Is there a role for screening gastric carcinoma or preneoplastic lesions?

Transcription

1 Is there a role for screening gastric carcinoma or preneoplastic lesions? Mário Dinis-Ribeiro, MD, PhD Instituto Português de Oncologia do Porto, Department of Gastroenterology Faculty of Medicine, University of Porto, MEDCIDS/CINTESIS

2 Assumptions Frequent cancer with relevant morbidity and mortality Efective treatment Screening test with high sensitivity and specificity... acceptable, safe and inexpensive Adequate means for diagnosis, management and follow-up

3 Gastric cancer incidence is decreasing Men Women World, age-standardized rates (per persons.year) WHO- Database,

4 Gastric cancer more relevant in Eastern countries IARC Globocan

5 Gastric cancer in Europe: increasing number of cases and high mortality IARC Globocan

6 Gastric cancer: ~14 millions years DALY lost in 2008 (sum of years lost to premature death (<80y men/82.5y women) or lived with disability )

7 Gastric cancer survival: median survival = 1 year very high in early cases % Time (Months) Dinis-Ribeiro M Eur J Oncolog2001

8 Gastric cancer treatment: early cases can be managed endoscopically R0 = 94% & S5 > 90% Pimentel-Nunes Endoscopy 2014

9 Endoscopic treatment preferred by patients Libanio D in press

10 Questions To whom? Population vs opportunistic What? Gastric cancer vs pre-neoplastic conditions How? Procedures and methods

11 Opportunistic screening during diagnostic upper GI endoscopy

12 Be aware! (Improve) a priori probability setting, older, known conditions, family Country The Netherlands (den Hoed, 2010) The Netherlands (de Vries A, 2010) Finland (Varis K, 2000) n Prevalence (histology) (%) Prevalence (endoscopy) (%) Risk factor ? Older Precancerous cond/lesions Low pepsinogen Portugal (Areia M, 2008) Precancerous cond/lesions Chromoendoscopy Romania (Alina B, 2011) Turkey (Aygun C, 2010) Brazil (Motta CCA, 2007) Older patients ? 98vs (7.1% vs 0.8%) 3.5 Family history 1/100 1/10

13 Be aware! locations of lesions / missed 9.4% 16% 40% 12% 43% 9% 4% 3% 21% 10% 17% 50% 10% 25% <10% Missed known locations

14 We need time Quality for procedures: blind spots & adequate insuflation Kuvaev R*

15 Quality procedures: Time High risk lesions: 14% vs. 6%; OR 2.5 ( ) Dysplasia/Cancer: 3.4% vs. 1%; OR 3.4 ( ) Slow endoscopists (>7 min) vs. fast endoscopists (<7 min) 837 endoscopies (98% sedation) 7 minutes Teh 2014

16 Adequate scopes Ezoe Y Gastro 2011 Pimentel-Nunes Endoscopy 2016

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18 Gastric carcinogenesis premalignant stomach = extension

19 MAPS Guidelines MAnagement of Precancerous conditions and lesions in Stomach Dinis-Ribeiro M Endoscopy / Virchows Arch 2012

20 Narrow Band Imaging Simple Mucosal, vascular pattern Kikuste I Scand J Gastro 2013 Pimentel-Nunes Endoscopy 2012

21 Narrow Band Imaging Easy to learn and effective in real time use Dias-da-Silva GIE WLE NBI WLE NBI WLE NBI WLE NBI WLE NBI WLE NBI Portugal Italy USA UK Romania Total Pimentel-Nunes Endoscopy 2016

22 Lage J Scan J Gastro 2015 Premalignant stomach endoscopy only?

23 NBI vs WLE versus mapping biopsy for GIM: a prospective blinded trial WLE + Mapping NBI + WLE NBI + Mapping 25 0 Per patient Per site Buxbaum J, GIE 2017

24 Atrophic mucosa and intestinal metaplasia can be accurately detected by image-enhanced endoscopy, after appropriate training Grade of recommendation: strong Evidence level: high Consensus level: 84.2% K. Sugano, J. Tack, E. J. Kuipers, D. Y. Graham, E. M. El-Omar, S. Miura, K. Haruma, M. Asaka, N. Uemura, P. Malfertheiner Kyoto global consensus report on Helicobacter pylori gastritis Gut 2015;64:

25 Surveillance pre-malignant: CE 3y OLGIM III/IV 50-75a ICER 18,336 Areia M Helicobacter 2014

26 Pepsinogen 1/50 endoscopies Dinis-Ribeiro M, et al. J Med Screen /~2000 to 1/~50 Lomba-Viana R EJGH 2014

27 Pepsinogen Good LR - but repeat at 3 years! Follow-up* Disease Risk of cancer (%)** 1 year 3 years 5 years Present 1 year 3 years 5 years Total PG PG Total Lomba-Viana R under review

28 Population screening Gupta L GIE 2011

29 Cost-effective stand alone vs together with CRC screening Areia M UEG Journal 2017

30 Cost-effective > 10 ASR Areia M UEG Journal 2017

31 Take home messages Population Opportunistic Gastric cancer Europe CE w/ CRC if ASR > 10 Always! Quality upper GI Pre-malignant conditions No Very easy after proper training during endoscopy Surveillance CE in some settings

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