Detection and treatment of early cancer in high-risk populations

doi:10.1016/j.bpg.2006.01.001

Best Practice & Research Clinical Gastroenterology

Volume 20, Issue 4, 2006, Pages 745-765

https://doi.org/10.1016/j.bpg.2006.01.001 Get rights and content

In this paper we describe how to more efficiently detect and treat early gastric cancer (EGC) in high-risk populations. For detection, we first assess the value of known risk factors from the viewpoint of availability for cancer screening. Serum pepsinogen appears to be the most useful and realistic of the factors examined, although its adequacy needs to be assessed in high-risk populations other than those in Japan. Helicobacter pylori infection is known to be a universal risk factor (or gastric carcinogen), and several interventional studies have recently shown positive results. However, H. pylori infection can be eradicated from at-risk populations, thereby decreasing its availability for cancer screening. Smokers are thought to be at risk epidemiologically, but the efficacy of screening in this population has yet to be elucidated, and further studies are warranted. Gender and aging can be risk factors in Japanese populations; male gender and old age are predominant in the intestinal type of carcinoma which is dominant in Japan, although this is not the case in the West. As for early diagnosis of cancer, only endoscopy can be commonly used for the detection of gastritis-like EGC, seen as a faint mucosal irregularity or discoloration. To make early diagnosis more accurate, it is indispensable to carry out detailed endoscopy together with careful scrutiny of the mucosa using dye-spraying techniques. The remarkable progress of early diagnosis in Japan prompted the endoscopic treatment for less invasive EGCs. The first success was with endoscopic mucosal resection (EMR). Although convenient, its therapeutic efficacy is inadequate, particularly for larger lesions. Endoscopic submucosal dissection (ESD) has no limitation on resection size and is expected to replace surgery, although it needs a high level of skill and there are several technical problems to be solved.

Section snippets

Smoking

Unlike pulmonary cancer, the effect of cigarette smoking on the risk of gastric cancer was not well elucidated until 2002, when the Japan Public Health Centre Study Group showed definitive results in a cohort study which prospectively examined a total of 19,957 Japanese men. According to this study, smoking was associated with an increased risk of the intestinal (differentiated) type of distal gastric cancer compared to the group who never smoked; the adjusted rate ratios (RRs) for past and

Resection using the snare loop

Endoscopic cancer removal was initially achieved in 1973 by colorectal polypectomy using high-frequency electric current.³⁷ In 1974 this was applied to the treatment of pedunculated or hemipedunculated EGCs in Japan. In 1984 Tada and co-workers devised a new technique of ‘jumbo biopsy’ as an application of snare polypectomy in order to get a much larger specimen and a more definitive histological diagnosis preoperatively. It was not long before they knew that this technique could completely

Discussion

As shown in the recent Japanese cancer statistics, with early diagnosis it is actually possible to decrease the mortality of gastric cancer. It will be beneficial, therefore, if simple serological screening can assess the cancer risk adequately. Although quite a few conditions have been reported to be associated with the development of this carcinoma, the risk of such conditions appears more or less to be associated with chronic atrophic gastritis, a condition believed to predispose to most

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La disección submucosa endoscópica (DSE) es una técnica terapéutica endoscópica aplicable a las neoplasias digestivas precoces y desarrollada con los objetivos de conseguir una resección radical curativa y una disminución de las intervenciones quirúrgicas innecesarias. Diseñada en los países orientales, se encuentra poco extendida en Occidente.
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Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West.
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Citation Excerpt :
Individuals with negative test results might therefore be spared from having other, more invasive, screening tests such as endoscopy. According to Japanese experience, pepsinogen testing is the most realistic and reliable serological marker for identifying high-risk populations with extensive atrophy45 that warrant endoscopy or more intensive surveillance. Gastrin-17 has been proposed for the identification of patients with gastric atrophy, particularly the extent of atrophic gastritis.
Gastric cancer is the second most common cause of death from cancer in Asia. Although surgery is the standard treatment for this disease, early detection and treatment is the only way to reduce mortality. This Review summarises the epidemiology of gastric cancer, and the evidence for, and current practices of, screening in Asia. Few Asian countries have implemented a national screening programme for gastric cancer; most have adopted opportunistic screening of high-risk individuals only. Although screening by endoscopy seems to be the most accurate method for detection of gastric cancer, the availability of endoscopic instruments and expertise for mass screening remains questionable—even in developed countries such as Japan. Therefore, barium studies or serum-pepsinogen testing are sometimes used as the initial screening tool in some countries, and patients with abnormal results are screened by endoscopy. Despite the strong link between infection with Helicobacter pylori and gastric cancer, more data are needed to define the role of its eradication in the prevention of gastric cancer in Asia. At present, there is a paucity of quality data from Asia to lend support for screening for gastric cancer.
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9Detection and treatment of early cancer in high-risk populations

Section snippets

Smoking

Resection using the snare loop

Discussion

Am J Gastroenterol

Dig Liver Dis

Clin Gastroenterol Hepatol

Cancer incidence profiles in the Miyagi Cohort Study

J Epidemiol

Trends in cancer incidence and survival in Osaka. Cancer mortality and morbidity statistics: Japan and the World-2004

Incidence and mortality from stomach cancer in Japan, Slovenia and the USA

Int J Cancer

Japan Public Health Center Study Group: cigarette smoking, alcohol consumption and subsequent gastric cancer risk by subsite and histologic type

Int J Cancer

Smoking and the risk of gastric cancer in the European Prospective Investigation Into Cancer and Nutrition (EPIC)

Int J Cancer

Associations between cigarette smoking and the risk of four leading cancers in Miyagi Prefecture, Japan: a multi-site case-control study

Cancer Sci

Cigarette smoking and the risk of gastric cancer: a pooled analysis of two prospective studies in Japan

Int J Cancer

Histological typing and grading of gastric carcinoma

Epidemiology of stomach cancer

Clinicopathological features of early gastric cancer in younger versus older patients in a high incidence area of northern Italy

Ital J Gastroenterol Hepatol

Helicobacter pylori infection and the risk of gastric carcinoma

N Engl J Med

A prospective study of atrophic gastritis and stomach cancer risk

Jpn J Cancer Res

Helicobacter pylori infection enhances N-methyl-N-nitrosourea-induced stomach carcinogenesis in the Mongolian gerbil

Cancer Res

Effect of early eradication on Helicobacter pylori-related gastric carcinogenesis in Mongolian gerbils

Cancer Sci

Impact of Helicobacter pylori infection on gastric cancer incidence in a general Japanese population: the Hisayama study

Arch Intern Med

Helicobacter pylori infection and the development of gastric cancer

N Engl J Med

Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China: a randomized controlled trial

JAMA

Helicobacter pylori eradication and gastric preneoplastic conditions: a randomized, double-blind, placebo-controlled trial

Cancer Epidemiol Biomarkers Prev

The significance of low serum pepsinogen levels to detect stomach cancer associated with extensive chronic gastritis in Japanese subjects

Jpn J Cancer Res

Meta-analysis on the validity of pepsinogen test for gastric carcinoma, dysplasia or chronic atrophic gastritis screening

J Med Screen

Serum levels of amidated gastrin-17 and pepsinogen I in atrophic gastritis: an observational case-control study

Scand J Gastroenterol

9
Detection and treatment of early cancer in high-risk populations