Is screening and surveillance for early detection of gastric cancer needed in Korean Americans?

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.

Early-Onset Gastrointestinal Malignancies: An Investigation into a Rising Concern

There is growing recognition of early-onset gastrointestinal (GI) malignancies in young adults < 50 years of age. While much of the literature has emphasized colorectal cancer, these also include esophageal, gastric, liver, pancreatic, and biliary tract malignancies. Various factors, including lifestyle, hereditary, and environmental elements, have been proposed to explain the rising incidence of GI malignancies in the younger population. This review aims to provide an overview of the recent literature, including global trends and information regarding genetic and environmental risk factors.

Individual Survival Distributions Generated by Multi-Task Logistic Regression Yield a New Perspective on Molecular and Clinical Prognostic Factors in Gastric Adenocarcinoma

Recent advances in our understanding of gastric cancer biology have prompted a shift towards more personalized therapy. However, results are based on population-based survival analyses, which evaluate the average survival effects of entire treatment groups or single prognostic variables. This study uses a personalized survival modelling approach called individual survival distributions (ISDs) with the multi-task logistic regression (MTLR) model to provide novel insight into personalized survival in gastric adenocarcinoma. We performed a pooled analysis using 1043 patients from a previously characterized database annotated with molecular subtypes from the Cancer Genome Atlas, Asian Cancer Research Group, and tumour microenvironment (TME) score. The MTLR model achieved a 5-fold cross-validated concordance index of 72.1 ± 3.3%. This model found that the TME score and chemotherapy had similar survival effects over the entire study time. The TME score provided the greatest survival benefit beyond a 5-year follow-up. Stage III and Stage IV disease contributed the greatest negative effect on survival. The MTLR model weights were significantly correlated with the Cox model coefficients (Pearson coefficient = 0.86, p < 0.0001). We illustrate how ISDs can accurately predict the survival time for each patient, which is especially relevant in cases of molecular subtype heterogeneity. This study provides evidence that the TME score is principally associated with long-term survival in gastric adenocarcinoma. Additional external validation and investigation into the clinical utility of this ISD model in gastric cancer is an area of future research.

A prospective Canadian gastroesophageal cancer database: What have we learned?

BACKGROUND

Minimal literature exists on outcomes for Canadian patients with gastroesophageal adenocarcinoma (GEA). The objective of our study was to establish a prospective clinical database to evaluate demographic characteristics, presentation and outcomes of patients with GEA.

METHODS

Patients diagnosed with GEA were recruited from Jan. 30, 2017, to Aug. 30, 2020. Data collected included demographic characteristics, presentation, treatment and survival. A multivariable model for overall survival in patients treated with curative intent was created using sex, lymph node status, resection margin status, age and tumour location as variables.

RESULTS

A total of 122 patients with adenocarcinoma of the stomach or gastroesophageal junction were included. Median age was 65 years (interquartile range [IQR] 59-74), 70% of patients were male and 26% were born outside of Canada. Median follow-up time was 14.5 (IQR 8.0-31.0) months. Following staging computed tomography scanning, 88% of patients were deemed to have potentially resectable disease. Eighty-one (76%) received staging laparoscopy and 74 (61%) were treated with curativeintent surgery. Forty-six (62%) patients had nodal metastases. The median number of nodes harvested was 22 (IQR 18-30). The R0 resection margin rate was 82%. The 3-year overall survival for patients who received curative-intent treatment was 63% and 38% for all patients. On multivariable analysis, female sex (hazard ratio [HR] 3.88, p = 0.01), positive nodal status (HR 3.58, p = 0.02), positive margins (HR 3.11, p = 0.03) and tumour location (HR 3.00, p = 0.03) were associated with decreased overall survival.

CONCLUSION

Many of the patients with GEA in this study presented with advanced disease, and only 61% were offered curative-intent surgery. A prospective multicentre national GEA database is now being established.

Prevalence of Extensive and Limited Gastric Intestinal Metaplasia and Progression to Dysplasia and Gastric Cancer

BACKGROUND AND AIMS

Guidelines cite extensive gastric intestinal metaplasia (GIM) as a bigger risk factor for gastric cancer (GC) than limited GIM and an indication for endoscopic surveillance. Data on progression of extensive GIM to GC in the USA are limited. This study aimed to estimate the prevalence and progression rates of extensive GIM in a US cohort.

METHODS

This retrospective study assessed the prevalence of extensive GIM between 1/1/1990 and 8/1/2019 at a large academic medical center. Multivariable regression was used to identify predictors of extensive GIM. Incidence of GC on follow-up was calculated as number of new diagnoses divided by person-years of follow-up. Presence of GIM on subsequent follow-up endoscopy was assessed.

RESULTS

Of 1256 individuals with GIM, 352 (28%) had extensive GIM and 904 (72%) had limited GIM. On multivariable analysis, older age (OR 1.01, 95% CI 1.00-1.02) and Hispanic ethnicity (OR 1.55, 95% CI 1.11-2.16) were predictive of extensive GIM. The annual incidence of GC for GIM overall was 0.09%. There was no difference in progression to GC between extensive or limited GIM (IRR 0, 95% CI 0-2.6), or to advanced lesions overall (IRR 0.37, 95% CI 0.04-1.62). 70% of individuals had persistent GIM on follow-up biopsy, and 22% with limited GIM had extensive GIM on follow-up biopsy.

CONCLUSIONS

28% of individuals with GIM have the extensive subtype, and are more likely to be older and of Hispanic ethnicity. There was no difference in progression to GC between extensive and limited GIM. Further research is needed to better assess risk of GIM in the US context.

Cancer among Immigrants: Diverse Histories, Diverse Disparities, Diverse Opportunities to Promote Equity

Immigrants-people who live in a country different from their country of birth-constitute approximately 250 million people globally. Migrants are diverse in their reasons for immigration, ranging from those who are forced to flee their home country for survival, to those seeking a better life. Migrants face diverse barriers in access to care. Therefore, it is critical in the context of cancer health to improve our understanding of the epidemiology of cancer amongst migrants to inform policy, screening, and management. In this issue of Cancer Epidemiology, Biomarkers & Prevention, Yu and colleagues evaluate patterns in the incidence of infection-associated cancers-cancers of the stomach, liver, and cervix-amongst migrants in Australia. They demonstrate that the incidence of infection-related cancers is heterogeneous amongst immigrant populations, underscoring the value of studies that disaggregate groups in ways that reflect the diversity amongst these groups. In this editorial, we contextualize the work of Yu and colleagues in the setting of studies exploring cancer health amongst migrants in various parts of the world. We call attention to disparities in risk factors, prevention, screening, and access to care. Finally, we call on the research and medical communities to work to elucidate their diverse stories, understand their diverse disparities, and act upon diverse opportunities to promote equity. See related article by Yu et al., p. 1394.

Introducing the Sanguis-Filum for Detection of Gastric Mucosal Lesions Prior to Endoscopy: A Study Protocol

Early diagnosis of gastric cancer (GC) is compromised by a lack of specific signs to enable identification of affected individuals. We designed the Sanguis-filum (S-filum) as a simple bedside tool that could be used to detect the presence of gastric mucosal lesions prior to endoscopy. We previously published evidence that at a sensitivity of 91%, the presence of free blood in the stomach was associated with mucosal lesions. The S-filum is made of an inert but absorbent string coiled up in a gelatin capsule (Capsuline, FL, USA), which can be swallowed and the string retrieved to test for free blood. Preliminary testing of the S-filum was successfully conducted on healthy volunteers. We now intend to test it on actual patients, comparing the results to oesophagogastroduodenoscopy (OGD) findings. This will enable us to determine the diagnostic accuracy of the S-filum at detecting GC and other mucosal lesions. The S-filum as a bedside tool has the potential to assist healthcare providers to identify individuals likely to have early gastric mucosal lesions and requiring OGD examination. The S-filum could, in the long run, facilitate population-wide screening for early GC prior to endoscopy.

Gastric Cancer Screening Methods: A Comparative Study of the Chinese New Gastric Cancer Screening Score and Kyoto Classification of Gastritis

Objective

To evaluate the Chinese new gastric cancer screening score (i.e., Li's score) and Kyoto Classification of Gastritis for screening gastric cancer.

Methods

A total of 702 patients were scored using the two scoring methods. Gastric atrophy, intestinal metaplasia, and gastric cancer (including early gastric cancer) were compared between the two scoring methods. The area under the ROC curve, sensitivity, and specificity of the two scoring methods were evaluated.

Results

Both of the two scoring methods found that gastric atrophy, intestinal metaplasia, and gastric cancer (including early gastric cancer) were all significantly higher in the medium-risk and high-risk group patients than those in the low-risk group patients. According to the Kyoto Classification of Gastritis, patients in the high-risk group had more gastric atrophy, intestinal metaplasia, and gastric cancer than those in the medium-risk group patients. Gastric atrophy, intestinal metaplasia, and gastric cancer in the low-risk and medium-risk group patients evaluated by the Li score were all significantly higher than those in patients with corresponding risk level evaluated by Kyoto Classification of Gastritis, respectively. The area under the ROC curve of the Li score was 0.702, and the sensitivity and specificity were 57.6% and 85.3%, respectively. The area under the ROC curve of the Kyoto Classification of Gastritis was 0.826, and the sensitivity and specificity were 75.4% and 83.6%, respectively.

Conclusion

Both Li's score and Kyoto Classification of Gastritis showed good screening value for gastric cancer, but Kyoto Classification of Gastritis was more sensitive than the Li score.

Race/Ethnicity and Birthplace as Risk Factors for Gastric Intestinal Metaplasia in a Multiethnic United States Population

INTRODUCTION

Several US subgroups have increased risk of gastric cancer and gastric intestinal metaplasia (GIM) and may benefit from targeted screening. We evaluated demographic and clinical risk factors for GIM and examined the interaction between race/ethnicity and birthplace on GIM risk.

METHODS

We identified patients who had undergone esophagogastroduodenoscopy with gastric biopsy from 3/2006-11/2016 using the pathology database at a safety net hospital in Houston, Texas. Cases had GIM on ≥1 gastric biopsy histopathology, whereas controls lacked GIM on any biopsy. We estimated odds ratios and 95% confidence intervals (CI) for associations with GIM risk using logistic regression and developed a risk prediction model of GIM risk. We additionally examined for associations using a composite variable combining race/ethnicity and birthplace.

RESULTS

Among 267 cases with GIM and 1,842 controls, older age (vs <40 years: 40-60 years adjusted odds ratios (adjORs) 2.02; 95% CI 1.17-3.29; >60 years adjOR 4.58; 95% CI 2.61-8.03), Black race (vs non-Hispanic White: adjOR 2.17; 95% CI 1.31-3.62), Asian race (adjOR 2.83; 95% CI 1.27-6.29), and current smoking status (adjOR 2.04; 95% CI 1.39-3.00) were independently associated with increased GIM risk. Although non-US-born Hispanics had higher risk of GIM (vs non-Hispanic White: adjOR 2.10; 95% CI 1.28-3.45), we found no elevated risk for US-born Hispanics (adjOR 1.13; 95% CI 0.57-2.23). The risk prediction model had area under the receiver operating characteristic of 0.673 (95% CI 0.636-0.710) for discriminating GIM.

DISCUSSION

We found that Hispanics born outside the United States were at increased risk of GIM, whereas Hispanics born in the United States were not, independent of Helicobacter pylori infection. Birthplace may be more informative than race/ethnicity when determining GIM risk among US populations.

Disparities and survival in newly diagnosed gastric cancer in Hispanic patients in the United States: a propensity score matched analysis

Background

The burden of gastric cancer involving Hispanic patients in the United States is growing as both the population and the incidence of gastric cancer in this group increases. This burden is compounded by presentation with advanced disease and socioeconomic challenges shaping cancer care. We sought to describe the demographics, socioeconomic factors, treatment, and survival experience of Hispanic patients with gastric adenocarcinoma.

Methods

Patients with gastric adenocarcinoma diagnosed between 2004 and 2015 (n=90,737) in the National Cancer Database were retrospectively identified. Patients of Hispanic ethnicity were compared against non-Hispanic white patients. Surgical cohort was further analyzed, and 1:1 propensity score matching was used to balance covariates between Hispanic and non-Hispanic white surgical patients. Survival was compared using Kaplan-Meier method. Cox regression was used to determine prognostic factors for survival.

Results

Compared to non-Hispanic white patients, Hispanic patients are more likely to be younger, female, and healthier. They were more likely to be uninsured, reside in poorer neighborhoods and reside in areas with lower rates of education. Hispanic patients were more likely to live in a metropolitan area, travel shorter distances for healthcare, and receive treatment at an academic and high volume centers. Hispanic patients were more likely to have higher stage disease presentation, higher grade tumors, lymphovascular invasion, and poorly cohesive adenocarcinoma. Hispanic patients were more likely to receive surgery, but less likely to receive adjuvant therapy. In Cox regression of all patients, unmatched surgical patients, and matched surgical patients, Hispanic ethnicity was an independent prognostic factor of improved survival.

Conclusions

Hispanic patients with gastric adenocarcinoma present with several unfavorable clinicopathologic and socioeconomic factors. Paradoxically, these patients demonstrate improved survival. Further study is warranted to characterize disease biology in this population.

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

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

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

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

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

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.

Quantification of the sensitivity of early detection surveillance

Early detection surveillance is used for various purposes, including the early detection of non‐communicable diseases (e.g. cancer screening), of unusual increases of disease frequency (e.g. influenza or pertussis outbreaks), and the first occurrence of a disease in a previously free population. This latter purpose is particularly important due to the high consequences and cost of delayed detection of a disease moving to a new population. Quantifying the sensitivity of early detection surveillance allows important aspects of the performance of different systems, approaches and authorities to be evaluated, compared and improved. While quantitative evaluation of the sensitivity of other branches of surveillance has been available for many years, development has lagged in the area of early detection, arguably one of the most important purposes of surveillance. This paper, using mostly animal health examples, develops a simple approach to quantifying the sensitivity of early detection surveillance, in terms of population coverage, temporal coverage and detection sensitivity. This approach is extended to quantify the benefits of risk‐based approaches to early detection surveillance. Population‐based clinical surveillance (based on either farmers and their veterinarians, or patients and their local health services) provides the best combination of sensitivity, practicality and cost‐effectiveness. These systems can be significantly enhanced by removing disincentives to reporting, for instance by implementing effective strategies to improve farmer awareness and engagement with health services and addressing the challenges of well‐intentioned disease notification policies that inadvertently impose barriers to reporting.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gastrointestinal Cancers: Screening and Early Detection

OBJECTIVE

To present an overview of current practices in the screening and early detection of gastrointestinal cancers.

DATA SOURCES

Literature reviews.

CONCLUSION

Screening for gastrointestinal cancers is less than desirable, particularly in underserved populations. There are inadequate methods of screening for early detection of esophageal and gastric cancers.

IMPLICATIONS FOR NURSING PRACTICE

Education of patients is needed to reinforce the importance of screening for gastrointestinal cancers.

Gastric cancer and family history

Gastric cancer is associated with high morbidity and mortality rates worldwide. Identifying individuals at high risk is important for surveillance and prevention of gastric cancer. Having first-degree relatives diagnosed with gastric cancer is a strong and consistent risk factor for gastric cancer, but the pathogenic mechanisms behind this familial aggregation are unclear. Against this background, we reviewed the risk factors for gastric cancer in those with a first-degree relative with gastric cancer, and the possible causes for familial clustering of gastric cancer including bacterial factors, inherited genetic susceptibility, environmental factors or a combination thereof. Among individuals with a family history, current or past Helicobacter pylori infection, having two or more first-degree affected relatives or female gender was associated with an increased risk of developing gastric cancer. To date, no specific single nucleotide polymorphism has been shown to be associated with familial clustering of gastric cancer. H. pylori eradication is the most important strategy for preventing gastric cancer in first-degree relatives of gastric cancer patients, particularly those in their 20s and 30s. Early H. pylori eradication could prevent the progression to intestinal metaplasia and reduce the synergistic effect on gastric carcinogenesis in individuals with both H. pylori infection and a family history. Endoscopic surveillance is also expected to benefit individuals with a family history. Further large-scale, prospective studies are warranted to evaluate the cost-effectiveness and optimal time point for endoscopy in this population. Moreover, genome-wide association studies that incorporate environmental and dietary factors on a 'big data' basis will increase our understanding of the pathogenesis of gastric cancer.

Endoscopic gastritis, serum pepsinogen assay, and Helicobacter pylori infection

Endoscopic findings of the background gastric mucosa are important in the Helicobacter pylori-seroprevalent population. It is strongly correlated not only with the risk of gastric cancer, but also with the excretion ability of gastric mucosa cells. In noninfected subjects, common endoscopic findings are regular arrangement of collecting venules, chronic superficial gastritis, and erosive gastritis. In cases of active H. pylori infection, nodularity on the antrum, hemorrhagic spots on the fundus, and thickened gastric folds are common endoscopic findings. The secreting ability of the gastric mucosa cells is usually intact in both noninfected and actively infected stomachs, and the intragastric condition becomes hyperacidic upon inflammation. Increased serum pepsinogen II concentration correlates well with active H. pylori infection, and also indicates an increased risk of diffuse-type gastric cancer. In chronic inactive H. pylori infection, metaplastic gastritis and atrophic gastritis extending from the antrum (closed-type chronic atrophic gastritis) toward the corpus (open-type chronic atrophic gastritis) are common endoscopic findings. The intragastric environment is hypoacidic and the risk of intestinal-type gastric cancer is increased in such conditions. Furthermore, there is a decrease in serum pepsinogen I concentration when the secreting ability of the gastric mucosa cells is damaged. Serologic and endoscopic changes that occur upon H. pylori infection are important findings for estimating the secreting ability of the gastric mucosa cells, and could be applied for the secondary prevention of gastric cancer.

How Do We Manage Gastric Intestinal Metaplasia? A Survey of Clinical Practice Trends for Gastrointestinal Endoscopists in the United States

BACKGROUND

Gastric intestinal metaplasia (GIM) is an accepted pathologic precursor to gastric adenocarcinoma (GAC). While surveillance of GIM in Europe and Asia is common, only limited recommendations related to endoscopic surveillance of GIM exist in the United States.

AIM

To understand the clinical practice patterns of US gastroenterologists in the management and endoscopic surveillance of GIM.

METHODS

A 23 item survey was developed to explore endoscopists' opinions regarding the surveillance of GIM and knowledge of current guidelines. Eight clinical vignettes were developed to address specific clinical scenarios where endoscopic surveillance of GIM might be considered.

RESULTS

There were 227 respondents, with 60 % working primarily in the private sector and 40 % in academic medicine. While 68 % of the respondents refer to major society guidelines for guidance in patient management, almost 78 % of endoscopist responders believe that there are no specific US guidelines pertaining to surveillance of GIM. Only two-thirds of respondents believe that based on current data, patients at increased risk of GAC should be a part of an endoscopic surveillance program, while 15 % believe all patients with GIM should receive endoscopic surveillance. Respondents use a wide range of biopsy techniques and surveillance intervals for patients with GIM, with no consistent pattern of practice identified.

CONCLUSIONS

There is variability in the knowledge and practice patterns of US endoscopists related to surveillance of gastric intestinal metaplasia. In the absence of detailed US GI society guidelines, many endoscopists perform surveillance endoscopy on patients with GIM using variable biopsy techniques and surveillance intervals.

Massive Endoscopic Screening for Esophageal and Gastric Cancers in a High-Risk Area of China

OBJECTIVE

This study aims to describe the findings from a massive endoscopic screening program in a high-risk area of China and to evaluate the prognosis of patients diagnosed through endoscopic screening compared with those diagnosed at usual hospital visits because of illness.

METHODS

In 2006, an early detection and treatment program was initiated in Yangzhong county, China. Local residents aged 40-69 years were eligible for free endoscopic screening. Endoscopic examination was performed with Lugol's iodine staining, followed by biopsies. Patients diagnosed with esophageal or gastric cancer were referred for treatment and followed to assess their long-term survival status.

RESULTS

From 2006 through 2012, we screened 12453 participants, including 5334 (42.8%) men and 7119 (57.2%) women. The average age was 52.8 ± 8.0 years. We detected 166 patients with upper digestive tract cancers, including 106 cancers in the esophagus (detection rate: 0.85%) and 60 cancers in the stomach (detection rate: 0.48%). Of these patients, 98.11% with esophageal cancer and 100% with gastric cancer were defined as at the early stage. In the process of follow-up, 17 patients died from cancer-related causes, and the median survival time was greater than 85 months. The overall survival rates for 1, 3 and 5 years were 98.0%, 90.0% and 89.0%, respectively. A significant positive effect was observed for the long-term survival of patients diagnosed through massive endoscopic screening.

CONCLUSIONS

In a high-risk population, massive endoscopic screening can identify early stage carcinoma of esophageal and gastric cancers and improve patients' prognosis through early detection and treatment.