
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Chang HS, Park EC, Chung W, Nam CM, Choi KS, Cho E, Cho WH. Comparing endoscopy and upper gastrointestinal X-ray for gastric cancer screening in South Korea: a cost-utility analysis. Asian Pac J Cancer Prev 2013; 13:2721-8. [PMID: 22938448 DOI: 10.7314/apjcp.2012.13.6.2721] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited data evaluating the cost-effectiveness of gastric cancer screening using endoscopy or upper gastrointestinal x-ray in the general population. OBJECTIVE To evaluate the cost- effectiveness of population-based screening for gastric cancer in South Korea by decision analysis. METHODS A time-dependent Markov model for gastric cancer was constructed for healthy adults 30 years of age and older, and a deterministic sensitivity analysis was performed. Cost-utility analysis with multiple strategies was conducted to compare the costs and effects of 13 different screening alternatives with respect to the following eligibility criteria: age at the beginning of screening, screening interval, and screening method. The main outcome measurement was the incremental cost-effectiveness ratio. RESULTS The results revealed that annual endoscopic screening from ages 50-80 was the most cost-effective for the male population. In the females, biennial endoscopy screening from ages 50-80 was calculated as the most cost-effective strategy among the 12 screening alternatives. The most cost-effective screening strategy may be adjustable according to the screening costs and the distribution of cancer stage at screening. The limitation was that effectiveness data were obtained from published sources. CONCLUSIONS Using the threshold of $19,162 per quality-adjusted life year on the basis of the Korean gross domestic product (2008), as suggested by the World Health Organization, endoscopic gastric cancer screening starting at the age of 50 years was highly cost-effective in the Korean population. The national recommendation for gastric cancer screening should consider the starting age of screening, the screening interval, and the screening modality.
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Affiliation(s)
- Hoo-Sun Chang
- Department of Preventive Medicine, Yonsei University, Seoul, Korea
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46
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CONTEDUCA VINCENZA, SANSONNO DOMENICO, LAULETTA GIANFRANCO, RUSSI SABINO, INGRAVALLO GIUSEPPE, DAMMACCO FRANCO. H. pylori infection and gastric cancer: State of the art. Int J Oncol 2012; 42:5-18. [DOI: 10.3892/ijo.2012.1701] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/29/2012] [Indexed: 01/02/2023] Open
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Abstract
PURPOSE OF REVIEW The review focuses on the latest endoscopic techniques that are emerging in the management of early gastric cancer. RECENT FINDINGS Improved sensitivity and specificity in the diagnosis of early gastric cancers has been demonstrated in a number of studies by narrow band imaging (92.7 and 94.5%), confocal laser endomicroscopy (90.2 and 98.5%), and magnification chromoendoscopy (88.6 and 93.2%), respectively. In early gastric cancer, endoscopic submucosal dissection (ESD) has been shown to be superior to endoscopic mucosal resection (EMR) with curative resection rate at 79.5% for ESD vs. 59% for EMR, and a lower local recurrence rate at 0.82% for ESD vs. 5.03% for EMR. SUMMARY Advanced diagnostic and therapeutic endoscopic techniques are changing the paradigm of care in patients with early gastric cancers.
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48
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Zullo A, Hassan C, Romiti A, Giusto M, Guerriero C, Lorenzetti R, Campo SM, Tomao S. Follow-up of intestinal metaplasia in the stomach: When, how and why. World J Gastrointest Oncol 2012; 4:30-6. [PMID: 22468181 PMCID: PMC3312926 DOI: 10.4251/wjgo.v4.i3.30] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 10/14/2011] [Accepted: 10/21/2011] [Indexed: 02/05/2023] Open
Abstract
Gastric cancer remains the second most frequent cause of cancer-related mortality in the world. Screening programs in some Asian countries are impractical in the majority of other countries worldwide. Therefore, follow-up of precancerous lesions is advisable for secondary gastric cancer prevention. Intestinal metaplasia (IM) is recognized as a precancerous lesion for gastric cancer, increasing the risk by 6-fold. IM is highly prevalent in the general population, being detected in nearly 1 of every 4 patients undergoing upper endoscopy. The IM prevalence rate is significantly higher in patients with Helicobacter pylori (H. pylori) infection, in first-degree relatives of gastric cancer patients, in smokers and it increases with patient age. IM is the “breaking point” in the gastric carcinogenesis cascade and does not appear to regress following H. pylori eradication, although the cure of infection may slow its progression. Gastric cancer risk is higher in patients with incomplete-type IM, in those with both antral and gastric body involvement, and the risk significantly increases with IM extension over 20% of the gastric mucosa. Scheduled endoscopic control could be cost-effective in IM patients, depending on the yearly incidence of gastric cancer in IM patients, the stage of gastric cancer at diagnosis discovered at surveillance, and the cost of endoscopy. As a pragmatic behavior, yearly endoscopic control would appear justified in all IM patients with at least one of these conditions: (1) IM extension > 20%; (2) the presence of incomplete type IM; (3) first-degree relative of gastric cancer patients; and (4) smokers. In the remaining IM patients, a less intensive (2-3 years) could be proposed.
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Affiliation(s)
- Angelo Zullo
- Angelo Zullo, Cesare Hassan, Michela Giusto, Carmine Guerriero, Roberto Lorenzetti, Salvatore MA Campo, Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, 00153 Rome, Italy
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Dinis-Ribeiro M, Areia M, de Vries AC, Marcos-Pinto R, Monteiro-Soares M, O'Connor A, Pereira C, Pimentel-Nunes P, Correia R, Ensari A, Dumonceau JM, Machado JC, Macedo G, Malfertheiner P, Matysiak-Budnik T, Megraud F, Miki K, O'Morain C, Peek RM, Ponchon T, Ristimaki A, Rembacken B, Carneiro F, Kuipers EJ. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012; 44:74-94. [PMID: 22198778 PMCID: PMC3367502 DOI: 10.1055/s-0031-1291491] [Citation(s) in RCA: 451] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.
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Affiliation(s)
- M. Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Portugal, Centre for Research in Health Technologies and Information Systems (CINTESIS), Medical Faculty, Porto, Portugal
| | - M. Areia
- Department of Gastroenterology, Portuguese Oncology Institute of Coimbra, Portugal, Centre for Research in Health Technologies and Information Systems (CINTESIS), Medical Faculty, Porto, Portugal
| | - A. C. de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - R. Marcos-Pinto
- Department of Gastroenterology, Centro Hospitalar do Porto, Portugal, Institute of Biomedical Sciences, University of Porto (ICBAS/UP), Porto, Portugal
| | - M. Monteiro-Soares
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Medical Faculty, Porto, Portugal
| | - A. O'Connor
- AMNCH/TCD, Adelaide and Meath Hospital/Trinity College, Gastroenterology Department, Dublin, Ireland
| | - C. Pereira
- Molecular Oncology Research Group, Portuguese Oncology Institute of Porto, Portugal
| | - P. Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Portugal
| | - R. Correia
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Medical Faculty, Porto, Portugal
| | - A. Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - J. M. Dumonceau
- Département de Gastroénterologie et d'Hépatopancréatologie, H.U.G. Hôpital Cantonal, Geneve, Switzerland
| | - J. C. Machado
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
| | - G. Macedo
- Department of Gastroenterology, Centro Hospitalar S. João/Medical Faculty, Porto, Portugal
| | - P. Malfertheiner
- Klinik der Gasroenterologie, Hepatologie und Infektologie, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
| | - T. Matysiak-Budnik
- Service d'Hépato-Gastroentérologie, Hôtel Dieu, CHU de Nantes, Nantes, France
| | - F. Megraud
- Inserm U853 & Université Bordeaux, Laboratoire de Bacteriologie, Bordeaux, France
| | - K. Miki
- Japan Research Foundation of Prediction, Diagnosis and Therapy for Gastric Cancer (JRF PDT GC), Tokyo, Japan
| | - C. O'Morain
- AMNCH/TCD, Adelaide and Meath Hospital/Trinity College, Gastroenterology Department, Dublin, Ireland
| | - R. M. Peek
- Division of Gastroenterology, Vanderbilt University School of Medicine, Nashville, USA
| | - T. Ponchon
- Hôpital Edouard Herriot, Department of Digestive Diseases, Lyon, France
| | - A. Ristimaki
- Department of Pathology, HUSLAB and Haartman Institute, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland., Genome-Scale Biology, Research Program Unit, University of Helsinki, Helsinki, Finland
| | - B. Rembacken
- Centre for Digestive Diseases, The General Infirmary at Leeds, Leeds, United Kingdom
| | - F. Carneiro
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal, Department of Pathology, Medical Faculty/Centro Hospitalar S. João, Porto, Portugal
| | - E. J. Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
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Dinis-Ribeiro M, Areia M, de Vries AC, Marcos-Pinto R, Monteiro-Soares M, O’Connor A, Pereira C, Pimentel-Nunes P, Correia R, Ensari A, Dumonceau JM, Machado JC, Macedo G, Malfertheiner P, Matysiak-Budnik T, Megraud F, Miki K, O’Morain C, Peek RM, Ponchon T, Ristimaki A, Rembacken B, Carneiro F, Kuipers EJ. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Virchows Arch 2011; 460:19-46. [DOI: 10.1007/s00428-011-1177-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 10/13/2011] [Accepted: 10/19/2011] [Indexed: 12/16/2022]
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