Elsevier

The Lancet Oncology

Volume 9, Issue 3, March 2008, Pages 279-287
The Lancet Oncology

Review
Screening for gastric cancer in Asia: current evidence and practice

https://doi.org/10.1016/S1470-2045(08)70072-XGet rights and content

Summary

Gastric cancer is the second most common cause of death from cancer in Asia. Although surgery is the standard treatment for this disease, early detection and treatment is the only way to reduce mortality. This Review summarises the epidemiology of gastric cancer, and the evidence for, and current practices of, screening in Asia. Few Asian countries have implemented a national screening programme for gastric cancer; most have adopted opportunistic screening of high-risk individuals only. Although screening by endoscopy seems to be the most accurate method for detection of gastric cancer, the availability of endoscopic instruments and expertise for mass screening remains questionable—even in developed countries such as Japan. Therefore, barium studies or serum-pepsinogen testing are sometimes used as the initial screening tool in some countries, and patients with abnormal results are screened by endoscopy. Despite the strong link between infection with Helicobacter pylori and gastric cancer, more data are needed to define the role of its eradication in the prevention of gastric cancer in Asia. At present, there is a paucity of quality data from Asia to lend support for screening for gastric cancer.

Introduction

Gastric cancer is the second most common cause of death from cancer worldwide,1, 2 and in many Asian countries, such as China, Japan, and Korea. Early gastric cancer (figure 1) is typically small and asymptomatic, and the high mortality from gastric cancer is mainly due to late presentation. Therefore, early detection and treatment is an important way to reduce death from gastric cancer. Nonetheless, screening for gastric cancer is not commonly practised and there is a paucity of data in Asia to lend support to such a programme.

To determine the current practice of gastric-cancer screening in Asia, experts on gastric cancer in the Asia Pacific region (including gastroenterologists, surgeons, and endoscopists) formed the Asia Pacific Working Group on Gastric Cancer. Experts from eight Asian countries—China, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, and Thailand—were invited to join the working-group meeting in Cebu, Philippines, during Asia Pacific Digestive Week in November, 2006, to discuss the epidemiology, screening, and prevention of gastric cancer. The working group was supported by the World Organisation of Digestive Endoscopy (OMED) and Asian Pacific Society of Digestive Endoscopy (APSDE).

Before the meeting, participants completed a written-opinion survey on screening for gastric cancer, which included questions on who to screen, when to screen, and how to screen. Eradication of Helicobacter pylori and cost-effectiveness of screening were also discussed during the meeting.

This Review summarises the working group's discussion. We also present epidemiology for gastric cancer and the current approaches to gastric-cancer screening in Asian countries that have high incidence of the disease.

Section snippets

Epidemiology of gastric cancer in Asia

Asia covers a large geographical area: it has more than 40 countries and diverse ethnic groups. Socioeconomic conditions, political status, and health-care systems vary widely between different Asian countries. We extracted the cancer incidence in Asian countries from GLOBOCAN 2002 of the WHO's database.3 Figure 2 and table 1 summarise the incidence of gastric cancer in men. Generally, countries in east Asia (including Japan, Korea, and China) have high incidence of gastric cancer (ie, >40

Risk factors for gastric cancer

An understanding of the risk factors associated with gastric carcinogenesis is important for identifying high-risk groups that may need screening, particularly in countries where mass screening is not practised.

Familial aggregation of gastric cancer

Gastric cancer tends to cluster in families. The risk of stomach cancer is increased at least 1·5-times in siblings or offspring of patients with stomach cancer.24, 25 In addition to genetic factors, the clustering of H pylori in family members may be an important contributory factor.26, 27, 28 In a case-control study from Hong Kong,29 the prevalence of H pylori in first-degree relatives of patients with gastric cancer was 1·8-times (95% CI 1·3–2·5) higher than age-matched and sex-matched

Screening guidelines in Asia

Apart from countries such as Japan and Korea where gastric cancer is highly prevalent, many Asian countries generally have no national guidelines or recommendations for gastric-cancer screening. Whether screening, especially that of the mass population, should be done remains controversial.

China

Although gastric cancer is the second most common cancer in China, there is no nationwide screening programme. Early detection of gastric cancer therefore relies on opportunistic screening only. Although endoscopy is widely available in major cities, availability and accessibility in rural areas is limited. The cost of upper-gastrointestinal endoscopy is low compared with that in developed countries, but it might not be affordable to less-privileged citizens. Barium-meal studies and

Cost-effectiveness

There is paucity of data for the cost-effectiveness of a mass screening programme for gastric cancer, even from Asian countries with high prevalence of the disease. A study from Singapore35 suggested that screening endoscopy every 2 years for a moderate to high-risk population (eg, Chinese men aged 50–70 years) is highly cost effective in the health-care system. Therefore, endoscopy screening in targeted high-risk populations might be more cost effective than mass screening in countries with

Conclusion

Although the incidence of gastric cancer is declining in most developed countries, it remains one of the most common causes of cancer-related death in Asia. Screening and early detection play a pivotal part in reducing mortality from this cancer. However, mass screening for gastric cancer, particularly by endoscopy, may not be the most practical approach because of reasons such as acceptance, availability, and cost. Multistage screening by serum-pepsinogen testing or H-pylori serology, or both,

Search strategy and selection criteria

Data for this Review were identified by searches of PubMed from relevant articles using the search terms “gastric cancer”, “screening”, and “Asia”. Abstracts and reports from meetings were included only when they related directly to previously published work. Only papers published between 1995 and 2007, preferably in English, but also in Chinese, Japanese, and Korean, were included. Epidemiological data were further searched by GLOBOCAN 20023 and cancer registries or health reports of

References (74)

  • United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2006...
  • L Yang

    Incidence and mortality of gastric cancer in China

    World J Gastroenterol

    (2006)
  • N Uemura et al.

    Helicobacter pylori infection and the development of gastric cancer

    N Engl J Med

    (2001)
  • H Yamagata et al.

    Impact of Helicobacter pylori infection on gastric cancer incidence in a general Japanese population

    Arch Intern Med

    (2000)
  • MH Derakhshan et al.

    Combination of gastric atrophy, reflux symptoms and histological subtype indicates two distinct aetiologies of gastric cardia cancer

    Gut

    (2007)
  • PI Hsu et al.

    Helicobacter pylori infection and the risk of gastric malignancy

    Am J Gastroenterol

    (2007)
  • BC Wong et al.

    Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China

    JAMA

    (2004)
  • WK Leung et al.

    Factors predicting progression of gastric intestinal metaplasia: results of a randomized trial on Helicobacter pylori eradication

    Gut

    (2004)
  • WC You et al.

    Randomized double-blind factorial trial of three treatments to reduce the prevalence of precancerous gastric lesions

    J Natl Cancer Inst

    (2006)
  • S Sasazuki et al.

    Cigarette smoking, alcohol consumption and subsequent gastric cancer risk by subsite and histologic type

    Int J Cancer

    (2002)
  • Y Nishino et al.

    Tobacco smoking and gastric cancer risk: an evaluation based on a systematic review of epidemiological evidence among the Japanese population

    Jpn J Clin Oncol

    (2006)
  • KL Goh et al.

    Ethnicity and H. pylori as risk factors for gastric cancer in Malaysia: a prospective case control study

    Am J Gastroenterol

    (2007)
  • NY Sung et al.

    Smoking, alcohol and gastric cancer risk in Korean men: the National Health Insurance Corporation Study

    Br J Cancer

    (2007)
  • M Kobayashi et al.

    Vegetables, fruit and risk of gastric cancer in Japan: a 10-year follow-up of the JPHC Study Cohort I

    Int J Cancer

    (2002)
  • WC You et al.

    Gastric dysplasia and gastric cancer: Helicobacter pylori, serum vitamin C, and other risk factors

    J Natl Cancer Inst

    (2000)
  • BT Ji et al.

    Dietary habits and stomach cancer in Shanghai, China

    Int J Cancer

    (1998)
  • HJ Kim et al.

    Dietary factors and gastric cancer in Korea: a case-control study

    Int J Cancer

    (2002)
  • K Shikata et al.

    A prospective study of dietary salt intake and gastric cancer incidence in a defined Japanese population: the Hisayama study

    Int J Cancer

    (2006)
  • G Zanghieri et al.

    Familial occurrence of gastric cancer in the 2-year experience of a population-based registry

    Cancer

    (1990)
  • C La Vecchia et al.

    Family history and the risk of stomach and colorectal cancer

    Cancer

    (1992)
  • YW Chang et al.

    Role of Helicobacter pylori infection among offspring or siblings of gastric cancer patients

    Int J Cancer

    (2002)
  • WK Leung et al.

    Helicobacter pylori infection in 1st degree relatives of Chinese gastric cancer patients

    Scand J Gastroenterol

    (2006)
  • WK Leung et al.

    Risk factors associated with the development of intestinal metaplasia in first-degree relatives of gastric cancer patients

    Cancer Epidemiol Biomarkers Prev

    (2005)
  • PJ Guilford et al.

    E-cadherin germline mutations define an inherited cancer syndrome dominated by diffuse gastric cancer

    Hum Mutat

    (1999)
  • P Guilford et al.

    E-cadherin germline mutations in familial gastric cancer

    Nature

    (1998)
  • JG Park et al.

    Report on the first meeting of the International Collaborative Group on Hereditary Gastric Cancer

    J Natl Cancer Inst

    (2000)
  • AR Brooks-Wilson et al.

    Germline E-cadherin mutations in hereditary diffuse gastric cancer: assessment of 42 new families and review of genetic screening criteria

    J Med Genet

    (2004)
  • Cited by (0)

    View full text