Stomach cancer screening
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]
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Overview
Screening cancer
The two main modalities for gastric cancer screening are upper endoscopy and contrast radiography.
Upper endoscopy
- Upper endoscopy is more sensitive than other screening studies. It allows direct visualization of the gastric mucosa and obtaining biopsies. [17-21].
Contrast radiography
- Barium radiographs can identify malignant gastric ulcers, infiltrating lesions, and some early gastric cancers.
- Barium studies can be false negative in 50 percent of cases. On the other hand, the sensitivity of a barium study may be 14 percent [4] [3]
- In patients with linitis plastica, barium study may be superior to upper endoscopy.
COMPARISON OF SCREENING METHODS
Test performance
Gastric cancer detection rates were 2.61 and 0.68 per 1000 screenings, respectively. The sensitivity rates for upper endoscopy versus upper GI series in detecting gastric cancer were 69 and 37 percent, respectively. Both studies had a specificity of 96 percent. The sensitivity of upper endoscopy in detecting a localized gastric cancer was also significantly higher as compared with upper GI series (68 versus 32 percent). In total, 2067 interval cancers occurred within one year of a negative upper GI series and 1083 cancers occurred after a negative upper endoscopy, but there was no difference in interval cancer rates (1.2 per 1000 screenings for both groups).
Effectiveness
There are no data from large randomized trials demonstrating lower gastric cancer-related mortality in screened populations [17,23-30]. In addition, lead time bias, length bias, and selection bias must be considered when appraising the overall effectiveness of screening demonstrated in observational studies. In a retrospective cohort study of 19,168 gastric cancer patients in Korea, endoscopy-screened patients and patients screened with upper GI series were significantly more likely to be diagnosed with localized gastric cancer as compared with never-screened patients (odds ratio 2.1, 95% CI 1.9-2.3 and 1.2, 95% CI 1.1-1.4, respectively) [30]. However, this study did not include data as to which patients were symptomatic or had undergone evaluation outside of the screening program for evaluation of symptoms.
Screening for gastric cancer may be cost-effective for high-risk subgroups, but not low-risk populations [31,32]. A cost-effectiveness analysis found that in a high-risk group of Chinese men ages 50 to 70 years (standardized incidence of gastric cancer of 25.9 per 100,000 population), screening with upper endoscopy every two years was highly cost-effective ($28,836 per quality-adjusted life-years saved [31]). By contrast, averting one gastric cancer death in men in the United States, assuming an incidence of gastric cancer of <10 per 100,000 population, would cost approximately $247,600, which does not compare favorably with other generally accepted cancer screening interventions
SCREENING STRATEGIES
Universal screening
In countries with a high incidence of gastric cancer such as east asia countaries, universal screening is recommended. [17-19]
In Japan, population-based screening for gastric cancer is recommended for individuals older than 50 years with conventional double-contrast barium radiograph with photofluorography every year or upper endoscopy every two to three years [20,33,34].
Screening interval is recommended to be every two years but may be widened to a three-year rather than a two-year interval without significant effect [38-40].
A total of 91 incident cases were found during 19,598,598 person-years of follow-up, and the MST for gastric cancer was 2.4 years (95% CI 1.9-3.0). Of note, the MST was shorter in individuals 40 to 49 years of age (1.3 years, 95% CI 1.0-1.7) than the MST in those 50 to 59 years of age or 60 to 69 (3.2 and 3.7, respectively).
Selective screening of high-risk subgroups
In areas of low gastric cancer incidence, screening for gastric cancer with upper endoscopy should be reserved for specific high-risk subgroups [41-52].
Individuals at increased risk for gastric cancer include those with the following:
●Gastric adenomas
●Pernicious anemia
●Gastric intestinal metaplasia
●Familial adenomatous polyposis
●Lynch syndrome
●Peutz-Jeghers syndrome
●Juvenile polyposis syndrome