Endoscopy for upper GI cancer screening in the general population: a cost-utility analysis

A Systematic Review of Cost-Effectiveness Studies on Gastric Cancer Screening

Gastric cancer (GC) poses notable economic and health burdens in settings where the incidence of disease is prevalent. Some countries have established early screening and treatment programs to address these challenges. The objectives of this systematic review were to summarize the cost-effectiveness of gastric cancer screening presented in the literature and to identify the critical factors that influence the cost-effectiveness of screening. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Economic evaluation studies of gastric cancer screening were reviewed from SCOPUS and PubMed. The Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) was used to assess the quality of reporting presented in the selected articles. Only primary economic evaluation studies addressing the cost-effectiveness, cost-utility, and cost-benefit of gastric cancer screening were selected. Two reviewers scrutinized the selected articles (title, abstract, and full text) to determine suitability for the systematic review based on inclusion and exclusion criteria. Authors' consensus was relied on where disagreements arose. The main outcome measures of concern in the systematic review were cost, effectiveness (as measured by either quality-adjusted life years (QALY) or life-years saved (LYS)), and incremental cost-effectiveness ratio (ICER) of screening versus either no screening or an alternative screening method. Thirty-one studies were selected for the final review. These studies investigated the cost-effectiveness of GC screening based on either primary, secondary, or a combination of primary and secondary interventions. The main primary intervention was Helicobacter pylori (Hp) screening with eradication, while the main secondary intervention was endoscopic screening. Cost-effectiveness was evaluated against no screening or screening using an alternative method in both observational and model-based studies. Screening was mainly cost-effective in Asian countries or their diasporas where the prevalence of GC was high. GC screening was generally not cost-effective among Western countries. GC screening can be cost-effective, but cost-effectiveness is dependent on context-specific factors, including geographical location, the prevalence of GC in the local population, and the screening tool adopted. However, there is benefit in targeting high-risk population groups in Asian countries and their diaspora for GC screening.

Genome-Scale Multimodal Analysis of Cell-Free DNA Whole-Methylome Sequencing for Noninvasive Esophageal Cancer Detection

PURPOSE

Simultaneous profiling of cell-free DNA (cfDNA) methylation and fragmentation features to improve the performance of cfDNA-based cancer detection is technically challenging. We developed a method to comprehensively analyze multimodal cfDNA genomic features for more sensitive esophageal squamous cell carcinoma (ESCC) detection.

MATERIALS AND METHODS

Enzymatic conversion-mediated whole-methylome sequencing was applied to plasma cfDNA samples extracted from 168 patients with ESCC and 251 noncancer controls. ESCC characteristic cfDNA methylation, fragmentation, and copy number signatures were analyzed both across the genome and at accessible cis-regulatory DNA elements. To distinguish ESCC from noncancer samples, a first-layer classifier was developed for each feature type, the prediction results of which were incorporated to construct the second-layer ensemble model.

RESULTS

ESCC plasma genome displayed global hypomethylation, altered fragmentation size, and chromosomal copy number alteration. Methylation and fragmentation changes at cancer tissue-specific accessible cis-regulatory DNA elements were also observed in ESCC plasma. By integrating multimodal genomic features for ESCC detection, the ensemble model showed improved performance over individual modalities. In the training cohort with a specificity of 99.2%, the detection sensitivity was 81.0% for all stages and 70.0% for stage 0-II. Consistent performance was observed in the test cohort with a specificity of 98.4%, an all-stage sensitivity of 79.8%, and a stage 0-II sensitivity of 69.0%. The performance of the classifier was associated with the disease stage, irrespective of clinical covariates.

CONCLUSION

This study comprehensively profiles the epigenomic landscape of ESCC plasma and provides a novel noninvasive and sensitive ESCC detection approach with genome-scale multimodal analysis.

Racial disparities of gastric cancer in the USA: an overview of epidemiology, global screening guidelines, and targeted screening in a heterogeneous population

Gastric cancer is the fifth most common cancer diagnosis and fourth leading cause of cancer-related death globally. The incidence of gastric cancer in the USA shows significant racial and ethnic disparities with gastric cancer incidence in Korean Americans being over five times higher than in non-Hispanic whites. Since gastric cancer is not common in the USA, there are no current screening guidelines. In countries with higher incidences of gastric cancer, screening guidelines have been implemented for early detection and intervention and this has been associated with a reduction in mortality. Immigrants from high incidence countries develop gastric cancer at lower rates once outside of their country of origin, but continue to be at higher risk for developing gastric cancer. This risk does seem to decrease with subsequent generations. With increasing availability of endoscopy, initiating gastric cancer screening guidelines for high-risk groups can have the potential to improve survival by diagnosing and treating gastric cancer at an earlier stage. This article aims to provide context to gastric cancer epidemiology globally, review risk factors for developing gastric cancer, highlight racial and ethnic disparities in gastric cancer burden in the USA, examine current guidelines that exist in high incidence countries, and suggest future studies examining the efficacy of additional screening in high-risk populations to reduce gastric cancer mortality and disparate burden on ethnic minorities in the USA.

Clinical and molecular characteristics of early-onset vs average-onset esophagogastric cancer

BACKGROUND

The rate of esophagogastric cancer is rising among individuals under 50 years of age. It remains unknown whether early-onset esophagogastric cancer represents a unique entity. This study investigated the clinical and molecular characteristics of early-onset and average-onset esophagogastric cancer .

METHODS

We reviewed the Memorial Sloan Kettering Cancer Center gastric, esophageal, and gastroesophageal junction cancer database. Associations between baseline characteristics and tumor and germline molecular alterations were compared between those with early-onset and average-onset esophagogastric cancer using Fisher exact tests and the Benjamini-Hochberg method for multiple-hypothesis correction.

RESULTS

We included 1123 patients with early-onset esophagogastric cancer (n = 219; median age = 43 years [range = 18-49 years]) and average-onset esophagogastric cancer (n = 904; median age = 67 years [range = 50-94 years]) treated between 2005 and 2018. The early-onset group had more women (39% vs 28%, P = .002). Patients with early-onset esophagogastric cancer were more likely to have a gastric primary site (64% vs 44%, P < .0001). The signet ring cell and/or diffuse type was 3 times more common in the early-onset esophagogastric cancer group (31% vs 9%, P < .0001). Early-onsite tumors were more frequently genomically stable (31% vs 18%, P = .0002) and unlikely to be microsatellite instability high (2% vs 7%, P = .003). After restricting to adenocarcinoma and signet ring cell and/or diffuse type carcinomas, we observed no difference in stage (P = .40) or overall survival from stage IV diagnosis (median = 22.7 vs 22.1 months, P = .78).

CONCLUSIONS

Our study supported a preponderance of gastric primary disease sites, signet ring histology, and genomically stable molecular subtypes in early-onset esophagogastric cancer. Our findings highlight the need for further research to define the underlying pathogenesis and strategies for early detection and prevention.

Evolving Concepts in Helicobacter pylori Management

Helicobacter pylori is the most common chronic bacterial infection worldwide and the most significant risk factor for gastric cancer, which remains a leading cause of cancer-related death globally. H pylori and gastric cancer continue to disproportionately impact racial and ethnic minority and immigrant groups in the United States. The approach to H pylori case-finding thus far has relied on opportunistic testing based on symptoms or high-risk indicators, such as racial or ethnic background and family history. However, this approach misses a substantial proportion of individuals infected with H pylori who remain at risk for gastric cancer because most infections remain clinically silent. Moreover, individuals with chronic H pylori infection are at risk for gastric preneoplastic lesions, which are also asymptomatic and only reliably diagnosed using endoscopy and biopsy. Thus, to make a significant impact in gastric cancer prevention, a systematic approach is needed to better identify individuals at highest risk of both H pylori infection and its complications, including gastric preneoplasia and cancer. The approach to H pylori eradication must also be optimized given sharply decreasing rates of successful eradication with commonly used therapies and increasing antimicrobial resistance. With growing acceptance that H pylori should be managed as an infectious disease and the increasing availability of susceptibility testing, we now have the momentum to abandon empirical therapies demonstrated to have inadequate eradication rates. Molecular-based susceptibility profiling facilitates selection of a personalized eradication regimen without necessitating an invasive procedure. An improved approach to H pylori eradication coupled with population-level programs for screening and treatment could be an effective and efficient strategy to prevent gastric cancer, especially in minority and potentially marginalized populations that bear the heaviest burden of H pylori infection and its complications.

Clinical applications and perspectives of circulating tumor DNA in gastric cancer

Gastric cancer remains a leading cause of cancer-related death worldwide, largely due to inadequate screening methods, late diagnosis, and limited treatment options. Liquid biopsy has emerged as a promising non-invasive approach for cancer screening and prognosis by detecting circulating tumor components like circulating tumor DNA (ctDNA) in the blood. Numerous gastric cancer-specific ctDNA biomarkers have now been identified. CtDNA analysis provides insight into genetic and epigenetic alterations in tumors, holding promise for predicting treatment response and prognosis in gastric cancer patients. This review summarizes current research on ctDNA biology and detection technologies, while highlighting clinical applications of ctDNA for gastric cancer diagnosis, prognosis, and guiding treatment decisions. Current challenges and future perspectives for ctDNA analysis are also discussed.

Comprehensive evaluation of serum circHAS2 as a novel diagnostic and prognostic biomarker for gastric cancer

The diagnosis and screening indicators for gastric cancer (GC) are not satisfactory, resulting in a large number of GC patients being missed and missing the best treatment time. Due to the special structure of circular RNAs (circRNAs), they have a more accurate and powerful ability to detect tumor occurrence. In addition, circHAS2 has been found to promote the proliferation, migration, and invasion of GC cells. Therefore, this study explored the potential of circHAS2 as a biomarker for GC. The expression level of circHAS2 in the specimens was detected by real-time fluorescent quantitative PCR. The molecular characteristics of circHAS2 were verified by agarose gel electrophoresis and Sanger sequencing. The feasibility of the circHAS2 detection method was verified by room temperature placement and repeated freezing and thawing. The diagnostic effect of circHAS2 on GC was evaluated by receiver-operating curve analysis. The correlation between circHAS2 expression level and clinical pathological parameters was analyzed using the χ2 -test. Kaplan-Meier survival curve analysis was used to analyze the survival situation of the circHAS2 high- and low-expression group. Univariate and multivariate Cox regression analysis was used to evaluate the influencing factors of prognosis in GC patients. CircHAS2 in cells can be secreted into the blood, and its expression level is significantly upregulated in the serum of patients with GC. The expression level of circHAS2 is correlated with the tissue differentiation, tumor node metastasis staging, classification, and lymph node metastasis of GC patients. CircHAS2 can effectively identify GC and even early GC. In addition, the expression levels of circHAS2 in postoperative GC patients significantly decreased and returned to normal after the second stage of chemotherapy. Finally, the circHAS2 low-expression group had better survival. The upregulated expression of circHAS2 in the serum of GC patients can effectively identify GC and early GC and can be used for effective monitoring of the prognosis of GC patients. In summary, circHAS2 can be used as an effective diagnostic and prognostic marker for GC.

Missed Opportunities: the Timing and Frequency of Screening Colonoscopy in Patients That Develop Esophageal Adenocarcinoma

INTRODUCTION

Screening colonoscopy (SC) is widely accepted and has been shown to decrease the rate of colorectal cancer death. Guidelines and acceptance of screening for Barrett's esophagus (BE) are less established despite the fact that esophageal adenocarcinoma (EA) remains the fastest increasing cancer in the USA. The aim of this study was to assess the timing and frequency of SC in patients ultimately found to have EA and to evaluate the presence of symptoms and risk factors that might have prompted an esophagogastroduodenoscopy (EGD) and potentially earlier diagnosis of the EA.

METHODS

A retrospective chart review was performed to identify all patients who were referred to a single center with esophageal cancer between July 2016 and November 2022. Patients with any histology other than adenocarcinoma were excluded.

RESULTS

There were 221 patients referred with EA. Of these, a SC had been done prior to the diagnosis of EA in 108 patients (49%): 96 men and 12 women. A total of 203 SC had been done (range 1-7 per patient), and 47% of patients had more than 1 SC. The median interval from the last SC to the diagnosis of EA was 2.9 years. At the time of SC, gastroesophageal reflux disease (GERD) symptoms or chronic acid suppression medication use was reported by 81% of patients, and 80% had an American Society of Gastrointestinal Endoscopy (ASGE) indication for a screening EGD. Only 19 patients (18%) that had a SC had an EGD at any time prior to the diagnosis of EA, and in these patients, 74% had erosive esophagitis or BE. The EA in most patients was stage III or IV and associated with lymph node metastases.

CONCLUSIONS

Nearly one-half of patients ultimately diagnosed with EA had one or more SCs, and most of these patients had GERD symptoms, were using acid suppression medications or had an ASGE indication for a screening EGD. Despite this, only 18% had an EGD prior to the EA diagnosis. The addition of an EGD at the time of SC in these patients may have allowed the detection of BE or EA at an early, endoscopically curable stage and represents a missed opportunity to intervene in the natural history of this disease.

Biennial Endoscopic Surveillance of Gastrointestinal Metaplasia and Its Subtypes Reduces Gastric Cancer Mortality and Is Cost-Effective in a Markov State Transition Model

OBJECTIVES

Gastric cancer in the United States has a low survival rate mainly because of the late stage of diagnosis. Furthermore, there are no well-established guidelines concerning screening and surveillance even for higher risk patients such as those with nondysplastic noncardia gastrointestinal metaplasia (GIM), and thus they are not routinely performed. This study was designed to provide new evidence-based data that can be used to support the implementation of biennial surveillance guidelines in individuals with nondysplastic noncardia GIM. This practice can help detect early malignant lesions, thereby decreasing morbidity and mortality. We evaluated the cost-effectiveness of surveillance endoscopies for noncardia gastric cancer in populations with two different pathological diagnoses: mixed GIM and incomplete GIM (iGIM).

METHODS

Markov state transition models were developed using a cohort simulation of 1000 hypothetical patients. Analysis was conducted for both mixed and iGIM. Quality-adjusted life-years and transition probabilities were derived from the published medical literature. Costs associated with endoscopy, cancer care, and surgery were based on Medicare reimbursement. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used to determine cost-effectiveness.

RESULTS

Our study determined that it is significantly cost-effective to perform biennial endoscopy surveillance in patients who have been incidentally found to have noncardia mixed GIM, with a cost savings of $5783.84 per person, and in those with iGIM, with a cost savings of $8093.08 per person.

CONCLUSIONS

Biennial endoscopy surveillance should be considered in all individuals found to have mixed or incomplete noncardia GIM on endoscopy. Furthermore, screening specifically for iGIM after differentiating between the two groups can lead to further cost savings. As such, we recommend that pathologists routinely differentiate between the two and recommend robust routine surveillance of iGIM.

The Dual-Response-Single-Amplification Fluorescent Nanomachine for Tumor Imaging and Gastric Cancer Diagnosis

Gastric cancer (GC) is one of the most common tumors worldwide and is the leading cause of tumor-related mortality. Traditional biomarkers and screening methods cannot meet the clinical demands. There is an urgent need for highly sensitive diagnostic markers as well as accurate quantification methods for early gastric cancer (EGC) screening. Here a dual-target cooperatively responsive fluorescent nanomachine by the innovative application of two targets─responsive strand migration system with a single-amplification-cycle element was developed for the simultaneous detection of GC biomarkers miR-5585-5p and PLS3 mRNA, which were selected by next-generation sequencing and RT-qPCR. It was also an RNA extraction-free, PCR-free, and nonenzymatic biosensor to achieve tumor cell imaging and serum diagnosis. Requiring only a 20 μL serum sample and 20 min incubation time, the nanomachine achieved an ultrasensitive detection limit of fM level with a broad linear range from fM to nM. More importantly, a higher AUC value (0.884) compared to the clinically used biomarker CA 72-4 was obtained by the nanomachine to distinguish GC patients successfully. Notably, for the key concerns of diagnosis of EGC patients, the nanomachine also achieved a satisfactory AUC value of 0.859. Taken together, this work has screened and obtained multiple biomarkers and developed a fluorescent nanomachine for combination diagnosis of GC, providing an ingenious design of a functionalized DNA nanomachine and a feasible strategy for the transformation of serum biomarkers into clinical diagnosis.

High prevalence of incidental endoscopic findings at routine endoscopy after atrial fibrillation ablation: Do we need a screening endoscopy for the upper gastrointestinal tract in the general population?

INTRODUCTION

High-power short-duration ablation (HPSD) is an effective therapy for atrial fibrillation with thermal esophageal injury as a rare but relevant side effect.

AIM AND METHODS

In this retrospective single-center analysis we evaluated the incidence and relevance of ablation-induced findings and the prevalence of ablation-independent incidental gastrointestinal findings. For 15 months all patients undergoing ablation were screened by postablation esophagogastroduodenoscopy. Pathological findings were followed up and treated if necessary.

RESULTS

286 consecutive patients (66±10 years; 54.9% male) were included. 19.6% of patients showed ablation-associated alterations (10.8% esophageal lesions, 10.8% gastroparesis, 1.7% both findings). Logistic multivariable regression analysis confirmed an influence of lower BMI on the occurrence of RFA-associated endoscopic findings (OR 0.936, 95% CI 0.878-0.997, p<0.05). 48.3% of patients demonstrated incidental gastrointestinal findings. In 1.0% neoplastic lesions were present, 9.4% showed precancerous lesions and in 4.2% neoplastic lesions of unknown dignity were found requiring further diagnostics or therapy. 18.1% of patients demonstrated findings associated with a potentially increased risk of bleeding under anticoagulation. Patients with clinically relevant incidental findings were significantly more often male, 68.8% vs. 49.5% (p<0.01).

CONCLUSION

HPSD ablation is safe, no devasting complication occurred in any patient. It resulted in 19.6% ablation-induced thermal injury whereas incidental findings of the upper GI tract were found in 48.3% of patients. Due to the high prevalence of 14.7% of findings requiring further diagnostics, therapy, or surveillance in a cohort that is mimicking the general population, screening endoscopy of the upper GI tract seems to be reasonable in the general population.

Global burden of gastric cancer: epidemiological trends, risk factors, screening and prevention

Gastric cancer remains a major cause of cancer-related mortality worldwide. The temporal trends for this malignancy, however, are dynamic, and reports from the past decade indicate important declines in some regions and demographic groups, as well as a few notable exceptions in which gastric cancer rates are either stable or increasing. Two main anatomical subtypes of gastric cancer exist, non-cardia and cardia, with different temporal trends and risk factors (such as obesity and reflux for cardia gastric cancer and Helicobacter pylori infection for non-cardia gastric cancer). Shifts in the distribution of anatomical locations have been detected in several high-incidence regions. H. pylori is an important aetiological factor for gastric cancer; importantly, the anticipated long-term findings from studies examining the effect of H. pylori eradication on the risk of (re)developing gastric cancer have emerged in the past few years. In this Review, we highlight the latest trends in incidence and mortality using an evidence-based approach. We make the best possible inferences, including clinical and public health inference, on the basis of the quality of the evidence available, and highlight burning questions as well as gaps in knowledge and public health practice that need to be addressed to reduce gastric cancer burden worldwide.

Clinical application and detection techniques of liquid biopsy in gastric cancer

Gastric cancer (GC) is one of the most common tumors worldwide and the leading cause of tumor-related mortality. Endoscopy and serological tumor marker testing are currently the main methods of GC screening, and treatment relies on surgical resection or chemotherapy. However, traditional examination and treatment methods are more harmful to patients and less sensitive and accurate. A minimally invasive method to respond to GC early screening, prognosis monitoring, treatment efficacy, and drug resistance situations is urgently needed. As a result, liquid biopsy techniques have received much attention in the clinical application of GC. The non-invasive liquid biopsy technique requires fewer samples, is reproducible, and can guide individualized patient treatment by monitoring patients' molecular-level changes in real-time. In this review, we introduced the clinical applications of circulating tumor cells, circulating free DNA, circulating tumor DNA, non-coding RNAs, exosomes, and proteins, which are the primary markers in liquid biopsy technology in GC. We also discuss the current limitations and future trends of liquid biopsy technology as applied to early clinical biopsy technology.

A deep learning and natural language processing-based system for automatic identification and surveillance of high-risk patients undergoing upper endoscopy: A multicenter study

BACKGROUND

Timely identification and regular surveillance of patients at high risk are crucial for early diagnosis of upper gastrointestinal cancer. However, traditional manual surveillance method is time-consuming, and current surveillance rate is below 50%. Here, we aimed to develop a surveillance system named ENDOANGEL-AS (automatic surveillance) for automatic identification and surveillance of high-risk patients.

METHODS

7874 patients from Renmin Hospital of Wuhan University between May 1 and July 31, 2021 were used as the training set, 6762 patients between August 1 and October 31, 2021 as the internal test set, and 7570 patients from two other hospitals between August 1 and October 31, 2021 as the external test sets. We first extracted descriptions of abnormalities from endoscopic and pathological reports based on natural language processing techniques to identify individuals. Then patients were classified at nine risk levels according to endoscopic and pathological findings, and a deep learning model was trained to identify demarcation line (DL) in gastric low-grade intraepithelial neoplasia (LGIN) using 1561 white-light still images for risk stratification of gastric LGIN. Finally, patients undergoing upper endoscopy were classified and assigned one of ten surveillance intervals according to guidelines. The performance of ENDOANGEL-AS was evaluated and compared with physicians.

FINDINGS

Patient identification module achieved an accuracy of 100% and 99.91% in internal and external test sets, respectively. Risk level classification module achieved an accuracy of 100% and 99.85% in the internal and external test sets, respectively. DL identification module achieved an accuracy of 87.88%. ENDOANGEL-AS on surveillance interval assignment achieved an accuracy of 99.23% and 99.67% in internal and external test sets, respectively. ENDOANGEL-AS had significantly higher accuracy compared with physicians (99.00% vs 38.87%, p < 0.001). The accuracy (63.67%, p < 0.001) of endoscopists with the assistance of ENDOANGEL-AS was significantly improved.

INTERPRETATION

We established a surveillance system that can automatically identify patients and assign surveillance intervals with high accuracy and good transferability.

FUNDING

This work was partly supported by a grant from the Hubei Province Major Science and Technology Innovation Project (2018-916-000-008) and the Fundamental Research Funds for the Central Universities (2042021kf0084).

Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis

BACKGROUND & AIMS

Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision.

METHODS

We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained.

RESULTS

Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm.

CONCLUSIONS

The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.

Advances in screening and detection of gastric cancer

With an estimated one million new cases and 769 000 deaths in 2020, gastric cancer is the fifth most frequent cancer and fourth leading cause of cancer death globally. Incidence rates are highest in Asia and Eastern Europe. This manuscript will review the current modalities of diagnosis, staging, and screening of gastric cancer. We will also highlight development of novel diagnostics and advancements in endoscopic detection of early gastric cancer.

Diagnostic efficacy of circular RNAs as noninvasive, liquid biopsy biomarkers for early detection of gastric cancer

BACKGROUND

Majority of gastric cancers (GC) are diagnosed at advanced stages which contributes towards their poor prognosis. In view of this clinical challenge, identification of non-invasive biomarker for early diagnosis is imperative. Herein, we aimed to develop a non-invasive, liquid-biopsy based assay by using circular RNAs (circRNAs) as molecular biomarkers for early detection of GC.

METHODS

We performed systematic biomarker discovery and validation of the candidate circRNAs in matched tissue specimens of GC and adjacent normal mucosa. Next, we translated the discovered circRNA based biomarker panel into serum samples in a training and validation cohort of GC patients (n = 194) and non-disease controls (n = 94) and evaluated their diagnostic performance. In addition, we measured the expression of circRNAs in serum samples of pre- and post-surgical GC patients and evaluated the specificity of circRNAs biomarker panel with respect to other gastro-intestinal (GI) malignancies.

RESULTS

We identified 10-circRNAs in the discovery phase with subsequent validation in a pilot cohort of GC tissue specimens. Using a training cohort of patients, we developed an 8-circRNA based risk-prediction model for the diagnosis of GC. We observed that our biomarker panel robustly discriminated GC patients from non-disease controls with an AUC of 0.87 in the training, and AUC of 0.83 in the validation cohort. Notably, the biomarker panel could robustly identify even early-stage GC patients, regardless of their tumor histology (diffuse vs. intestinal). The decreased expression of circRNAs in post-surgery serum specimens indicated their tumor-specificity and their potential source of origin in the systemic circulation.

CONCLUSIONS

We identified a panel of 8-circRNAs as non-invasive, liquid-biopsy biomarkers which might serve as potential diagnostic biomarkers for the early detection of GC.

Discovery and validation of methylation signatures in circulating cell-free DNA for early detection of esophageal cancer: a case-control study

BACKGROUND

Plasma cell-free DNA (cfDNA) methylation has shown promising results in the early detection of multiple cancers recently. Here, we conducted a study to investigate the performance of cfDNA methylation in the early detection of esophageal cancer (ESCA).

METHODS

Specific methylation markers for ESCA were identified and optimized based on esophageal tumor and paired adjacent tissues (n = 24). Age-matched participants with ESCA (n = 85), benign esophageal diseases (n = 10), and healthy controls (n = 125) were randomized into the training and test sets to develop a classifier to differentiate ESCA from healthy controls and benign esophageal disease. The classifier was further validated in an independent plasma cohort of ESCA patients (n = 83) and healthy controls (n = 98).

RESULTS

In total, 921 differentially methylated regions (DMRs) between tumor and adjacent tissues were identified. The early detection classifier based on those DMRs was first developed and tested in plasma samples, discriminating ESCA patients from benign and healthy controls with a sensitivity of 76.2% (60.5-87.9%) and a specificity of 94.1% (85.7-98.4%) in the test set. The performance of the classifier was consistent irrespective of sex, age, and pathological diagnosis (P > 0.05). In the independent plasma validation cohort, similar performance was observed with a sensitivity of 74.7% (64.0-83.6%) and a specificity of 95.9% (89.9-98.9%). Sensitivity for stage 0-II was 58.8% (44.2-72.4%).

CONCLUSION

We demonstrated that the cfDNA methylation patterns could distinguish ESCAs from healthy individuals and benign esophageal diseases with promising sensitivity and specificity. Further prospective evaluation of the classifier in the early detection of ESCAs in high-risk individuals is warranted.

Gastric cancer: lessons learned from high-incidence geographic regions

Gastric cancer is a global health concern. There is a marked geographical variability in the incidence of gastric cancer, with higher incidence in East and Central Asia followed by Latin America and Eastern Europe. Survival rates in gastric cancer are low and strongly stage dependent. Due to the limited survival benefit achieved from currently available therapeutic options, prevention and early diagnosis are essential to minimize morbidity and mortality from this disease. Countries with high incidence of gastric cancer have pioneered the development and implementation of prevention and screening programs. Helicobacter pylori (H. pylori) eradication and dietary modifications are the main preventive strategies. Upper gastrointestinal (UGI) endoscopy is the mainstay screening strategy for early diagnosis. In this article, we review the lessons learned for gastric cancer diagnosis and treatment from high-incidence areas and discuss their applicability for treatment in the Western world to reduce morbidity and mortality from this disease.

Estimated Cost-effectiveness of Endoscopic Screening for Upper Gastrointestinal Tract Cancer in High-Risk Areas in China

IMPORTANCE

Upper gastrointestinal tract cancer, including esophageal and gastric cancers, in China accounts for 50% of the global burden. Endoscopic screening may be associated with a decreased incidence of and mortality from upper gastrointestinal tract cancer.

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic screening for esophageal and gastric cancers among people aged 40 to 69 years in areas of China where the risk of these cancers is high.

DESIGN, SETTING, AND PARTICIPANTS

For this economic evaluation, a Markov model was constructed for initial screening at different ages from a health care system perspective, and 5 endoscopic screening strategies with different frequencies (once per lifetime and every 10 years, 5 years, 3 years, and 2 years) were evaluated. The study was conducted between January 1, 2019, and October 31, 2020. Model parameters were estimated based on this project, government documents, and published literature. For each initial screening age (40-44, 45-49, 50-54, 55-59, 60-64, and 65-69 years), a closed cohort of 100 000 participants was assumed to enter the model and follow the alternative strategies.

MAIN OUTCOMES AND MEASURES

Cost-effectiveness was measured by calculating the incremental cost-effectiveness ratio (ICER), and the willingness-to-pay threshold was assumed to be 3 times the per capita gross domestic product in China (US $10 276). Univariate and probabilistic sensitivity analyses were conducted to assess the robustness of model findings.

RESULTS

The study included a hypothetical cohort of 100 000 individuals aged 40 to 69 years. All 5 screening strategies were associated with improved effectiveness by 1087 to 10 362 quality-adjusted life-years (QALYs) and increased costs by US $3 299 000 to $22 826 000 compared with no screening over a lifetime, leading to ICERs of US $1343 to $3035 per QALY. Screening at a higher frequency was associated with an increase in QALYs and costs; ICERs for higher frequency screening compared with the next-lower frequency screening were between US $1087 and $4511 per QALY. Screening every 2 years would be the most cost-effective strategy, with probabilities of 90% to 98% at 3 times the per capita gross domestic product of China. The model was the most sensitive to utility scores of esophageal cancer- or gastric cancer-related health states and compliance with screening.

CONCLUSIONS AND RELEVANCE

The findings suggest that combined endoscopic screening for esophageal and gastric cancers may be cost-effective in areas of China where the risk of these cancers is high; screening every 2 years would be the optimal strategy. These data may be useful for development of policies targeting the prevention and control of upper gastrointestinal tract cancer in China.

Endoscopic Screening and Surveillance for Gastric Cancer

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

Circulating exosomal long non-coding RNA H19 as a potential novel diagnostic and prognostic biomarker for gastric cancer

Objective

Long non-coding RNAs (lncRNAs) are involved in carcinogenesis and could be used as diagnostic biomarkers. Our study aimed to elucidate the clinical role of serum exosomal lncRNA H19 in gastric cancer (GC).

Methods

In this prospective clinical study, we determined serum exosomal lncRNA H19 levels in 81 patients with GC and analysed the correlations between serum lncRNA H19 levels and clinical characteristics. Receiver operating characteristics (ROC) curves were constructed to determine the diagnostic performance of exosomal lncRNA H19 in GC.

Results

Serum exosomal lncRNA H19 levels were significantly upregulated in patients with GC both before and after surgery compared with healthy controls. Furthermore, serum exosomal lncRNA H19 levels were significantly decreased after compared with before surgery in patients with GC. Preoperative lncRNA H19 levels were significantly correlated with TNM stage. The area under the ROC curve (AUC) value for exosomal lncRNA H19 was 0.849, which was significantly higher than the AUC values for cancer antigens 19-9 and 72-4 and carcinoembryonic antigen, either alone or combined.

Conclusions

These results suggest that circulating exosomal lncRNA H19 may be a potential biomarker with diagnostic and prognostic value in GC.

Systematic upper endoscopy concomitant with colonoscopy performed within the colorectal cancer screening program: Impact on the patients' management

BACKGROUND AND AIMS

The French colorectal cancer screening program is based on a fecal immunochemical test, followed by colonoscopy in case of positivity. The benefit of adding a concomitant upper endoscopy to detect upper digestive lesions (precancerous or others) is still debated. Our aim was to evaluate the frequency of upper digestive lesions detected by upper endoscopy performed concomitantly with colonoscopy following a positive fecal immunochemical test, and their impact on the patients' management (i.e., surveillance, medical treatment, endoscopic or surgical procedure).

METHODS

Data of all the patients who consulted for a positive test between May 2016 and May 2019 in our center, and for whom concomitant upper endoscopy and colonoscopy were performed, were analyzed retrospectively. Patients with significant history of upper gastrointestinal diseases or with current gastrointestinal symptoms were excluded.

RESULTS

One hundred patients were included [median age (min-max): 62 (50-75), men 64%]. Macroscopic and/or microscopic upper digestive lesions were found in 58 of them (58%): Helicobacter pylori infection in 17 patients, gastric precancerous lesions in 9 patients (chronic atrophic gastritis with intestinal metaplasia, n=8, low grade dysplasia, n=1), Barrett's esophagus requiring surveillance in 4 patients, and 1 duodenal adenoma with low-grade dysplasia. In 44 patients (44%), the upper endoscopy findings had an impact on patients' management, with no significant difference between the groups with positive (CRC or advanced adenoma)- or negative (any other lesions or normal) colonoscopy.

CONCLUSION

A systematic upper endoscopy combined with colonoscopy for positive fecal immunochemical test could represent an efficient strategy for upper digestive lesions screening in France. Further studies are necessary to confirm these results and to evaluate cost-effectiveness of this approach.

Opportunistic upper endoscopy during colonoscopy as a screening strategy for countries with intermediate gastric cancer risk

BACKGROUND AND AIM

Screening upper endoscopy can detect esophagogastric (OG) cancers early with improved outcomes. Recent cost-utility studies suggest that opportunistic upper endoscopy at the same setting of colonoscopy might be a useful strategy for screening of OG cancers, and it may be more acceptable to the patients due to cost-saving and convenience. We aim to study the diagnostic performance of this screening strategy in a country with intermediate gastric cancer risk.

METHODS

A retrospective cohort study using a prospective endoscopy database from 2015 to 2017 was performed. Patients included were individuals age > 40 who underwent opportunistic upper endoscopy at the same setting of colonoscopy without any OG symptoms. Neoplastic OG lesions are defined as cancer and high-grade dysplasia. Pre-neoplastic lesions include Barrett's esophagus (BE), intestinal metaplasia (IM), and atrophic gastritis (AG).

RESULTS

The study population involved 1414 patients. Neoplastic OG lesions were detected in five patients (0.35%). Pre-neoplastic lesions were identified in 174 (12.3%) patients. IM was found in 146 (10.3%) patients with 21 (1.4%) having extensive IM. The number needed to scope to detect a neoplastic OG lesion is 282.8 with an estimated cost of USD$141 400 per lesion detected. On multivariate regression, age ≥ 60 (RR: 1.84, 95% CI: 1.29-2.63) and first-degree relatives with gastric cancer (RR: 1.64, 95% CI: 1.06-2.55) were independent risk factors for neoplastic or pre-neoplastic OG lesion.

CONCLUSION

For countries with intermediate gastric cancer risk, opportunistic upper endoscopy may be an alternative screening strategy in a selected patient population. Prospective trials are warranted to validate its performance.

Esophageal Cancer: An Updated Review

The incidence of esophageal cancer (EC) is on the rise. With the distinct subtypes of adenocarcinoma and squamous cell carcinoma comes specific risk factors, and as a result, people of certain regions of the world can be more prone to a subtype. For example, squamous cell carcinoma of the esophagus has the highest incidence in eastern Africa and eastern Asia, with smoking being a major risk factor, whereas adenocarcinoma is more prevalent in North America and western Europe, with gastroesophageal reflux disease being a leading risk factor. With that being said, adenocarcinoma and squamous cell carcinoma have similar and unfortunately poor survival rates, partly because EC is prone to early metastasis given that the esophagus does not have a serosa, as well as the superficial nature of its lymphatics compared with the rest of the gastrointestinal tract. This makes early detection of the utmost importance, and certain patients have been shown to have the benefit of screening/surveillance endoscopies, including those with Barrett's esophagus, lye-induced/caustic strictures, tylosis, and Peutz-Jeghers syndrome. Until treatments significantly improve, identifying EC at the earliest stage will have the best success for patient outcomes, and further elucidation of its pathogenesis and risk factors may lead to identifying other high-risk groups that should be screened.

Cost-effectiveness of prevention and early detection of gastric cancer in Western countries

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.

Prevalence of Barrett's esophagus and performance of societal screening guidelines in an unreferred primary care population of U.S. veterans

BACKGROUND AND AIMS

Less than 10% of patients diagnosed with esophageal adenocarcinoma have a pre-existing Barrett's esophagus (BE) diagnosis, possibly because of suboptimal performance of guidelines. We examined the prevalence of BE in a previously unscreened primary care population and the potential yield of practice BE screening guidelines.

METHODS

This was a retrospective analysis of a prospective cross-sectional study of consecutively recruited unreferred patients from primary care clinics who underwent study upper endoscopy. We examined the performance of BE screening guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and our own modification of guidelines.

RESULTS

We identified 44 BE cases and 469 control subjects (prevalence, 8.6%). Among 371 patients without GERD symptoms, 25 (6.7%) had BE. The AGA guidelines requiring ≥2 BE risk factors had sensitivity of 100% and specificity of only .2%, whereas ACG, ASGE, ESGE, and BSG guidelines (all requiring GERD first) had low sensitivities (38.6%-43.2%), specificities ranging from 67.4% to 76.5%, and area under the receiver operating curve (AUROC) of .50 to .60. Our 2-pronged approach depending on presence or absence of GERD symptoms but with other risk factors achieved sensitivity of 81.8%, specificity of 51.2%, and AUROC of .66.

CONCLUSIONS

Over half of BE cases were without frequent GERD symptoms, but virtually all had at least 1 known BE risk factor. Practice guidelines requiring GERD symptoms have low sensitivity, whereas those not requiring GERD have low specificity. We have proposed a screening guideline with better use of known risk factors.

Cost-Effectiveness of Screening, Surveillance, and Endoscopic Eradication Therapies for Managing the Burden of Esophageal Adenocarcinoma

The authors conducted a review of the literature of cost-effectiveness analyses regarding management of Barrett's esophagus, including screening, surveillance, and treatment strategies. Because of the presence of multiple systematic reviews on this topic, they chose to focus on more recent economic analyses, with an emphasis on comparative modeling because these analyses have been demonstrated to achieve greater validity and impact when there are multiple competing strategies that are clinically reasonable to pursue. The authors identified areas of consensus across studies regarding management strategies and also areas that require additional empirical data.

Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.

Value of oesophagoscopy and bronchoscopy in diagnosis of synchronous malignancies in patients with head and neck squamous cell carcinomas

Background

Routine screening of patients with head and neck squamous cell carcinomas (HNSCCs) for synchronous malignancies using oesophagoscopy and bronchoscopy had been controversial. The aim of this study is therefore to find out the rate of synchronous malignancies in patients with primary HNSCCs, the risk factors for its occurrence and the effectiveness of oesophagoscopy and bronchoscopy from a 10-year experience in a single centre.

Methods

A retrospective review of medical records was conducted from July 2008 to June 2018 in a tertiary referral centre in Hong Kong. All patients with newly diagnosed HNSCCs were screened with oesophagoscopy and bronchoscopy at the time of diagnosis and therefore all patients were included in the study. The incidence of synchronous malignancies along the aerodigestive tract and the yield of oesophagoscopy and bronchoscopy were studied.

Results

Of the 702 patients included in the study, the overall rate of synchronous malignancies was 8.3% (58/702), with the rate of synchronous oesophageal and lung malignancies being 5.8% (41/702) and 0.85% (6/702) respectively. Fourteen out of the 41 oesophageal malignancies were only detectable with oesophagoscopy. Only one of the synchronous lung malignancies was detectable by bronchoscopy. Risk factors for synchronous malignancies include male gender, smokers, drinkers and primary hypopharyngeal cancer.

Conclusions

Oesophagoscopy is essential for detecting synchronous oesophageal malignancies in patients with HNSCCs especially in male patients, smokers and drinkers, and it is most valuable in primary hypopharyngeal cancer patients among all primary subsites. Bronchoscopy had a low yield for synchronous lung malignancies and can be potentially replaced by imaging techniques.

Decision model analyses of upper endoscopy for gastric cancer screening and preneoplasia surveillance: a systematic review

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.

Health-related quality of life and health utility score of patients with gastric cancer: A multi-centre cross-sectional survey in China

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) and health state utility scores of gastric cancer patients in daily life at different clinical stages after treatment, and to explore influencing factors associated with HRQoL.

METHODS

Gastric cancer patients discharged from hospitals and healthy controls identified by screening were recruited. The three-level EQ-5D was employed to assess HRQoL and was scored using two Chinese-specific tariffs published in 2014 and 2018.

RESULTS

A total of 1,399 patients and 2,179 healthy controls were recruited. The likelihood of reporting problems in the five dimensions for patients was 4.0-23.8 times higher than controls. Based on the 2014/2018 tariff, the mean EQ-5D utility score was 0.321/0.163 lower than controls, and the mean utility scores of each patient subgroup were 0.077/0.039 (high-grade intraepithelial neoplasia/carcinoma in situ), 0.254/0.121 (Stage I), 0.249/0.123 (Stage II), 0.353/0.182 (Stage III) and 0.591/0.309 (Stage IV) lower than controls (all statistically significant). Age, occupation, duration of illness, other chronic disease status and therapeutic regimen had a significant impact upon different aspects of HRQoL in patients.

CONCLUSIONS

Gastric cancer significantly impaired patients' HRQoL in daily life after treatment. More advanced cancer stages were associated with larger decrements on health state utility.

Development of a clinical score to distinguish malignant from benign esophageal disease in an undiagnosed patient population referred to an esophageal diagnostic assessment program

Background

Esophageal cancer is associated with poor prognosis. Diagnosis is often delayed, resulting in presentation with advanced disease. We developed a clinical score to predict the risk of a malignant diagnosis in symptomatic patients prior to any diagnostic tests.

Methods

We analyzed data from patients referred to a regional esophageal diagnostic assessment program between May 2013 and August 2016. Logistic regression was performed to identify predictors of malignancy based on patient characteristics and symptoms. Predicted probabilities were used to develop a score from 0 to 10 which was weighted according to beta coefficients for predictors in the model. Score accuracy was evaluated using a receiver operating characteristic (ROC) curve and internally validated using bootstrapping techniques. Patients were classified into low (0–2 points), medium (3–6 points), and high (7–10 points) risk groups based on their scores. Pathologic tissue diagnosis was used to assess the effectiveness of the developed score in predicting the risk of malignancy in each group.

Results

Of 530 patients, 363 (68%) were diagnosed with malignancy. Factors predictive of malignancy included male sex, family history of cancer and esophageal cancer, fatigue, chest/throat/back pain, melena and weight loss. These factors were allocated 1–2 points each for a total of 10 points. Low-risk patients had 70% lower chance of malignancy (RR =0.28, 95% CI: 0.21–0.38), medium-risk had 50% higher chance of malignancy (RR =1.5, 95% CI: 1.26–1.77), and high-risk patients were 8 times more likely to be diagnosed with malignancy (RR =8.2, 95% CI: 2.60–25.86). The area under the ROC curve for malignancy was 0.82 (95% CI: 0.77–0.87).

Conclusions

A simple score using patient characteristics and symptoms reliably distinguished malignant from benign diagnoses in a population of patients with upper gastrointestinal symptoms. This score might be useful in expediting investigations, referrals and eventual diagnosis of malignancy.

Differences in Stage of Cancer at Diagnosis, Treatment, and Survival by Race and Ethnicity Among Leading Cancer Types

IMPORTANCE

Information about stage of cancer at diagnosis, use of therapy, and survival among patients from different racial/ethnic groups with 1 of the most common cancers is lacking.

OBJECTIVE

To assess stage of cancer at diagnosis, use of therapy, overall survival (OS), and cancer-specific survival (CSS) in patients with cancer from different racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 950 377 Asian, black, white, and Hispanic patients who were diagnosed with prostate, ovarian, breast, stomach, pancreatic, lung, liver, esophageal, or colorectal cancers from January 2004 to December 2010. Data were collected using the Surveillance, Epidemiology, and End Results (SEER) database, and patients were observed for more than 5 years. Data analysis was conducted in July 2018.

MAIN OUTCOMES AND MEASURES

Multivariable logistic and Cox regression were used to evaluate the differences in stage of cancer at diagnosis, treatment, and survival among patients from different racial/ethnic groups.

RESULTS

A total of 950 377 patients (499 070 [52.5%] men) were included in the study, with 681 251 white patients (71.7%; mean [SD] age, 65 [12] years), 116 015 black patients (12.2%; mean [SD] age, 62 [12] years), 65 718 Asian patients (6.9%; mean [SD] age, 63 [13] years), and 87 393 Hispanic patients (9.2%; mean [SD] age, 61 [13] years). Compared with Asian patients, black patients were more likely to have metastatic disease at diagnosis (odds ratio [OR], 1.144; 95% CI, 1.109-1.180; P < .001). Black and Hispanic patients were less likely to receive definitive treatment than Asian patients (black: adjusted OR, 0.630; 95% CI, 0.609-0.653; P < .001; Hispanic: adjusted OR, 0.751; 95% CI, 0.724-0.780; P < .001). White, black, and Hispanic patients were more likely to have poorer CSS and OS than Asian patients (CSS, white: adjusted HR, 1.310; 95% CI, 1.283-1.338; P < .001; black: adjusted HR, 1.645; 95% CI, 1.605-1.685; P < .001; Hispanic: adjusted HR, 1.300; 95% CI, 1.266-1.334; P < .001; OS, white: adjusted HR, 1.333; 95% CI, 1.310-1.357; P < .001; black: adjusted HR, 1.754; 95% CI, 1.719-1.789; P < .001; Hispanic: adjusted HR, 1.279; 95% CI, 1.269-1.326; P < .001).

CONCLUSIONS AND RELEVANCE

In this study of patients with 1 of 9 leading cancers, stage at diagnosis, treatment, and survival were different by race and ethnicity. These findings may help to optimize treatment and improve outcomes.

No Barrett's-No Cancer: A Proposed New Paradigm for Prevention of Esophageal Adenocarcinoma

Esophageal adenocarcinoma is inflammation-associated cancer with a recognizable preneoplastic stage, Barrett's. Barrett's describes the metaplastic transformation of esophageal squamous mucosa into columnar epithelium that typically results secondary to mucosal damage caused by acidic gastroduodenal reflux. Continued acid reflux may then result in mucosal inflammation which results in progressive inflammation-induced genetic instability that may eventuate in esophageal adenocarcinoma. Barrett's is the only recognized precursor lesion to esophageal carcinoma. Barrett's mucosa is unique among preneoplastic lesions; ablation therapy results in restitution of a squamous epithelium reducing or eliminating accumulated genetic instabilities and resetting the biological clock progressing toward invasive cancer. However, recurrence of Barrett's after ablation is common. We propose that both Barrett's and recurrence of Barrett's after ablation can be prevented and discuss how current approaches to therapy for gastroesophageal reflux disease, for Barrett's screening, chemoprevention, and ablation therapy all might be reconsidered. We propose (1) improved approaches to Barrett's prevention, (2) universal Barrett's screening by linking Barrett's screening to colon cancer screening, (3) ablation of all Barrett's mucosa along with (4) acid-suppressive-antireflux therapy tailored to prevent development of Barrett's or the recurrence of Barrett's after ablation therapy. We propose that ultimately, treatment decisions for gastroesophageal reflux disease and prevention of Barrett's and esophageal carcinoma should be based on assessing and maintaining esophageal mucosal integrity. This will require development and verification of specific measurements that reliably correlate with prevention of Barrett's. We outline the new research and technical advances needed to cost-effectively achieve these goals.

Risk of gastrointestinal cancer in a symptomatic cohort after a complete colonoscopy: Role of faecal immunochemical test

BACKGROUND

Faecal immunochemical test (FIT) has been recommended to assess symptomatic patients for colorectal cancer (CRC) detection. Nevertheless, some conditions could theoretically favour blood originating in proximal areas of the gastrointestinal tract passing through the colon unmetabolized. A positive FIT result could be related to other gastrointestinal cancers (GIC).

AIM

To assess the risk of GIC detection and related death in FIT-positive symptomatic patients (threshold 10 μg Hb/g faeces) without CRC.

METHODS

Post hoc cohort analysis performed within two prospective diagnostic test studies evaluating the diagnostic accuracy of different FIT analytical systems for CRC and significant colonic lesion detection. Ambulatory patients with gastrointestinal symptoms referred consecutively for colonoscopy from primary and secondary healthcare, underwent a quantitative FIT before undergoing a complete colonoscopy. Patients without CRC were divided into two groups (positive and negative FIT) using the threshold of 10 μg Hb/g of faeces and data from follow-up were retrieved from electronic medical records of the public hospitals involved in the research. We determined the cumulative risk of GIC, CRC and upper GIC. Hazard rate (HR) was calculated adjusted by age, sex and presence of significant colonic lesion.

RESULTS

We included 2709 patients without CRC and a complete baseline colonoscopy, 730 (26.9%) with FIT ≥ 10 µgr Hb/gr. During a mean time of 45.5 ± 20.0 mo, a GIC was detected in 57 (2.1%) patients: An upper GIC in 35 (1.3%) and a CRC in 14 (0.5%). Thirty-six patients (1.3%) died due to GIC: 22 (0.8%) due to an upper GIC and 9 (0.3%) due to CRC. FIT-positive subjects showed a higher CRC risk (HR 3.8, 95%CI: 1.2-11.9) with no differences in GIC (HR 1.5, 95%CI: 0.8-2.7) or upper GIC risk (HR 1.0, 95%CI: 0.5-2.2). Patients with a positive FIT had only an increased risk of CRC-related death (HR 10.8, 95%CI: 2.1-57.1) and GIC-related death (HR 2.2, 95%CI: 1.1-4.3), with no differences in upper GIC-related death (HR 1.4, 95%CI: 0.6-3.3). An upper GIC was detected in 22 (0.8%) patients during the first year. Two variables were independently associated: anaemia (OR 5.6, 95%CI: 2.2-13.9) and age ≥ 70 years (OR 2.7, 95%CI: 1.1-7.0).

CONCLUSION

Symptomatic patients without CRC have a moderate risk increase in upper GIC, regardless of the FIT result. Patients with a positive FIT have an increased risk of post-colonoscopy CRC.

Prevalence, risk factors, and surveillance patterns for gastric intestinal metaplasia among patients undergoing upper endoscopy with biopsy

BACKGROUND AND AIMS

Gastric intestinal metaplasia (GIM) is an important precursor lesion to gastric cancer (GC), the second leading cause of cancer death worldwide. There exist few data regarding the prevalence of, risk factors for, and clinical practice patterns regarding GIM in the United States. Furthermore, there are currently no U.S. guidelines regarding screening/surveillance for GIM.

METHODS

All consecutive upper endoscopic procedures from 2 academic medical centers in Seattle between 1999 and 2014 were reviewed. Demographic, clinical, and endoscopic covariates were recorded at time of endoscopy. Procedures with gastric biopsy were matched to final the histologic diagnoses, including the presence of Helicobacter pylori. Cases of GIM and dysplasia were recorded and compared with non-GIM controls using univariate and multivariable regression. Surveillance patterns for cases of GIM were recorded.

RESULTS

Data from 36,799 upper endoscopies, 17,710 gastric biopsies, 2073 cases of GIM, 43 cases of dysplasia, and 78 cases of GC were captured. The point prevalence of GIM was 11.7% in patients who underwent gastric biopsy. Non-white race (P < .001), increasing age (P < .001), and presence of H pylori (P < .001) were associated with GIM. If GIM was present, increasing age (P < .001) and male gender (P < .001) were associated with progression, and the presence of H pylori (P < .001) was inversely associated with progression to dysplasia/GC. Few cases of GIM/dysplasia/GC were identified during procedures for GIM screening/surveillance. Only 16% of patients with a diagnosis of GIM received a recommendation for surveillance.

CONCLUSIONS

There is a high prevalence of GIM among non-white and Hispanic Americans. Risk factors for development of GIM may be distinct from the risk factors for progression to GC.

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

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

Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness

In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett’s esophagus (BE). Barrett’s mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.

High-risk symptoms do not predict gastric cancer precursors

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.

A nomogram for endoscopic screening in a high esophageal squamous cell cancer risk area: results from a population-based study

Background

Endoscopy is the main approach used for esophageal squamous cell carcinoma (ESCC) screening, especially in high-risk areas. However, little consensus has been achieved in recent ESCC screening programs, and endoscopists have selected patients only by age and family history.

Patients and methods

To generate a proper strategy for selecting an eligible population for endoscopic screening based on demographic factors, lifestyle, and eating habits, a total of 7,830 residents in an area with a high risk of ESCC were recruited for this study. All participants underwent endoscopic examinations that were conducted by experienced endoscopists. Risk factors for ESCC and other lesions were selected by univariate and multivariate logistic regressions. A nomogram for the prediction of ESCC and premalignant lesions was constructed, which included information on age, sex, occupation, labor intensity, income, and mining exposure. Receiver operating characteristic (ROC) curve analysis was performed to present the predictive accuracy of the nomograms.

Results

The area under the curve (95% CI) was 0.749 (0.711–0.788) for this nomogram. By applying this nomogram, we could exclude 60% (4704/7830) of patients before endoscopy screening and detect all ESCC cases as well as most esophageal lesions in the remaining population.

Conclusion

In conclusion, we provided a ready-to-use preclinical tool with the potential to select eligible people with high risk of ESCC for endoscopy screening.

Cost Effectiveness of Gastric Cancer Screening According to Race and Ethnicity

BACKGROUND & AIMS

There are marked racial and ethnic differences in non-cardia gastric cancer prevalence within the United States. Although gastric cancer screening is recommended in some regions of high prevalence, screening is not routinely performed in the United States. Our objective was to determine whether selected non-cardia gastric cancer screening for high-risk races and ethnicities within the United States is cost effective.

METHODS

We developed a decision analytic Markov model with the base case of a 50-year-old person of non-Hispanic white, non-Hispanic black, Hispanic, or Asian race or ethnicity. The cost effectiveness of a no-screening strategy (current standard) for non-cardia gastric cancer was compared with that of 2 endoscopic screening modalities initiated at the time of screening colonoscopy for colorectal cancer: upper esophagogastroduodenoscopy with biopsy examinations and continued surveillance only if intestinal metaplasia or more severe pathology is identified or esophagogastroduodenoscopy with biopsy examinations continued every 2 years even in the absence of identified pathology. We used prevalence rates, transition probabilities, costs, and quality-adjusted life years (QALYs) from publications and public data sources. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/QALY.

RESULTS

Compared with biennial and no screening, screening esophagogastroduodenoscopy with continued surveillance only when indicated was cost effective for non-Hispanic blacks ($80,278/QALY), Hispanics ($76,070/QALY), and Asians ($71,451/QALY), but not for non-Hispanic whites ($122,428/QALY). The model was sensitive to intestinal metaplasia prevalence, transition rates from intestinal metaplasia to dysplasia to local and regional cancer, cost of endoscopy, and cost of resection (endoscopic or surgical).

CONCLUSIONS

Based on a decision analytic Markov model, endoscopic non-cardia gastric cancer screening for high-risk races and ethnicities could be cost effective in the United States.

Screening and Surveillance for Barrett's Esophagus: Is It Cost-Effective?

The cost-effectiveness of screening and surveillance for Barrett's esophagus continues to evolve as the incidence of esophageal adenocarcinoma increases, biomarkers enhance the identification of individuals at highest risk for developing cancer, and endoscopic eradication of Barrett's esophagus improves. Screening to detect Barrett's esophagus may be cost-effective in selected high-risk groups based on age, race, sex and other factors such as symptoms of heartburn. Currently, endoscopic eradication therapy for Barrett's esophagus and high-grade dysplasia is a cost-effective intervention, while endoscopic therapy for non-dysplastic Barrett's esophagus is not a cost-effective strategy. As diagnosis of low-grade dysplasia improves, endoscopic eradication therapy may also prove to be a cost-effective intervention.

Liquid biopsy provides new insights into gastric cancer

Liquid biopsies have great promise for precision medicine as they provide information about primary and metastatic tumors via a minimally invasive method. In gastric cancer patients, a large number of blood-based biomarkers have been reported for their potential role in clinical practice for screening, early diagnosis, prognostic evaluation, recurrence monitoring and therapeutic efficiency follow-up. This current review focuses on blood liquid biopsies' role and their clinical implications in gastric cancer patients, with an emphasis on circulating tumor cells (CTCs), circulating tumor DNA (ctDNA) and circulating non-coding RNAs (ncRNAs). We also provide a brief discussion of the potential and limitations of liquid biopsies use and their future use in the routine clinical care of gastric cancer.

Genomic and Epigenomic Profiling of High-Risk Intestinal Metaplasia Reveals Molecular Determinants of Progression to Gastric Cancer

Intestinal metaplasia (IM) is a pre-malignant condition of the gastric mucosa associated with increased gastric cancer (GC) risk. We performed (epi)genomic profiling of 138 IMs from 148 cancer-free patients, recruited through a 10-year prospective study. Compared with GCs, IMs exhibit low mutational burdens, recurrent mutations in certain tumor suppressors (FBXW7) but not others (TP53, ARID1A), chromosome 8q amplification, and shortened telomeres. Sequencing identified more IM patients with active Helicobacter pylori infection compared with histopathology (11%-27%). Several IMs exhibited hypermethylation at DNA methylation valleys; however, IMs generally lack intragenic hypomethylation signatures of advanced malignancy. IM patients with shortened telomeres and chromosomal alterations were associated with subsequent dysplasia or GC; conversely patients exhibiting normal-like epigenomic patterns were associated with regression.

Helicobacter pylori management in ASEAN: The Bangkok consensus report

Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.