Introduction

Discrepancies in gastric cancer (GC) mortality reduction are evident across global GC screening programs. Specifically, the reduction brought by endoscopic screening nearly doubled in Japan and Korea compared with China. Despite studies indicating that economic status, screening methods, and public health awareness may influence screening efficiency, there is no comprehensive study that has summarized and compared the outcomes of available screening programs and identified factors potentially influencing the cancer-preventive effects.

Aims & Methods

Here we present data, including response to invitation, uptake of endoscopy screening and cancer screening positivity, of global GC screening programs. By pooling three key indicators throughout screening process, including endoscopic compliance rate, GC detection rate and early diagnosis rate, we conducted a meta-analysis of global GC endoscopic screening programs, in order to compare the outcomes of available screening programs and identify possible influencing factors. PubMed, Embase, Web of Science, and Scopus were searched for relevant articles published until September 20, 2023. Original articles providing enough information to calculate the indicators in the general screening population were included. Pooled random effect estimates of the indicators were computed, and further subgroup analysis stratified according to study period, country or region, setting, screening interval, education level and socioeconomic status was conducted. This study was registered with PROSPERO (CRD42023464921).

Results

90 studies (59 reported endoscopic compliance rate, 68 reported GC detection rate and 33 reported GC early diagnosis rate) were included. Overall, the rates of endoscopic compliance, GC detection, and early-cancer diagnosis were 46.94% (95%CI 41.35-52.53%), 0.62% (95%CI 0.46-0.80%), and 61.41% (95%CI 51.42-71.40%), respectively. Subgroup analysis demonstrated a gradual increase in endoscopic compliance and a counterintuitive decline in GC detection rate over time. Stratified by countries, the three indicators in Japan (51.05% [37.06-65.05%] for endoscopic compliance rate, 0.89% [0.55-1.31%] for GC detection rate, and 78.98% [68.83-87.66%] for GC early diagnosis rate) and Korea (49.78% [38.77-60.80%] for endoscopic compliance rate, 1.07% [0.05-3.38%] for GC detection rate, and 69.84% [61.51-77.57%] for GC early diagnosis rate) were significantly higher in China (39.68% [31.84-47.52%] for endoscopic compliance rate, 0.51% [0.33-0.74%] for GC detection rate, and 51.35% [36.33-66.37%] for GC early diagnosis rate). The highest endoscopic compliance and GC detection rate was reported in hospital, while GC early diagnosis rate was higher in community and health checkup. Screening programs with 2-3 years intervals, public health campaigns, higher education levels, and socioeconomic status showed higher compliance. Screening programs based on new endoscopic techniques generally reported higher GC detection and early diagnosis rates.

Conclusion

Among high-incidence countries for GC, China lags behind Japan and Korea regarding endoscopic compliance rate, GC detection rate and early diagnosis rate. Screening settings, intervals, campaigns, education and socioeconomic stratum may affect endoscopic compliance, while GC detection and early diagnosis rates are mainly influenced by screening settings and endoscopic techniques. In the future, continuous monitoring of quality control indicators should be applied in GC screening programs and the screening strategy should be adjusted accordingly to improve screening effectiveness.

Introduction

Gastric Cancer has been a heavy burden in far East Asian countries. Although there are national programs in South Korea and Japan, their evidence has been suggested as insufficient. We aimed to synthesize currently available comparative data on gastric cancer mortality in healthy, asymptomatic adults by explicitly classifying the screening effects through study designs and types of intervention effects.

Aims & Methods

We searched multiple databases through October 31, 2022, for this systematic review　and meta-analysis. Studies of any design that compared gastric cancer mortality among radiographic or endoscopic screening and no screening in a community-dwelling adult population was included. The method included a duplicate assessment of eligibility, double extraction of summary data, and validity assessment using the Risk Of Bias In Non-randomized Studies of Interventions tool. Bayesian three-level hierarchical random-effects meta-analysis synthesized data corrected for self-selection bias on the relative risk (RR) for per-protocol (PP) and intention-to-screening (ITS) effects. The study registration number at PROSPERO is CRD42021277126.

Results

We included seven studies in which a screening program was newly introduced (median attendance rate, 31%; at a moderate-to-critical risk of bias) and seven cohort and eight case-control studies with ongoing screening programs (median attendance rate, 21%; all at critical risk of bias); thus, data of 1,667,117 subjects were included. For the PP effect, the average risk reduction was significant for endoscopy (RR 0.58; 95% credible interval: 0.39–0.90) but non-significant for radiography (RR 0.80; 95%CI 0.60–1.06). The ITS effect was not significant for both radiography (0.98; 95%CI 0.86–1.21) and endoscopy (RR 0.94; 95%CI 0.74–1.44). The effects' magnitude depended on the self-selection bias correction assumptions. Restricting the scope of East Asian studies only did not change the results.

Conclusion

In limited-quality observational evidence from high-prevalence regions, screening reduced gastric cancer mortality; however, the effects diminished at a program level.

Disclosure

I have no conflict of interest.

Introduction

The diagnosis of advanced gastric cancer (AGC) is occasionally challenging for endoscopists. In particular, scirrhous gastric cancer (SGC) is often missed by esophagogastroduodenoscopy (EGD) alone because it may not form obvious ulcers or tumors. Early detection of SGC is difficult, and the prognosis is often poor. Considering the rapid progression of SGC, an accurate endoscopic diagnosis of the disease is desirable. SGC is diagnosed using computed tomography, EGD, and EGD-biopsy. In AGC, except for SGC, a definitive diagnosis can be made in >90% of cases when EGD findings are combined with EGD-biopsy. However, SGC is often difficult to diagnose even with EGD-biopsy. One report has indicated that the false-negative proportion of EGD-biopsy in SGC is >50%, because compared to other AGCs, SGC presents a variety of endoscopic findings, as well as special growth forms and morphological features. Therefore, the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) instead of EGD-biopsy in the diagnosis of SGC has recently been reported, and the positive diagnosis proportion is as high as 71.4%–82.6%. Against this background, we believe that EUS-FNA is an alternative for diagnosing EGD-biopsy-negative SGC. Therefore, we conducted a systematic review and meta-analysis to analyze the EUS-FNA diagnosis rate from previous reports in the diagnosis of SGC, verify the advantages and disadvantages of EUS-FNA, and evaluate the utility of EUS-FNA for the current SGC diagnostic landscape.

Aims & Methods

A systematic review was conducted using the PubMed (MEDLINE) and Ichushi-Web (NPO Japan Medical Abstracts Society) data and included all entries since their inception to October 10, 2022, in which SGC was evaluated using EUS-FNA. The following electronic search terms were used to retrieve the literature in PubMed: ("endosonography"[MeSH] OR "endosonography"[tiab] OR “EUS”[tiab] OR "biopsy, fine needle"[MeSH] OR “fine needle aspiration”[tiab] OR “fine needle biopsy”[tiab]) AND ("linitis plastica"[MeSH] OR “linitis plastica”[tiab] OR "stomach neoplasms"[MeSH] OR “gastric cancer”[tiab]). Additionally, Ichushi-Web created an electronic search strategy based on the above words. The primary outcome was the proportion of SGC diagnosed using EUS-FNA. In addition, we analyzed the proportion of adverse events associated with EUS-FNA. The study protocol was registered in the UMIN Clinical Trials Registry on October 10, 2022 (No: UMIN000049169).

Results

The electronic search identified 1890 studies; overall, 4 studies met the selection criteria and reported data on EUS-FNA performed on 114 patients with suspected SGC. In our systematic review, the overall diagnostic yield of EUS-FNA for SGC was 82.6% (95% confidence interval, 74.6–90.6%) and the statistical heterogeneity was 0% (I² = 0%), indicating a low heterogeneity. Furthermore, the EUS-FNA diagnostic proportion for SGC lymph node metastasis was 75–100%, indicating a high diagnostic performance. No apparent adverse events were observed in these 4 studies.

Conclusion

We believe that EUS-FNA is a useful examination because of its minimally invasive nature and high tissue diagnostic proportion. In particular, we consider it to be a useful alternative examination for patients with suspected SGC who cannot be definitively diagnosed by CT or EGD-biopsy.

Introduction

The risk of gastric cancer is expected to decrease with reduced Helicobacter pylori (H. pylori) infection rate. Although periodic endoscopic screening for gastric cancer is widely performed in East Asia, the optimal screening strategy remains unclear. Cost-effectiveness analysis (CEA) is an effective method to objectively compare different screening methods. However, no studies have compared the cost-effectiveness of endoscopy-based screening strategies.

Aims & Methods

This study aimed to determine the most cost-effective endoscopic screening strategy for the detection and treatment of gastric cancer in a modern Japanese cohort. This study consisted of two phases: clinical data collection and analysis, followed by simulation model development. The following data was retrospectively extracted from participants who received screening endoscopy between April 2019 and March 2023: age, H. pylori infection status, presence of intestinal metaplasia, pathological diagnosis of gastric cancer, and the interval between the most recent endoscopies. A Markov state transition model was constructed based on the cohort data. In this model, the prevalence of H. pylori infection and intestinal metaplasia, the transition probabilities between each state, and the probabilities of incidence of gastric cancer and treatment were defined. In the base-case analysis, the cost-effectiveness of 15 strategies with different starting ages (40/50/60 years) and screening intervals (1/2/3/4/5 years) was compared. The net monetary benefit (NMB) and incremental cost-effectiveness ratio (ICER) of quality-adjusted life-years (QALY) gained by treatment were used as outcomes. The NMB is a measure of the difference between the cost required for a strategy and the cost threshold for the same effect; the larger the NMB of a strategy, the more cost-effective it is. In contrast, a lower ICER is considered more cost-effective.

Results

A simulation model was constructed based on the cohort data of 94,137 participants (mean age 54.5 years, males 57.9%; 74.4% H. pylori-naïve, 94.2% intestinal metaplasia-negative). The results of the base-case analysis showed that the screening strategy of 4-year intervals starting at the age of 40 years had the highest net monetary benefit (97,401,578 yen) (Table). Based on the Monte Carlo simulation, the cost-effectiveness acceptability curve demonstrated that the 4-year interval screening strategy starting at the age of 40 years was superior to the other strategies when the willingness-to-pay was set at 5,000,000 yen. In one-way sensitivity analysis with a varying probability of H. pylori infection status transition, the incremental cost-effectiveness ratio was superior in the screening strategy every 4 years, starting at age 40 years.

Conclusion

Gastric cancer screening strategies can be modified in terms of cost-effectiveness in a modern Japanese cohort. Our simulation showed that endoscopic screening at 4-year intervals starting at 40 years was the most cost-effective method.

Disclosure

The authors declare that there is no conflict of interest.

Introduction

Gastric cancer (GC) is a leading cause of cancer-related deaths worldwide, ranking fourth in terms of mortality and fifth in terms of incidence, according to the 2020 GLOBOCAN report (1). Early detection of preneoplastic conditions such as gastric atrophy and intestinal metaplasia is crucial to reduce GC mortality (2). Moreover, its pathogenesis is a multifactorial process that is influenced by environmental and genetic factors. European guidelines (3) suggest shortening the interval of follow-up in patients with a family history. However, it is a weak recommendation with a low quality of evidence, as evidence regarding familiarity for GC and its related preneoplastic conditions is lacking.

Aims & Methods

To evaluate the risk of GC and preneoplastic conditions and lesions, including gastric atrophy, intestinal metaplasia, and dysplasia, in first-degree relatives for GC patients.
We conducted a systematic review and meta-analysis of case-control studies published on MEDLINE (PubMed and Embase) until November 2022. The primary outcome was the risk of GC in first-degree relatives for GC patients. The secondary findings were the risk of preneoplastic conditions and dysplasia in these patients. Two independent reviewers blindly performed the systematic review and data extraction. The disagreements were resolved through discussion. Homogeneity of effects across studies quantified by I². Odds ratio (OR) and 95% confidence intervals (CIs) were expressed using random effects models.

Results

Of the 1642 studies initially found, 18 studies met the inclusion criteria for GC, and 6 studies were included for preneoplastic conditions. The pooled analysis included a total of 59490 patients for the risk of GC and 4463 patients for the risk of preneoplastic conditions. The results showed a significantly increased risk of GC in first-degree relatives of GC patients (OR = 3.034; 95%CI 2.395 to 3.843; p <.001; I² 85.66%, 95%CI 78.73 to 90.33, p<.001). The risk of gastric atrophy was also significantly increased (OR = 3.812; 95%CI 1.674 to 8.682; p <.001, I² 78,26%, 95%CI 41.41 to 91.93; p = .003). However, the risk of intestinal metaplasia was not significant (OR = 1.207; 95%CI 0.937 to 1.555, p = .15). Furthermore, the risk of gastric dysplasia was found to be significant (OR = 5.480; 95%CI 1.054 to 28.482, p = .043, I² 80.34%, 95%CI 48.18 to 92.55 p = .002).

Conclusion

Our meta-analysis showed that the risk of GC and preneoplastic conditions and lesions, including gastric atrophy and dysplasia, is significantly increased in first-degree relatives for GC patients, even if a significant heterogeneity between studies was found. These findings highlighted the importance of identifying individuals at high risk to facilitate early detection and treatment of preneoplastic conditions, which could potentially reduce the burden of GC.

References

1. Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 71(3), 209-249.
2. Pimentel-Nunes, P., Libânio, D., Marcos-Pinto, R., Areia, M., Leja, M., Esposito, G., ... & Dinis-Ribeiro, M. (2019). Management of epithelial precancerous conditions and lesions in the stomach (maps II): European Society of gastrointestinal endoscopy (ESGE), European Helicobacter and microbiota Study Group (EHMSG), European Society of pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy, 51(04), 365-388.
3. Yaghoobi, M., Bijarchi, R., & Narod, S. A. (2010). Family history and the risk of gastric cancer. British journal of cancer, 102(2), 237-242.

Introduction

The temporal trend of mortality rates among young individuals with gastric cancer has sparked a contentious debate over the past few decades. Additionally, there remains an ambiguous distribution alteration of disease burden among different countries.

Aims & Methods

​​​​This population-based systematic analysis was conducted to investigate changes in health inequality related to mortality caused by young gastric cancer from 1990 to 2019. We performed a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 by extracting cross-sectional data on young gastric cancer (<40 years). The age-specific mortality rate was used to determine deaths attributed to young gastric cancer. A prediction of young gastric cancer mortality rate and case number up to 2030 was performed using the Norpred APC model. The slope index of inequality (SII) and the health concentration index were used to quantitatively measure absolute and relative changes in health inequalities, taking into account the socio-demographic indexes (SDI) level. The data was further analysed across different GBD regions and sexes.

Results

The global mortality rate of young gastric cancer declined from 1.61 (95% Uncertainty interval [UI]: 1.49 to 1.72) per 100,000 in 1990 to 0.94 (95% UI: 0.87 to 1.02) per 100,000 in 2019, with an annual rate of change -0.42% (95% Confidence interval (CI): -0.47 to -0.35). The projected data suggests that the number of global mortality case and rate of young gastric cancer would decrease to 24,450 and 0.761 per 100,000 by 2030. Countries belong to the lower 50% of SDI accounted for 49.9% and 52.3% of the global young gastric cancer deaths in 1990 and 2019, respectively. Although the absolute cross-national inequality (SII) of mortality rate fell from 0.133 (95%CI: -0.533 to 0.416) in 1990 to -0.239 (95%CI: -0.432 to -0.046) in 2019, the relative inequality (concentration index) for global young gastric cancer mortality increased from 1990 (−0.058, 95%CI: −0.532 to 0.416) to 2019 (−0.104, 95%CI: −0.526 to 0.317). The observed rise in absolute health inequality was evident in both sexes, but relative health inequality increased in females only. The regions of Sub-Saharan Africa (including Western and Southern), Central Asia, and Central Europe exhibited an increase in both absolute and relative health disparities in young gastric cancer mortality.

Conclusion

Although there has been a decline in the global young gastric cancer mortality rate, health inequality has increased over the past three decades, especially in females and some low SDI countries. It is imperative to prioritize efforts in addressing inequality to further reduce the global burden of young gastric cancer mortality.

Introduction

Although Gastric Peroral Endoscopic Myotomy (G-POEM) has shown substantial efficacy in patients with medically refractory gastroparesis (GP), comprehensive long-term data on its effectiveness are lacking.

Aims & Methods

We conducted a systematic review and meta-analysis including observational studies assessing long-term outcomes after G-POEM in patients with refractory GP. Our primary outcome was the pooled rate of clinical success1-year after G-POEM. Secondary outcomes included clinical success rates beyond 1 year, and the rate of adverse events (AEs).

Results

Fifteen studies, comprising 986 patients with refractory GP undergoing G-POEM, were eligible. The pooled 1 year-success rate was 0.722 (95% CI: 0.56, 0.86, I²=94.92%). In the subgroup analysis, which included only studies enrolling patients with 4-hour Postprandial Gastric Residual (PGR) ≥ 10%, the clinical success rate was 0.610 (95% CI: 0.526, 0.709, I²=46.66%). The pooled success rates at 2 and 3 years calculated on followed-up patients were 0.861 (95% CI: 0.72, 0.96, I²=85.11%) and 0.838 (95% CI: 0.56, 0.99, I²=91.90%), respectively. In the subgroup analysis including studies that did not exclude non-responding patients from follow-up, the 2-year pooled success rate was 0.838 (95% CI: 0.60, 0.98, I²=89.49%). The pooled rate of AEs was 0.092 (95% CI: 0.06, 0.13, I²=81.35%), specifically 0.078 mild and 0.014 moderate AEs, according to the American Society for Gastrointestinal Endoscopy classification.

Conclusion

G-POEM is a safe procedure with 1-year success in more than 2/3 of treated cases and substantial benefit also at 2 and 3-years follow-ups. Future studies with strict patient selection and uniform outcome definitions are warranted.