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Evidence of Benefit

Gastroscopic examination has been proposed as a screening method for the early detection of gastric cancer. No randomized trials evaluating the impact of screening on mortality from gastric cancer have been reported, although a Japanese study randomizing municipalities within a prefecture is ongoing.[1]

Time-trend analysis and case-control studies of gastric endoscopy suggest a twofold decrease in gastric cancer mortality in screened versus unscreened individuals;[2,3,4,5,6] however, this stands in contrast to studies of stronger design.

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A cohort study of 24,134 individuals with a follow-up period of 40 months did not demonstrate a statistically significant decrease in gastric cancer mortality among men or women who were screened compared with those who were not screened.[7] A larger prospective study examined the association between screening in the past 12 months and subsequent gastric cancer mortality and other-cause mortality. The risk of death from gastric cancer and from causes of death other than gastric cancer were reduced among those who had participated in gastric cancer screening programs, demonstrating a selection for healthier individuals into screening programs.[8]

Another cohort study was conducted in Linqu County, China, where gastric cancer rates are high, in which over 4,000 adult residents were screened. Individuals were screened at an average of 4.5-year intervals, except for a high-risk subset (689 individuals) that was screened 2 years after the initial examination. Of the 85 cases of gastric cancer occurring in the cohort, 58 were detected with screening. No impact on gastric cancer mortality was observed among screened individuals. The standardized mortality ratio (SMR) for gastric cancer 10 years after the initial screen was 1.01 (95% confidence interval, 0.72-1.37). The SMR for all-cause mortality was significantly lower among participants since individuals with hypertension, liver disease, and chronic obstructive pulmonary disease were not eligible to participate.[9] The study was not designed to evaluate screening, and the intervals between screens were long.

A screening study was begun in Venezuela in 1980, using radiographic fluorography.[10] The efficacy of this program in reducing mortality from stomach cancer was evaluated by means of a case-control study. Analyses determined that the tests were ineffective in reducing mortality from gastric cancer.

In Japan, measurement of serum pepsinogen (PGI and PGII) levels in 5,113 subjects also screened by endoscopy (13 gastric cancers detected), used cut-off points for identifying risk for gastric cancer of less than 70 ng/mL for pepsinogen I and less than 3 for the PGI:PGII ratio. This combination provided a sensitivity of 84.6%, a specificity of 73.5%, a positive predictive value of 0.81%, and a negative predictive value of 99.6%.[11]

There may be some justification for screening some populations of Americans at higher risk, although there is considerable discussion about how much incidence would make the examination worthwhile. Potential subgroups might include elderly patients with atrophic gastritis or pernicious anemia, patients with partial gastrectomy,[12] patients with the diagnosis of sporadic adenomas,[13] familial adenomatous polyposis,[14] or hereditary nonpolyposis colon cancer,[15] and immigrant ethnic populations from countries with high rates of gastric carcinoma.[16,17]

References:

  1. Hisamuchi S, Fukao P, Sugawara N, et al.: Evaluation of mass screening programme for stomach cancer in Japan. In: Miller AB, Chamberlain J, Day NE, et al., eds.: Cancer Screening. Cambridge: Cambridge University Press, 1991, pp 357-372.
  2. Murakami R, Tsukuma H, Ubukata T, et al.: Estimation of validity of mass screening program for gastric cancer in Osaka, Japan. Cancer 65 (5): 1255-60, 1990.
  3. Kampschöer GH, Fujii A, Masuda Y: Gastric cancer detected by mass survey. Comparison between mass survey and outpatient detection. Scand J Gastroenterol 24 (7): 813-7, 1989.
  4. Oshima A, Hirata N, Ubukata T, et al.: Evaluation of a mass screening program for stomach cancer with a case-control study design. Int J Cancer 38 (6): 829-33, 1986.
  5. Hirayama T, Hisamichi S, Fujimoto I, et al.: Screening for gastric cancer. In: Miller AB, ed.: Screening for Cancer. New York, NY: Academic Press, 1985, pp 367-376.
  6. Tytgat GN, Mathus-Vliegen EM, Offerhaus J: Value of endoscopy in the surveillance of high-risk groups for gastrointestinal cancer. In: Sherlock P, Morson BC, Barbara L, et al., eds.: Precancerous Lesions of the Gastrointestinal Tract. New York, NY: Raven Press, 1983, pp 305-318.
  7. Inaba S, Hirayama H, Nagata C, et al.: Evaluation of a screening program on reduction of gastric cancer mortality in Japan: preliminary results from a cohort study. Prev Med 29 (2): 102-6, 1999.
  8. Mizoue T, Yoshimura T, Tokui N, et al.: Prospective study of screening for stomach cancer in Japan. Int J Cancer 106 (1): 103-7, 2003.
  9. Riecken B, Pfeiffer R, Ma JL, et al.: No impact of repeated endoscopic screens on gastric cancer mortality in a prospectively followed Chinese population at high risk. Prev Med 34 (1): 22-8, 2002.
  10. Pisani P, Oliver WE, Parkin DM, et al.: Case-control study of gastric cancer screening in Venezuela. Br J Cancer 69 (6): 1102-5, 1994.
  11. Kitahara F, Kobayashi K, Sato T, et al.: Accuracy of screening for gastric cancer using serum pepsinogen concentrations. Gut 44 (5): 693-7, 1999.
  12. Staël von Holstein C, Eriksson S, Huldt B, et al.: Endoscopic screening during 17 years for gastric stump carcinoma. A prospective clinical trial. Scand J Gastroenterol 26 (10): 1020-6, 1991.
  13. Ming S, Goldman H: Gastric polyps: a histogenetic classification and its relation to carcinoma. Cancer 18(6): 721-726, 1965.
  14. Utsunomiya J, Maki T, Iwama T, et al.: Gastric lesion of familial polyposis coli. Cancer 34 (3): 745-54, 1974.
  15. Aarnio M, Salovaara R, Aaltonen LA, et al.: Features of gastric cancer in hereditary non-polyposis colorectal cancer syndrome. Int J Cancer 74 (5): 551-5, 1997.
  16. Kurtz RC, Sherlock P: The diagnosis of gastric cancer. Semin Oncol 12 (1): 11-8, 1985.
  17. Boeing H: Epidemiological research in stomach cancer: progress over the last ten years. J Cancer Res Clin Oncol 117 (2): 133-43, 1991.
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Last Updated: October 07, 2011
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