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
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 http://who.int/cancer/detection
Gastric cancer incidence is decreasing Men Women World, age-standardized rates (per 100.000 persons.year) WHO- Database, 1950-1998
Gastric cancer more relevant in Eastern countries IARC Globocan
Gastric cancer in Europe: increasing number of cases and high mortality IARC Globocan
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 )
Gastric cancer survival: median survival = 1 year very high in early cases % 100 50 0 0 12 24 36 48 60 Time (Months) Dinis-Ribeiro M Eur J Oncolog2001
Gastric cancer treatment: early cases can be managed endoscopically R0 = 94% & S5 > 90% Pimentel-Nunes Endoscopy 2014
Endoscopic treatment preferred by patients Libanio D in press
Questions To whom? Population vs opportunistic What? Gastric cancer vs pre-neoplastic conditions How? Procedures and methods
Opportunistic screening during diagnostic upper GI endoscopy
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 383 1.4? Older 112 5 3 Precancerous cond/lesions 2332 2.4 2.4 Low pepsinogen Portugal (Areia M, 2008) 45 2 2 Precancerous cond/lesions Chromoendoscopy Romania (Alina B, 2011) Turkey (Aygun C, 2010) Brazil (Motta CCA, 2007) 1651 9 4.8 Older patients 234 3.8? 98vs 116 4 (7.1% vs 0.8%) 3.5 Family history 1/100 1/10
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
We need time Quality for procedures: blind spots & adequate insuflation Kuvaev R*
Quality procedures: Time High risk lesions: 14% vs. 6%; OR 2.5 (1.5-4.1) Dysplasia/Cancer: 3.4% vs. 1%; OR 3.4 (1.3-10.4) Slow endoscopists (>7 min) vs. fast endoscopists (<7 min) 837 endoscopies (98% sedation) 7 minutes Teh 2014
Adequate scopes Ezoe Y Gastro 2011 Pimentel-Nunes Endoscopy 2016
Gastric carcinogenesis premalignant stomach = extension
MAPS Guidelines MAnagement of Precancerous conditions and lesions in Stomach Dinis-Ribeiro M Endoscopy / Virchows Arch 2012
Narrow Band Imaging Simple Mucosal, vascular pattern Kikuste I Scand J Gastro 2013 Pimentel-Nunes Endoscopy 2012
Narrow Band Imaging Easy to learn and effective in real time use 100 90 80 70 60 50 40 30 20 10 0 97 Dias-da-Silva GIE 2013 91 81 84 87 76 64 59 51 47 53 37 WLE NBI WLE NBI WLE NBI WLE NBI WLE NBI WLE NBI Portugal Italy USA UK Romania Total Pimentel-Nunes Endoscopy 2016
Lage J Scan J Gastro 2015 Premalignant stomach endoscopy only?
NBI vs WLE versus mapping biopsy for GIM: a prospective blinded trial 100 100 95 75 82 71 75 60 50 WLE + Mapping NBI + WLE NBI + Mapping 25 0 Per patient Per site Buxbaum J, GIE 2017
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;64:1353 1367
Surveillance pre-malignant: CE 3y OLGIM III/IV 50-75a ICER 18,336 Areia M Helicobacter 2014
Pepsinogen 1/50 endoscopies Dinis-Ribeiro M, et al. J Med Screen 2004 + 1/~2000 to 1/~50 Lomba-Viana R EJGH 2014
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 + 2 7 8 9 0.9 3.1 3.6 225 PG - 2 5 10 17 0 0.1 0.2 5688 Total 4 12 18 26 0.1 0.2 0.3 5913 Lomba-Viana R under review
Population screening Gupta L GIE 2011
Cost-effective stand alone vs together with CRC screening Areia M UEG Journal 2017
Cost-effective > 10 ASR Areia M UEG Journal 2017
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