Cost-effectiveness analysis of chemotherapy for advanced gastric cancer in China

Quality of Health Economic Evaluations in Mainland China: A Comparison of Peer-Reviewed Articles in Chinese and in English

OBJECTIVE

Our objective was to assess the incidence and quality of reporting of published health economic evaluations in mainland China and compare the quality of peer-reviewed articles in Chinese and English.

METHODS

A comprehensive search was conducted for economic evaluations pertaining to China published from 2006 to 2015 using the PubMed, CBM, CMCC, CNKI, VIP, and Wanfang databases. All studies in English that met the inclusion criteria were included. For studies in Chinese, 200 sampled studies were included according to the random seeds method, and the same number of the most-cited studies in Chinese as those in English were included according to the number of citations and journal grades. Researchers independently assessed the quality of the studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

After literature search and screening, a total of 310 studies were identified. The majority of these studies were cost-effectiveness studies (82.26%). Scores among different CHEERS items varied greatly. There was a gap between the average quality scores of the studies published in Chinese and those published in English (49.78 ± 9.31 vs. 82.48 ± 17.69) and between the average quality scores of the included most-cited studies in Chinese and English, which was slightly smaller (54.08 ± 10.27 vs. 82.48 ± 17.69). The methods, results, and discussion sections of studies published in Chinese were of low quality.

CONCLUSION

The quality of reporting of health economic evaluations in mainland China has developed slowly. Most of the included studies were incomplete in the presentation of content, making the results less reliable. It is important to standardize and improve the quality of Chinese health economic research.

Patient-based cost-effectiveness analysis of FOLFIRI versus FOLFOX7 for advanced gastric adenocarcinoma in China: A 4-year prospective randomised phase II study

BACKGROUND

Using data from the 4-year follow-up results of an open, randomised, phase II study, this patient-based cost-effectiveness analysis compares mFOLFIRI (irinotecan, 5-fluorouracil and leucovorin, the IRI arm) with mFOLFOX7 (oxaliplatin, 5-fluorouracil and leucovorin, the OXA arm) as first-line treatments in patients with locally advanced gastric adenocarcinoma (GC).

METHODS

A Markov model was created based on previous results reported at the 2016 Gastrointestinal Cancers Symposium to evaluate mFOLFIRI and mFOLFOX7 for advanced GC quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were examined as the primary outcomes.

RESULTS

For the evaluable 128 patients, treatment efficacy was 0.59 QALYs for the IRI arm and 0.70 QALYs for the OXA arm, with a total cost of $13,861.34 for the IRI arm and $14,127.30 for the OXA arm. Hence, the ICER was $2,417.82 per QALY the OXA arm, which was below the threshold of 3 × per capita GDP of China. For subgroup analysis of those receiving mFOLFIRI followed by mFOLFOX7 (the IRI arm) and the reverse (the OXA arm), the OXA arm gained 0.44 more QALYs than the IRI arm with a total cost of $28,890.09 for the IRI arm and $31,147.30 for the OXA arm. However, the cost per QALY was also lower for the OXA arm than for the IRI arm, and the cost per QALY gained was $5,129.55 (below the Chinese WTP).

CONCLUSION

mFOLFOX7 is a very high cost-effective alternative as the first-line treatment for those patients with advanced GC compared with mFOLFIRI.

Targeted literature review of the global burden of gastric cancer

Gastric cancer (GC) and gastroesophageal junction cancers (GEJCs) are the third leading cause of cancer-related death worldwide. Although several studies have evaluated the epidemiology and management of GC and GEJC, to our knowledge, no global estimates of the economic burden of GC and GEJC have yet been reported. This targeted literature review was conducted to summarise the epidemiology and management of GC and GEJC and to estimate its global economic and humanistic burden. The incidence of GC and GEJC is highest in Eastern Asia, several South and Central American countries and Central and Eastern Europe and lowest in North America and Africa. Prognosis is generally poor; the global 5-year survival rate is 5%-10% in advanced stages. Patients with GC and GEJC have more severe symptoms compared with patients with other cancers, and health-related quality of life (HRQoL) worsens as the disease progresses. Given the rapid progression of GC and GEJC at advanced stages, chemotherapy, despite its toxicity, improves HRQoL compared with best supportive care. The costs of GC/GEJC are generally higher than for other cancers; in the US, the average annual cost per patient between 1998 and 2003 was 46,501 USD, compared with 29,609 USD and 35,672 USD for colorectal and lung cancer, respectively. Based on the 2012 incidence data and average costs per patient, estimates of the annual financial burden of GC and GEJC revealed great regional differences. Japan and Iran had the highest (8,492 million USD) and lowest (27 million USD) costs for 2017, respectively, while the estimate for the US was 3,171 million USD. The overall annual cost of GC and GEJC estimated for 2017 in a geographic area including Europe (France, Germany, Italy, Spain and the UK), Asia (Iran, Japan and China), North America (Canada and the US) and Australia was 20.6 billion USD.

Cost-effectiveness and safety of ramucirumab plus paclitaxel chemotherapy in the treatment of advanced and recurrent gastric cancer

Introduction Weekly paclitaxel (PTX), irinotecan (CPT-11) and ramucirumab plus paclitaxel (Ram + PTX) are currently recommended as the standard second-line or later chemotherapies for advanced and recurrent gastric cancer. This study aims to compare the cost-effectiveness of using Ram + PTX vs. PTX or CPT-11. Furthermore, we investigated the safety and treatment continuity of Ram + PTX in Japan. Methods Expected costs were calculated based on data from patients with advanced and recurrent gastric cancer who were treated with PTX, CPT-11 and Ram + PTX. A literature review was performed to obtain clinical information so that the probability of the efficacy of each chemotherapy could be calculated. The cost-effectiveness ratio of each chemotherapy agent was calculated by dividing the expected cost by the median survival time (MST). Results The cost-effectiveness ratio per month was JPY 85,395.8/MST for the PTX regimen, JPY 132,735.4/MST for the CPT-11 regimen and JPY 657,175.4/MST for the Ram + PTX regimen (p < 0.001). The incremental cost-effectiveness ratio per month of the Ram + PTX regimen to the PTX regimen was JPY 2,780,432.4/MST. The incremental cost-effectiveness ratio of the Ram + PTX regimen to the CPT-11 regimen was JPY 2,185,179.0/MST. With regard to the reasons for discontinuation of treatment, the Ram + PTX regimen had only one case of being discontinued owing to adverse events, and had a profile similar to that of the PTX and CPT-11 regimens. Conclusion These findings show that the Ram + PTX regimen is less cost-effective compared to both the PTX and CPT-11 regimen, but the Ram + PTX regimen is a well-tolerated regimen with sufficient efficacy.

Combination of cecropinXJ and LY294002 induces synergistic cytotoxicity, and apoptosis in human gastric cancer cells via inhibition of the PI3K/Akt signaling pathway

The aim of the present study was to investigate the cytotoxic and apoptotic effects of cecropinXJ against human gastric cancer BGC823 cells, either alone, or in combination with a specific phosphatidylinositol 3-kinase (PI3K) inhibitor, LY294002. Cell viability and the apoptosis rate were measured using flow cytometry with Annexin-V staining. Additionally, the expression levels of several RAC-α serine/threonine kinase (Akt) phosphorylation-associated proteins and apoptosis-regulating proteins were evaluated by western blot analysis. It was observed that the combination of cecropinXJ and LY294002 resulted in significant synergistic cytotoxic and apoptosis effects, as compared with any single agent alone, in a dose-dependent manner. Corresponding to enhanced apoptosis, the expression levels of certain apoptosis-regulating proteins were changed, the most notable being the upregulation of caspase-3, B-cell lymphoma-2 (Bcl-2)-associated death promotor, Bcl-2 homologous antagonist killer, Bcl-2 interacting killer, Bcl-2-like protein 11, Bcl-2-like protein 4 and cytochrome c, and the downregulation of phosphorylated-Bad and Bcl-2 proteins. The present study provided a novel therapeutic regimen for the use of the cecropinXJ in combination with LY294002 for the treatment of gastric cancer.

Comparisons of short-term and survival outcomes of laparoscopy-assisted versus open total gastrectomy for gastric cancer patients

OBJECTIVES

The safety and surgical oncology of laparoscopy-assisted total gastrectomy (LATG) remain inconclusive and challenging. This study aimed to compare the short-term and long-term outcomes between LATG and open total gastrectomy (OTG) procedures.

RESULTS

In the all-included analyses, there were 69 patients in the LATG group and 268 in the OTG group. LATG was as safe as OTG without increasing postoperative morbidity and mortality. Stage imbalance might introduce differences in the numbers of harvested lymph nodes in LATG (34.4 ± 12.0) and OTG (40.9 ± 16.9), whereas 95.7% of patients underwent D2/D2+ dissection during the LATG procedure. After a median 31 months of follow-up, the overall survival outcomes were comparable between the LATG and OTG procedures (HR = 1.16, 95% CI 0.68-1.97). Sensitivity analysis found comparable node retrieval and stage-specific or treatment-specific overall survival.

MATERIALS AND METHODS

A retrospective case-control study was conducted among gastric cancer patients who underwent either LATG or OTG with curative intention between June 2006 and December 2015. Data retrieval was based on the Surgical Gastric Cancer Patient Registry in the West China Hospital. The primary outcome was overall survival. The secondary outcomes were postoperative complication incidence and severity, operation duration, blood loss, number of harvested lymph nodes, and postoperative hospital stay. Matched pairwise case-control comparisons were performed as a sensitivity analysis.

CONCLUSIONS

LATG by experienced surgeons possibly has comparable short-term surgical outcomes and long-term survival outcomes compared with OTG for gastric cancer patients. However, high-quality RCTs are necessary before confirmative judgment and recommendation as an optional treatment in general practice.

Relationship of Amplification and Expression of the C-MYC Gene with Survival among Gastric Cancer Patients

BACKGROUND

During the past decades, the incidence and mortality rate of stomach cancer has demonstrated a great decrease in the world, but it is still one of the most common and fatal cancers especially among men worldwide, including Iran. The MYC proto-oncogene, which is located at 8q24.1, regulates 15% of genes and is activated in 20% of all human tumors. MYC amplification and overexpression of its protein product has been reported in 15-30% of gastric neoplasias. The aim of this investigation was to find the relative efficacy of CISH (chromogenic in situ hybridization) or IHC (immunohistochemistry) in diagnosis and prognosis of gastric cancer, as well as the relationship of amplification and expression of C-MYC gene with patient survival.

MATERIALS AND METHODS

In this cross-sectional study, 102 samples of gastric cancer were collected from patients who had undergone primary surgical resection at the Cancer Institute Hospital, Tehran University of Medical Sciences, from July 2009 to March 2014. All samples were randomly selected from those who were diagnosed with gastric adenocarcinomas. CISH and IHC methods were performed on all of them.

RESULTS

Patients were classified into two groups. The first consisted of stage I and II cases, and the second of stage III and IV. Survival tests for both groups was carried out with referrnce to CISH test reults. Group II (stage III and IV) with CISH+ featured lower survival than those with CISH- (p=0.233), but group I (stage I and II) patients demonstrated no significant variation with CISH+ or CISH- (p=0.630). Kaplan-Meier for both groups was carried out with IHC test findings and showed similar results. This data revealed that both diffuse and intestinal types of gastric cancer occurred significantly more in men than women. Our data also showed that CISH+ patients (43%) were more frequent in comparison with IHC+ patients (14.7%).

CONCLUSIONS

For planning treatment of gastric cancer patients, by focusing on expanding tumors, which is the greatest concern of the surgeons and patients, CISH is a better and more feasible test than IHC, in regard to sensitivity and specificity. Therefore, CISH can be used as a feasible test for tumor growth and prognosis in stage III and IV lesions. This study also indicated that C-MYC amplification in gastric cancer is correlated with survival in advanced stages.

Associations between serum CA724 and HER2 overexpression among stage II-III resectable gastric cancer patients: an observational study

OBJECTIVES

Associations between serum tumor biomarkers and human epidermal growth factor receptor 2 (HER2) overexpression among locally advanced gastric cancer patients were yet to be determined and therefore warranted investigation.

RESULTS

A total of 318 patients were analyzed. The odds ratios of CA724 were 4.79 (95% CI 1.55-14.79) and 6.29 (1.40-28.19) in comparing the HER2 (2+/3+) and HER2 (3+) with the negative group, respectively (p < 0.05). A combination of the four biomarkers yielded slightly but not significantly greater areas under the curve (AUC = 0.83; 0.71-0.94) than that of serum CA724 alone (0.80; 0.68-0.91); however, an index generated from the combination had better diagnostic performance with 85.7% sensitivity, 80.4% specificity and 97.8% negative predictive value to predict the strong overexpression of HER2 (3+). CA199, CEA or CA125 alone was not associated with HER2 overexpression. Leave-one-out cross-validation found a consistent association between serum CA724 and HER2 (2+/3+) overexpression.

METHODS

Patients undergoing radical gastrectomy from 8/2012 to 12/2013 and with pathological stage II-III gastric cancer were retrospectively analyzed. HER2 expression of the surgical samples was estimated using immunohistochemistry; serum CA724, CA199, CEA and CA125 were preoperatively tested. Internal validation was performed using the leave-one-out approach.

CONCLUSIONS

Serum CA724 is significantly associated with the overexpression of HER2 among locally advanced gastric cancer patients. The combination of CA724, CA199, CEA and CA125 is better than serum CA724 alone in predicting HER2 overexpression. External validation and further investigation of the biological mechanisms of these associations are required.

Preoperative serum CEA and CA19-9 in gastric cancer--a single tertiary hospital study of 1,075 cases

To evaluate the clinical impact of preoperative serum CEA and CA19-9 on resectable gastric cancer (GC), a total of 1,075 consecutive cases with gastric adenocarcinoma were obtained retrospectively from January 2012 and December 2013 in a single tertiary hospital, and the relationships between serum CEA, CA19-9 and clinicopathologic features were investigated. Positive preoperative serum rates of CEA and CA19-9 were 22.4% and 12.3% respectively, levels significantly correlating with each other and depth of invasion, lymph node involvement, pTNM and stage. The CEA level also presented a remarkable association with lymphovascular invasion. Both CEA and CA19-9 positivity significantly and positively correlated with depth of invasion, nodal involvement, pTNM stage, lymphovascular invasion, tumor size and tumor location. Stratified analyses according to gender or tumor location showed preoperative CEA or CA19-9 had different associations with clinicopathologic features in different gender subgroups or location subgroups. Preoperative serum CA19-9 positivity may be more meaningful for tumor size rather than CEA. In conclusion, preoperative serum CEA and CA19-9 correlate with disease progression of GC, and may have applications in aiding more accurate estimation of tumor stage, decision of treatment choice and prognosis evaluation.

The Cost Effectiveness of Docetaxel and Active Symptom Control versus Active Symptom Control Alone for Refractory Oesophagogastric Adenocarcinoma: Economic Analysis of the COUGAR-02 Trial

BACKGROUND

The COUGAR-02 trial recently showed survival and quality-of-life benefits of docetaxel and active symptom control (DXL + ASC) over active symptom control (ASC) alone in patients with refractory oesophagogastric adenocarcinoma.

AIM

The aim of this study was to conduct an economic evaluation conforming to National Institute for Health and Care Excellence (NICE) technology appraisal guidance to evaluate the cost effectiveness of DXL + ASC versus ASC from the perspective of the English National Health Service (NHS).

METHODS

Cost-utility analyses were conducted using trial data. Utility values were captured using the EQ-5D completed by patients at 3- and 6-weekly intervals, while resource use was captured using nurse-completed report forms and patient reports. Incremental cost-effectiveness ratios (ICERs) were calculated and the main outcome was cost per incremental quality-adjusted life-year (QALY). Nonparametric bootstrapping was conducted to capture sampling uncertainty and to generate a cost-effectiveness acceptability curve (CEAC). The analysis horizon was the trial period (median follow-up 12 months) and no modelling or discounting of future costs and benefits was conducted.

RESULTS

Average costs were £9352 and £6218 for DXL + ASC and ASC, respectively, and average QALYs were 0.302 and 0.186, respectively. This yielded an ICER of £27,180 for DXL + ASC. DXL + ASC had a 24 % chance of being cost effective at a £20,000 QALY threshold (lambda) and a mean net monetary benefit of -£821; this rose to 59 % and £332 when the threshold was raised to £30,000. If NICE end-of-life criteria are applied, the probability of cost effectiveness increases to 90 % (at lambda = £50,000). Results were robust to sensitivity analyses.

CONCLUSIONS

DXL + ASC is likely to be cost effective if an end-of-life premium is applied. Further research should determine the impact of different utility measurement strategies and different chemotherapy delivery modes on estimates of cost effectiveness.

Risk factors and prognostic significance of retropancreatic lymph nodes in gastric adenocarcinoma

Background. The studies on risk factors and metastatic rate of retropancreatic (number 13) lymph nodes in gastric adenocarcinoma were few and the results were still controversial. The aim of this study was to elucidate risk factors and prognostic significance of number 13 lymph nodes in gastric adenocarcinoma. Method. From January 2000 to December 2011, 114 patients who underwent gastrectomy with number 13 lymph nodes dissection were enrolled and followed up to January 2014. Patients were grouped according to whether number 13 lymph nodes were positive or negative. Results. The metastatic rate of number 13 lymph nodes was 22.8%. In multivariate analysis, pT stage (P = 0.027), pN stage (P = 0.005), and number 11p (P = 0.015) lymph nodes were independent risk factors of positive number 13 lymph nodes. In all patients (P < 0.001) and subpopulation with TNM III stage (P = 0.007), positive number 13 lymph nodes had significantly worse prognosis than those of patients with negative number 13 LNs in Kaplan-Meier analysis. Conclusion. Number 13 lymph nodes had relatively high metastatic rate and led to poor prognosis. pT stage, pN stage, and number 11p lymph nodes were independent risk factors of positive number 13 lymph nodes.

Individualized proximal margin for early gastric cancer patients

There is no robust evidence to define a safe proximal margin by distance for early gastric cancer (EGC). The discussion on resection margin should not only focus on the oncologic safety, but also the postgastrectomy quality of life. The distance 1-10 mm is only acceptable for those endoscopic treatment fit EGC patients. For endoscopic unfit EGC cases, if the borderline of tumor is able to be clearly determined intraoperatively, the distance 1-3 cm is recommended for proximal resection margin. If there is any uncertainty on the tumor borderline, the distance 3-5 cm should be considered for proximal margin.

Genetic variation in C12orf51 is associated with prognosis of intestinal-type gastric cancer in a Chinese population

Recent genome-wide association study (GWAS) on esophageal squamous-cell carcinoma (ESCC) among Chinese population has identified two novel single nucleotide polymorphisms (SNPs) rs11066280 and rs2074356 on C12orf51 gene. We hypothesized that SNPs rs11066280 and rs2074356 could influence gastric cancer survival outcomes. We genotyped the SNPs rs11066280 and rs2074356 in 940 patients with surgically resected gastric cancer. Analyses of genotype association with survival outcomes were assessed by the Kaplan-Meier method, Cox proportional hazards models and the log-rank test. There was no significant association between rs11066280 and survival of gastric cancer. However, in the stratification analysis of histology, we found that the rs11066280 TA/AA genotypes were associated with a poor survival of intestinal-type gastric cancer (log-rank P=0.041, hazard ratio [HR]=1.40, 95% confidence interval [CI]=1.02-1.93), Moreover, this hazardous effect was more prominent among patients with tumor size>5cm, no distant metastasis, chemotherapy and drinking. No significant association was observed between rs2074356 and the survival of gastric cancer. C12orf5 rs11066280 could be useful marker of survival assessment and individualized clinical therapy for gastric cancer, particularly among the intestinal-type gastric cancer.

Combined use of lysyl oxidase, carcino-embryonic antigen, and carbohydrate antigens improves the sensitivity of biomarkers in predicting lymph node metastasis and peritoneal metastasis in gastric cancer

The purpose of this study was to determine whether lysyl oxidase (LOX) is a useful marker of metastasis in gastric cancer (GC) patients in combination with tumor markers carcino-embryonic antigen (CEA), carbohydrate antigen 724 (CA724), carbohydrate antigen 19-9 (CA19-9), and carbohydrate antigen 125 (CA125). There were 215 GC patients (67 without metastasis, 102 with lymph node metastasis, and 46 with peritoneal metastasis) who presented to the Affiliated Cancer Hospital of Guangxi Medical University between May 2009 and November 2012 that were enrolled in this study. The LOX expression level and the serum concentration of the four tumor markers were evaluated preoperatively. All patients underwent computed tomography (CT) and ultrasonography (US) before surgery. Statistical analysis, including receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) analysis, and logistic regression analysis, was performed to evaluate the diagnostic value of these markers in predicting metastasis in GC. For predicting lymph node metastasis in GC, the sensitivity of LOX, CEA, CA724, CA199, and CA125 was 44.12, 12.75, 21.57, 23.53, and 15.69 %, respectively, and increased to 79.41 % in combination. For predicting peritoneal metastasis in GC, the sensitivity of these markers was 56.52, 23.91, 34.78, 36.96, and 34.78 %, respectively, and increased to 91.30 % in combination. Combining LOX with CEA, CA724, CA199, and CA125 could increase the sensitivity of predicting lymph nodes metastasis and peritoneal metastasis in GC. Surgeons can use these markers to determine the best treatment options for patients. Additional large-scale, prospective, multicenter studies are urgently needed to further confirm the results of this study.

Metastasis, risk factors and prognostic significance of splenic hilar lymph nodes in gastric adenocarcinoma

Background

The metastatic rate and risk factors of splenic hilar (No.10) lymph nodes (LNs) in gastric adenocarcinoma were still variable and uncertain, and the prognostic significance of No.10 LNs was also controversial. The aim of this retrospective study was to analyze the metastatic rate, risk factors and prognostic significance of No.10 LNs in gastric adenocarcinoma.

Methods

From August 2007 to December 2011, 205 patients who were diagnosed with primary gastric adenocarcinoma and underwent total or proximal gastrectomy plus No.10 LNs dissection in West China Hospital were enrolled. Clinicopathological features and survival outcomes were retrospectively analyzed.

Results

Mean numbers of harvested LNs and metastatic LNs were 34.8±12.6 (15–73) and 8.7±10.8 (0–67), respectively. The proportion of cases with positive No.10 LNs was 8.8% (18/205). In all 204 dissected No.10 LNs, 47 LNs (23.0%) were metastatic. In 52.2% (107/205) patients, the dissected splenic hilar tissues were histologically determined as only fat tissues but without LNs structure. Histological evidence of LNs structure was found in 98 (47.8%) patients with 18.4% (18/98) metastatic No.10 LNs. In multivariate logistic regression analysis, metastasis of No.10 LNs was significantly correlated with No.4sa LNs (p = 0.010) and pN stage (p = 0.012). Regarding survival analysis, 199 (97.1%) patients were followed up (0.6–74.8 months). In all patients with R0 resection, metastatic No.10 LNs caused significantly worse prognosis both in Kaplan-Meier (p = 0.006) and Cox regression analysis (p = 0.031).

Conclusions

Although the metastatic rate of No.10 LNs was 8.8%, dissection of No.10 LNs might be meaningful due to the poor prognosis of positive cases. And attentions should be also paid to its correlated factors including pN stage and No.4sa LNs.

Quantitative comparisons of summary receiver operating characteristics (sROC) curves among conventional serological tumor biomarkers for predicting gastric cancer in Chinese population

The objective of this study is to quantitatively analyze the predictive strength among the conventional serological tumor biomarkers for gastric cancer in Chinese population. Thirty-three hospital-based case-control studies were searched out through Chinese databases and PubMed during 1999-2009. Gastric cancer cases and healthy volunteers or benign gastric diseases controls were detected of any of serological CA724, CA242, CEA, CA199, CA125, or CA153. Areas under the curve (AUC) and optimal Q indexes of summary receiver operating characteristics (sROC) curves were quantitatively compared. The summary positive and negative likelihood ratios (sLR + and sLR-) were pooled. Totally, 2,390 gastric cancer cases and 2,893 controls were analyzed. CA724 and CA242 both had the greatest AUCs (0.88), respectively, followed by the combination CA724 + CEA + CA199 (0.85), CA125 (0.82), CEA (0.80), and CA199 (0.76), but all of them had no statistical significance to CA153 (negative control) by Z tests, possibly due to relatively great standard errors. The results of Q index analyses were similar to those of AUCs, that CA724 and CA242 had the optimal strength. The sLR + of CA724 (16.08, 95 % confidence interval (CI) 7.86-32.86) or CA242 (11.03, 95 % CI 7.12-17.08) was strong to judge the gastric cancer status based on its positive result. The combination of CA724 + CEA + CA199 had the prior sLR- (0.33, 95 % CI 0.25-0.43) to the others. Serological CA724 or CA242 has predictive effect for screening gastric cancer and can be recommended into the screening program of population-based or symptomatic cases. However, prospective epidemiological studies are required before confirmative conclusion.

FOXM1 mediates resistance to docetaxel in gastric cancer via up-regulating Stathmin

Docetaxel is commonly used as an effective chemotherapeutic drug for gastric cancer patients recently. With the increasing emergence of docetaxel resistance nowadays, identification of suitable biomarkers for predicting chemosensitivity to docetaxel may be a key role for improving therapeutic effects for gastric cancer patients. In this study, we investigated the correlation between the expression of transcription factor forkhead box protein M1 (FOXM1) and chemotherapy response to docetaxel in gastric cancer, the possible mechanism for which was further explored. As a result, FOXM1 overexpression was shown to mediate resistance to docetaxel in gastric cancers. It altered microtubule dynamics to protect tumour cells from docetaxel-induced apoptosis. Mechanistic investigations revealed that tubulin-destabilizing protein Stathmin, which mediated docetaxel resistance in FOXM1-silenced gastric cancer cells, is a direct down-stream target of FOXM1, whereas another microtubule dynamics protein mitotic centromere–associated kinesin (MCAK), shown to be related to docetaxel resistance in gastric cancer cells, is not associated with FOXM1 expression significantly. These results were further provided by immunohistochemical analysis, indicating that FOXM1 and Stathmin expression levels were correlated in 103 post-operational gastric cancer specimens. Moreover, when we attenuated FOXM1 expression with FOXM1 inhibitor thiostrepton, docetaxel resistance in gastric cancers was found to be reversed, simultaneously with the down-regulation of FOXM1 and Stathmin. Therefore, FOXM1 can be a useful marker for predicting and monitoring docetaxel response. Through the inhibition of FOXM1, docetaxel resistance can be reversed, and thus FOXM1 could be a new therapeutic target in docetaxel-resistant gastric cancer.

Cost-utility analysis of the newly recommended adjuvant chemotherapy for resectable gastric cancer patients in the 2011 Chinese National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Gastric Cancer

BACKGROUND

Postoperative adjuvant chemotherapy with capecitabine and oxaliplatin was first recommended for resectable gastric cancer patients in the 2011 Chinese National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Gastric Cancer, but the economic influence of this therapy in China is unknown.

OBJECTIVE

The aim of the present study was to determine the cost-effectiveness of adjuvant chemotherapy with capecitabine and oxaliplatin after a gastrectomy with extended (D2) lymph-node dissection, compared with a D2 gastrectomy alone, for patients with stage II-IIIB gastric cancer.

METHODS

On the basis of data from the CLASSIC trial, a Markov model was created to determine economic and clinical data for patients in the chemotherapy and surgery group (CSG) and the surgery-only group (SOG). The costs, presented in 2010 US dollars and estimated from the perspective of the Chinese health-care system, were obtained from the published literature and the local health system. The utilities were based on published literature. Costs, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICER) were estimated. A lifetime horizon and a 3 % annual discount rate were used. One-way and probabilistic sensitivity analyses were performed.

RESULTS

For the base case, the CSG compared with SOG would increase LYs and QALYs in a 3-, 5-, 10- or 30-year time horizon (except the QALYs at 3 or 5 years). In the short run (such as in 3 or 5 years), the medical costs would increase owing to adjuvant chemotherapy of capecitabine plus oxaliplatin after D2 gastrectomy, but in the long run the costs would decline. The ICERs suggested that the SOG was dominant at 3 or 5 years and the CSG was dominant at 10 or 30 years. The one-way sensitivity analysis showed that the utility of disease-free survival for 1-10 years for the SOG and the cost of oxaliplatin were the most influential parameters. The probabilistic sensitivity analysis predicted a 98.6 % likelihood that the ICER for the CSG would be less than US$13,527/QALY (three times the per capita gross domestic product of China).

CONCLUSION

For patients in China with resectable disease, our results suggest that adjuvant chemotherapy with capecitabine plus oxaliplatin after a D2 gastrectomy is cost-saving and dominant in the long run on the basis of a current clinical trial, compared with treatment with a D2 gastrectomy alone.

A genetic polymorphism in TOX3 is associated with survival of gastric cancer in a Chinese population

Purpose

Recently, genetic polymorphism (rs3803662C>T) in TOX3 was reported to induce the risk of breast cancer. In this study, we hypothesized that rs3803662 could influence gastric cancer survival outcomes.

Methods

With multiplex SNaPshot method, we genotyped TOX3 rs3803662 in 880 gastric patients with surgical resection. The association between genotype and survival outcomes was performed by the Kaplan-Meier method, Cox regression analysis models and the log-rank test.

Results

There was no association in the analyses of rs3803662 and survival of gastric cancer. However, the stratified analysis by histology showed that rs3803662 CT/TT genotype was associated with a significantly better survival for diffuse-type gastric cancer (log-rank p = 0.030, hazard ratio [HR]  = 0.67, 95% confidence interval [CI]  = 0.46–0.96), than the CC genotype. In addition, this favorable effect was especially obvious among gastric cancer patients with tumor size >5 cm, T3 and T4 depth of invasion, lymph node metastasis, no drinking, no distant metastasis, no chemotherapy and gastric cardia cancer.

Conclusions

TOX3 rs3803662 might play an important role in the prognostic outcome and treatment of gastric cancer, especially perhaps further help in explaining the reduced risk of death associated with diffuse-type gastric cancer.

Forkhead box transcription factor 1 expression in gastric cancer: FOXM1 is a poor prognostic factor and mediates resistance to docetaxel

Background

Forkhead box transcription factor 1 (FOXM1) has been reported to overexpress and correlate with pathogenesis in a variety of human malignancies. However, little research has been done to investigate its clinical significance in gastric cancer.

Methods

We examined the expression of FOXM1 in 103 postoperational gastric cancer tissues and 5 gastric cell lines by immunohistochemistry and western blot analysis respectively. Data on clinic-pathological features and relevant prognostic factors in these patients were then analyzed. Moreover, the association of FOXM1 expression and chemosensitivity to docetaxel in gastric cancer cells was further explored.

Results

Our study demonstrated that the level of FOXM1 expression was significantly higher in gastric cancer than in para-cancer tissues (P < 0.001) and normal gastric cell lines (P = 0.026). No significant association was found between FOXM1 expression and any clinical pathological features (P > 0.1). FOXM1 amplification was identified as an independent prognostic factor in gastric cancer (P = 0.001), and its affection is more significant in patients with tumor size larger than 5 cm (P = 0.004), pT3-4 (P = 0.003) or pIII-IV (P = 0.001). Additionally, shown to mediate docetaxel resistance in gastric cancers by our research, FOXM1 was revealed to alter microtubule dynamics in response to the treatment of docetaxel, and the drug resistance could be reversed with FOXM1 inhibitor thiostrepton treatment.

Conclusions

FOXM1 can be a useful marker for predicting patients’ prognosis and monitoring docetaxel response, and might be a new therapeutic target in docetaxel resistant gastric cancer.

Docetaxel, cisplatin and fluorouracil (DCF) regimen compared with non-taxane-containing palliative chemotherapy for gastric carcinoma: a systematic review and meta-analysis

BACKGROUND

Gastric carcinoma (GC) is one of the highest cancer-mortality diseases with a high incidence rate in Asia. For surgically unfit but medically fit patients, palliative chemotherapy is the main treatment. The chemotherapy regimen of docetaxel, cisplatin and 5-fluorouracil (DCF) has been used to treat the advanced stage or metastatic GC. It is necessary to compare effectiveness and toxicities of DCF regimen with non-taxane-containing palliative chemotherapy for GC.

METHODS

PubMed, EmBase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure databases were searched to select relative randomized controlled trials (RCTs) comparing DCF to non-taxane-containing chemotherapy for patients with palliatively resected, unresectable, recurrent or metastatic GC. Primary outcome measures were 1-year and 2-year overall survival (OS) rates. Secondary outcome measures were median survival time (MST), median time to progression (TTP), response rate and toxicities.

RESULTS

Twelve RCTs were eligible and 1089 patients were analyzed totally (549 in DCF and 540 in control). DCF regimen increased partial response rate (38.8% vs 27.9%, p = 0.0003) and reduced progressive disease rate (18.9% vs 33.3%, p = 0.0005) compared to control regimen. Significant improvement of 2-year OS rate was found in DCF regimen (RR = 2.03, p = 0.006), but not of 1-year OS rate (RR = 1.22, p = 0.08). MST was significantly prolonged by DCF regimen (p = 0.039), but not median TTP (p = 0.054). Both 1-year OS rate and median TTP had a trend of prolongation by DCF regimen. Chemotherapy-related mortality was comparable (RR = 1.23, p = 0.49) in both regimens. In grade I-IV toxicities, DCF regimen showed a major raise of febrile neutropenia (RR = 2.33, p<0.0001) and minor raises of leucopenia (RR = 1.25, p<0.00001), neutropenia (RR = 1.19, p<0.00001), and diarrhea (RR = 1.59, p<0.00001), while in other toxicities there were no significant differences.

CONCLUSION

DCF regimen has better response than non-taxane containing regimen and could potentially improve the survival outcomes. The chemotherapy-related toxicity of DCF regimen is acceptable to some extent.

Prognostic value of cancer stem cell marker CD133 expression in gastric cancer: a systematic review

Objective

To investigate the correlation between CD133-positive gastric cancer and clinicopathological features and its impact on survival.

Methods

A search in the Medline and Chinese CNKI (up to 1 Dec 2011) was performed using the following keywords gastric cancer, CD133, AC133, prominin-1 etc. Electronic searches were supplemented by hand searching reference lists, abstracts and proceedings from meetings. Outcomes included overall survival and various clinicopathological features.

Results

A total of 773 gastric cancer patients from 7 studies were included. The median rate of CD133 expression by immunohistochemistry (IHC) was 44.8% (15.2%–57.4%) from 5 studies, and that by reverse transcription polymerase chain reaction (RT-PCR) was 91.3% (66.7%–100%) from 4 studies. The accumulative 5-year overall survival rates of CD133-positive and CD133-negative patients were 21.4% and 55.7%, respectively. Meta-analysis showed that CD133-positive patients had a significant worse 5-year overall survival compared to the negative ones (OR = 0.20, 95% CI 0.14–0.29, P<0.00001). With respect to clinicopathological features, CD133 overexpression by IHC method was closely correlated with tumor size, N stage, lymphatic/vascular infiltration, as well as TNM stage.

Conclusion

CD133-positive gastric cancer patients had worse prognosis, and was associated with common clinicopathological poor prognostic factors.

c-Jun N-terminal kinase is required for thermotherapy-induced apoptosis in human gastric cancer cells

AIM: To investigate the role of c-Jun N-terminal kinase (JNK) in thermotherapy-induced apoptosis in human gastric cancer SGC-7901 cells.

METHODS: Human gastric cancer SGC-7901 cells were cultured in vitro. Following thermotherapy at 43 °C for 0, 0.5, 1, 2 or 3 h, the cells were cultured for a further 24 h with or without the JNK specific inhibitor, SP600125 for 2 h. Apoptosis was evaluated by immunohistochemistry [terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)] and flow cytometry (Annexin vs propidium iodide). Cell proliferation was determined by 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide. The production of p-JNK, Bcl-2, Bax and caspase-3 proteins was evaluated by Western blotting. The expression of JNK at mRNA level was determined by reverse transcription polymerase chain reaction.

RESULTS: The proliferation of gastric carcinoma SGC-7901 cells was significantly inhibited following thermotherapy, and was 32.7%, 30.6%, 43.8% and 52.9% at 0.5, 1, 2 and 3 h post-thermotherapy, respectively. Flow cytometry analysis revealed an increased population of SGC-790l cells in G0/G1 phase, but a reduced population in S phase following thermotherapy for 1 or 2 h, compared to untreated cells (P < 0.05). The increased number of SGC-790l cells in G0/G1 phase was consistent with induced apoptosis (flow cytometry) following thermotherapy for 0.5, 1, 2 or 3 h, compared to the untreated group (46.5% ± 0.23%, 39.9% ± 0.53%, 56.6% ± 0.35% and 50.4% ± 0.29% vs 7.3% ± 0.10%, P < 0.01), respectively. This was supported by the TUNEL assay (48.2% ± 0.4%, 40.1% ± 0.2%, 61.2% ± 0.29% and 52.0% ± 0.42% vs 12.2% ± 0.22%, P < 0.01) respectively. More importantly, the expression of p-JNK protein and JNK mRNA levels were significantly higher at 0.5 h than at 0 h post-treatment (P < 0.01), and peaked at 2 h. A similar pattern was detected for Bax and caspase-3 proteins. Bcl-2 increased at 0.5 h, peaked at 1 h, and then decreased. Furthermore, the JNK specific inhibitor, SP600125, suppressed p-JNK, Bax and caspase-3 at the protein level in SGC790l cells following thermotherapy, compared to mock-inhibitor treatment, which was in line with the decreased rate of apoptosis. The expression of Bcl-2 was consistent with thermotherapy alone.

CONCLUSION: Thermotherapy induced apoptosis in gastric cancer cells by promoting p-JNK at the mRNA and protein levels, and up-regulated the expression of Bax and caspase-3 proteins. Bcl-2 may play a protective role during thermotherapy. Activation of JNK via the Bax-caspase-3 pathway may be important in thermotherapy-induced apoptosis in gastric cancer cells.

Correlation between serum CA724 and gastric cancer: multiple analyses based on Chinese population

Serum tumor biomarker carbohydrate antigen 724 (CA724) is noticeable for gastric cancer. Correlation between CA724 and gastric cancer was investigated based on Chinese population. Chinese Biomedical Database, Chinese Journal Full-text Database and PubMed were searched. Gastric cancer patients were proven by biopsy, and control included health volunteers or benign gastric diseases. Participants received at least one test of CA724, CA125, CA153, CA199, CA242 or CEA. Meta-analysis, summary ROC (SROC) and post hoc analysis were performed by RevMan 5.0 and SPSS 11.5. Totally, 33 eligible studies were analyzed. Meta-analysis showed CA724 had the highest odds ratio 32.86 compared to control, orderly followed by CA242, CA199, CEA, CA125 and CA153. Accumulated accuracy rate of CA724 was 77 %, superior to others. In SROC analysis, specificity of all studies was above 0.70, but sensitivity of few studies was above 0.70; CA724 was selected as the preferable single test, followed by CA242, CA199, CEA, CA125 and CA153. If threshold of both specificity and sensitivity up to 0.70, CA153 was unacceptable; if up to 0.80, only CA724 and CA242 were considerable. In CA724-combined patterns, CA724+CEA+CA199 combination performed best by increasing sensitivity to 0.74 without impairing specificity, while CA724 + CA199 pattern was not a proper combination. CA724 was the most correlative serum tumor biomarker for gastric cancer in Chinese population. Sensitivity of serum CA724 is limited, but CA724+CEA+CA199 combination is considerable to improve sensitivity without impairing specificity.

Comparison of short-term outcomes and perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer

OBJECTIVE

To compare the perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer.

METHODS

Patients with gastric adenocarcinoma proven by endoscopy and biopsy were eligible, while patients with preoperative staging of T4, N2-3, or M1 were excluded. Eligible patients willing to undertake laparoscopic surgery in the consecutive cohort were assigned to the laparoscopy-assisted gastrectomy (LAG) group, while concurrent patients were assigned to the conventional open gastrectomy (OG) group. All operations were performed with the intention of radical resection. Various immunological parameters were tested in peripheral venous blood collected at preoperative 1(st) day and postoperative 2(nd) day (POD2) and 7(th) day (POD7). SPSS 13.0 software was used for statistical analysis.

RESULTS

Thirty patients were included, 15 each in the LAG and OG groups. The general characteristics and short-term outcomes (harvested lymph nodes number, hospital stay, complications, and mortality rate) of the two groups were comparable, but the operation time was significantly longer in LAG (P = 0.001). Moreover, intergroup comparisons indicated no significant differences between the groups in levels of neutrophils, T-lymphocytes, natural killer cells, IgG, IgM, IgA, C3, C4, interleukin-6, or interleukin-10 at any time point (P>0.05). However, there was a gradual decrease in natural killer cell count in the LAG group up to POD7 (P = 0.008).

CONCLUSION

The changes in systemic immunity markers were comparable between laparoscopy-assisted and open gastrectomy for gastric cancer. However, there was a trend of suppression of natural killer cells in the laparoscopy-assisted gastrectomy group.

Neoadjuvant plus adjuvant chemotherapy benefits overall survival of locally advanced gastric cancer

Neoadjuvant chemotherapy (NAC) has drawn more attention to the treatment of locally advanced gastric cancer (AGC) in the current multidisciplinary treatment model. EORTC trial 40954 has recently reported that NAC plus surgery without postoperative adjuvant chemotherapy could not benefit the locally AGC patients in their overall survival. We performed a meta-analysis of 10 studies including 1518 gastric cancer patients. Stratified subgroups were NAC plus surgery and NAC plus both surgery and adjuvant chemotherapy (AC), while control was surgery alone. The results showed that NAC plus surgery did not benefit the patients with locally AGC in their overall survival [odds ratio (OR) = 1.20, 95% CI 0.80-1.80, P = 0.37] and the number needed to treat (NNT) was 74. However, the NAC plus both surgery and AC had a slight overall survival benefit (OR = 1.33, 95% CI 1.03-1.71, P = 0.03) and NNT was 14, which is superior to the NAC plus surgery. Therefore, we recommend that combined NAC and AC should be used to improve the overall survival of the locally AGC patients.

CDH1 -160C>A gene polymorphism is an ethnicity-dependent risk factor for gastric cancer

The associations between E-cadherin (CDH1) gene polymorphisms and gastric cancer (GC) susceptibility are still controversial. Given this uncertainty, we carried out a meta-analysis of published case-control studies to derive more precise estimations of these relationships. Relevant studies were identified from PubMed and EMBASE up to March 2011. Seventeen studies with 3511 GC cases and 4826 controls were selected. Crude odds ratios (OR) and 95% confidence intervals (CI) were used to investigate the strength of the associations. No associations between CDH1 (+54T>C, -160C>A, -347G>GA, -616G>C, -2076C>T and -3159T>C) gene polymorphisms and GC risk for all genetic models were found. As for CDH1 -160C>A polymorphism, subgroup analyses by country, gender, study design, smoking status, Helicobacter pylori infection, and the Lauren classification of GC did not change the results. When stratified by ethnicity, we found the A allele carriers had a significantly increased risk of GC among Caucasians (AA vs. CA+CC: OR=1.50, 95% CI=1.03-2.19, P=0.03), but not among Asians (AA vs. CA+CC: OR=0.87, 95% CI=0.56-1.37, P=0.56). No publication bias was found in the present study. This meta-analysis suggests that CDH1 -160C>A gene polymorphism may contribute to increased risk of GC among Caucasians.

Widespread sequence variation in the Epstein-Barr virus latent membrane protein 2A gene among northern Chinese isolates

Latent membrane protein 2A (LMP2A) is expressed in most Epstein-Barr virus (EBV)-associated malignancies. Besides its roles in the maintenance of latent infection and epithelial-cell transformation, LMP2A could also act as the target for a CTL-based therapy for EBV-associated malignancies. In the present study, sequence polymorphisms in LMP2A from northern Chinese EBV-associated gastric carcinoma patients, nasopharyngeal carcinoma patients and healthy donors were identified and compared with the prototype B95-8 strain. Four consistent mutations were detected in all isolates. Frequent mutations in the analysed sequences distinguished two and seven types of sequence variation in exon 1 and exons 2-8, respectively, with no consistent association shown between the genotyping of the two gene fragments. The immunoreceptor tyrosine-based activation motif and PY motif in the amino terminus were strictly conserved. Nine of the 16 identified CTL epitopes were affected by at least one point mutation, which may confer complexity to proposed immunotherapeutic approaches for EBV-associated malignancies. Most changed epitopes showed higher mutation rates in tumour isolates than in throat-washing samples from healthy donors, in accordance with the idea that virus strains can evade immune surveillance by altering amino acids within LMP epitopes. This first detailed investigation of sequence variations in the LMP2A gene reveals classifiable sequence polymorphisms in exon 1 and exons 2-8, and encourages further work on the impact of viral gene variations on tumour persistence and CTL-based immunotherapy.

Astrocyte-elevated gene-1 overexpression is associated with poor prognosis in gastric cancer

Astrocyte-elevated gene-1 (AEG-1) plays an important role in diverse cancers and its up-regulation is associated with poor survival of patients. However, the status of AEG-1 expression and its significance in gastric cancer are still unclear. In this study, the expression of AEG-1 was studied in different gastric cancer cell lines and gastric cancer tissues. Expression of AEG-1 was significantly higher in gastric cancer tissues than that in normal tissues. Overexpression of AEG-1 was found in 62.9% of gastric cancers and significantly associated with TNM stage and Ki-67 proliferation index (P < 0.01). For survival study, overexpression of AEG-1 was significantly associated with poor survival (P < 0.01). Further multivariate analysis suggested that AEG-1 overexpression was an independent prognostic factor for the disease. We demonstrated that inhibition of AEG-1 expression by specific siRNA clearly inhibited SGC-7901 cell growth and enhanced cell apoptosis (P < 0.01). Inhibition of AEG-1 reduced phosphorylation of AKT and glycogen synthase kinase (GSK)-3β (Ser 9) and decreased the level of β-catenin, lymphoid enhancer binding factor 1 (LEF1), and Cyclin D1. This indicated that AEG-1 may play a role in Wnt/β-catenin-mediated cancer progression. Taken together, overexpression of AEG-1 could be a useful prognostic factor in patients with gastric cancer. Targeted inhibition of AEG-1 may provide a novel therapeutic strategy for gastric cancer.

Short-term evaluation of laparoscopy-assisted distal gastrectomy for predictive early gastric cancer: a meta-analysis of randomized controlled trials

BACKGROUND

In recent decade, laparoscopy-assisted distal gastrectomy (LADG) has been introduced to treatment of early gastric cancer (EGC). Previous meta-analyses included the randomized controlled trial (RCT) apparently contaminated with advanced gastric cancer. Besides, more RCTs enrolling the predictive EGC are available. The present meta-analysis was aimed to compare LADG with open distal gastrectomy (ODG) by updating the literature search and repooling the RCTs of only predictive EGC with improved methodology.

METHODS

Comprehensive search of PubMed, EmBase, and multiple websites of clinical trials registration and oncologic groups were performed. Only short-term outcomes measures were considered to meta-analysis. The RevMan 5.0 was used for pooled estimates.

RESULTS

Six RCTs of 629 patients totally were included for meta-analysis. Comparing LADG to ODG, results found less postoperative early morbidity (risk ratios=0.61, P=0.01), similar mortality (risk difference=0.01, P=0.32), prolonged operation time [mean difference (MD)=86.64 min, P<0.00001], decreased intraoperative blood loss (MD=-108.33 mL, P=0.001), decreased number of harvested lymph nodes (MD=-4.88, P<0.00001), forwarded time to oral intake (MD=-0.48 d, P=0.32), and shortened hospital stay (MD=-2.03 d, P=0.14).

CONCLUSIONS

LADG could bring the patients with EGC slight benefits by decreasing intraoperative blood loss and postoperative early morbidity, but unfavorably, might increase the operation time and decease the number of harvested lymph nodes. The long-term survival benefit is still eager to be proven by further outcomes of RCTs.