How long should we continue gastric cancer screening? From an epidemiological point of view

Current Status of Gastric Cancer Screening and Future Perspectives

Gastric cancer (GC) remains a major global health concern, particularly in East Asia, Central Asia, and Eastern Europe, where its incidence and mortality rates are high. Helicobacter pylori infection is the primary cause of GC and leads to carcinogenic progression from nonatrophic gastritis to cancer. Although screening programs have been implemented in high-risk countries, such as Japan and South Korea, comprehensive strategies remain limited globally. This study reviewed the status of GC screening worldwide and prevention strategies in regions with different risks. Various GC screening methods have been developed, including H. pylori serology, serum pepsinogen testing, upper gastrointestinal contrast radiography, and endoscopy. Endoscopic screening has shown superior sensitivity and specificity, reducing GC mortality by up to 47% in South Korea and demonstrating higher detection rates than upper gastrointestinal contrast radiography and pepsinogen testing. However, cost-effectiveness remains a challenge, particularly in Western countries where the overall GC prevalence is lower. Risk stratification using a combination of H. pylori serology and pepsinogen testing has been adopted in Japan to optimize screening efficiency. Additionally, H. pylori eradication has been recognized as a cost-effective strategy to reduce the incidence of GC with economic benefits demonstrated in Japan and other high-risk regions. In the United States, targeted screening of high-risk immigrant populations has been suggested to enhance cost-effectiveness. GC screening strategies should consider developing epidemiological trends, cost-effectiveness, and risk-based approaches. Future efforts should focus on expanding targeted screening initiatives to high-risk groups to improve early detection and survival rates.

Precision risk stratification of primary gastric cancer after eradication of H. pylori by a DNA methylation marker: a multicentre prospective study

BACKGROUND

Precision cancer risk stratification for gastric cancer is urgently needed for the growing number of healthy people after Helicobacter pylori eradication. The epimutation burden in non-malignant tissues has been associated with cancer risk in multiple cross-sectional studies.

OBJECTIVE

To confirm the clinical usefulness of a DNA methylation marker for epimutation burden, and to identify a cut-off methylation level for a super-high-risk population.

DESIGN

Healthy people after H. pylori eradication with open-type atrophy were prospectively recruited. DNA methylation levels of a marker gene, RIMS1, were measured in biopsy specimens from gastric antrum and body. The primary endpoint was the incidence rate of gastric cancer in quartiles of the methylation levels.

RESULTS

1624 participants had at least one endoscopic follow-up with a median follow-up of 4.05 years, and a primary gastric cancer developed in 27 participants. The highest quartile of RIMS1 methylation levels had a higher incidence rate (972.8 per 100 000 person-years) than the lowest quartile (127.1). Cox regression analysis revealed a univariate HR of 7.7 (95% CI 1.8-33.7) and an age- and sex-adjusted HR of 5.7 (95% CI 1.3-25.5). As a secondary objective, a cut-off methylation level of 25.7% (95% CI 1.7-7.7) was obtained to identify a population with a super-high risk based on the number needed to screen of 1000.

CONCLUSION

A DNA methylation marker can risk-stratify healthy people after H. pylori eradication even though all of them have clinically high risk. Individuals with super-high risk will need more frequent gastric cancer screening than currently recommended.

TRIAL REGISTRATION NUMBER

UMIN-CTR000016894.

Population effectiveness of endoscopy screening for mortality reduction in gastric cancer

Objectives

No randomized controlled trials have compared endoscopic screening with no screening for gastric cancer on an intention-to-screen basis, and the population-based evidence is insufficient. This study aimed to identify factors contributing to the population effectiveness of cancer screening, estimate the number needed to screen (NNS) to reduce one gastric cancer-related death, and evaluate the expected mortality-rate reduction in endoscopic screening for gastric cancer in 184 countries.

Methods

Factors contributing to the attributable risk, NNS, and mortality-rate reduction were identified. A rapid review was performed in PubMed to estimate the pooled relative risk of endoscopic screening compared to that of no screening for mortality reduction. NNSs and mortality-rate reduction were estimated using the pooled relative risk and GLOBOCAN data.

Results

The crude mortality rate, the effectiveness of the screening modality, and the screened rate contributed to the attributable risk, NNS, and mortality-rate reduction in cancer screening. The pooled relative risk was 0.58 in endoscopy screening compared to that in no screening. NNSs and expected mortality-rate reduction differed across countries and ranged from 2522 to 91,575 and 0.2 to 7.9 (per 100,000 individuals) for the screened rate of 20%, respectively.

Conclusions

In addition to the effectiveness of the used modality, the disease burden and screened rate were important in the population effectiveness of cancer screening. Regarding the high NNSs and the low expected mortality-rate reduction, population-based endoscopic screening seems not to be effective in many countries, and these results are meaningful in decision-making regarding the introduction of endoscopic screening.

Population-based X-ray gastric cancer screening in Hiroshima prefecture, Japan

BACKGROUND

X-ray gastric cancer (GC) screening has been shown to decrease mortality. Population-based X-ray GC screening has been performed in Hiroshima Prefecture, Japan, since 1983 but time trends and the efficacy of the method over 39 years have not been assessed.

AIM

To evaluate time trends and efficacy of population-based X-ray GC screening and identify challenges and suggested solutions for the future.

METHODS

This was a population-based retrospective study. The data were derived from aggregated data of the Hiroshima Regional Health Medical Promotion Organization, including the number and rate of participants and those requiring esophagogastroduodenoscopies (EGDs), the number and rate of participants diagnosed as having GC, and the positive predictive value of the abnormal findings detected by X-ray and confirmed by EGDs. The number and rate of esophageal cancers were also collected. Further, the cost of detecting one GC was evaluated.

RESULTS

The number of participants has decreased during the last four decades, from 39925 in 1983 to 12923 in 2021. The rate of those requiring EGDs decreased significantly in recent years (P < 0.001). The number of participants diagnosed as having GC has also declined, from 76 to 10 cases. However, the rate of cases diagnosed as GC among the participants remained around 0.1%. The positive predictive value increased significantly in recent years except during 1983-1991. The number and rate of accidentally detected esophageal cancers have risen recently, from 0% in 2008 to 0.02% in 2021, one-fifth of the diagnosis rate of GC. One GC diagnosis costs approximately 4200000 Japanese Yen (30000 United States Dollars) for the X-ray screenings and EGDs.

CONCLUSION

X-ray GC screening in Hiroshima has been efficient, but one challenge is the cost. Esophageal cancers may also need to be considered because they have gradually increased in recent years.

Endoscopic Resection of Undifferentiated Early Gastric Cancer

Endoscopic resection (ER) is widely performed for early gastric cancer (EGC) with a negligible risk of lymph node metastasis (LNM) in Eastern Asian countries. In particular, endoscopic submucosal dissection (ESD) leads to a high en bloc resection rate, enabling accurate pathological evaluation. As undifferentiated EGC (UD-EGC) is known to result in a higher incidence of LNM and infiltrative growth than differentiated EGC (D-EGC), the indications for ER are limited compared with those for D-EGC. Previously, clinical staging as intramucosal UD-EGC ≤2 cm, without ulceration, was presented as 'weakly recommended' or 'expanded indications' for ER in the guidelines of the United States, Europe, Korea, and Japan. Based on promising long-term outcomes from a prospective multicenter study by the Japan Clinical Oncology Group (JCOG) 1009/1010, the status of this indication has expanded and is now considered 'absolute indications' in the latest Japanese guidelines published in 2021. In this study, which comprised 275 patients with UD-EGC (cT1a, ≤2 cm, without ulceration) treated with ESD, the 5-year overall survival (OS) was 99.3% (95% confidence interval, 97.1%-99.8%), which was higher than the threshold 5-year OS (89.9%). Currently, the levels of evidence grades and recommendations for ER of UD-EGC differ among Japan, Korea, and Western countries. Therefore, a further discussion is warranted to generalize the indications for ER of UD-EGC in countries besides Japan.

Gastric Cancer Screening in Japan: A Narrative Review

Gastric cancer is the second leading cause of cancer incidence in Japan, although gastric cancer mortality has decreased over the past few decades. This decrease is attributed to a decline in the prevalence of H. pylori infection. Radiographic examination has long been performed as the only method of gastric screening with evidence of reduction in mortality in the past. The revised 2014 Japanese Guidelines for Gastric Cancer Screening approved gastric endoscopy for use in population-based screening, together with radiography. While endoscopic gastric cancer screening has begun, there are some problems associated with its implementation, including endoscopic capacity, equal access, and cost-effectiveness. As H. pylori infection and atrophic gastritis are well-known risk factors for gastric cancer, a different screening method might be considered, depending on its association with the individual's background and gastric cancer risk. In this review, we summarize the current status and problems of gastric cancer screening in Japan. We also introduce and discuss the results of gastric cancer screening using H. pylori infection status in Hoki-cho, Tottori prefecture. Further, we review risk stratification as a system for improving gastric cancer screening in the future.

The tRNA-Derived Fragment tRF-24-V29K9UV3IU Functions as a miRNA-like RNA to Prevent Gastric Cancer Progression by Inhibiting GPR78 Expression

Emerging studies have proved that tRNA-derived fragments (tRFs) play vital roles in tumor metastasis; however, the function of tRFs in gastric cancer (GC) remains largely unclear. We investigated the role of tRF-24-V29K9UV3IU in growth and metastasis of GC using a xenograft mouse model. Differential gene expression downstream of tRF-24-V29K9UV3IU was identified by transcriptome sequencing, and interaction was then verified by a dual luciferase reporter and RNA immunoprecipitation. MKN-45 cells were also used to explore the biological functions of tRF-24-V29K9UV3IU in vitro. Here, knockdown of tRF-24-V29K9UV3IU promoted tumor growth and metastasis of GC in vivo. The expression of tRF-24-V29K9UV3IU and E-cadherin (epithelial cell marker) was down-regulated in tumors of mice following tRF-24-V29K9UV3IU knockdown, whereas the mesenchymal cell markers N-cadherin and vimentin displayed an opposite trend. Transcriptome sequencing identified 87 differentially expressed genes (DEGs) down-regulated in the tRF-24-V29K9UV3IU-overexpressed groups compared with the control group. Among them, G-protein–coupled receptor 78 (GPR78), the most significantly down-regulated DEG, was also predicted to be a target of tRF-24-V29K9UV3IU. Moreover, tRF-24-V29K9UV3IU could function as a miRNA-like fragment and bind to AGO2 and directly silence GPR78 expression by complementing with the 3′-untranslated region of the GPR78 mRNA. Functionally, overexpression of tRF-24-V29K9UV3IU significantly suppressed proliferation, migration, and invasion and promoted apoptosis of MKN-45 cells, whereas GPR78 attenuated these effects. Therefore, our data suggest that tRF-24-V29K9UV3IU functions as a miRNA-like fragment to suppress GPR78 expression and thus inhibit GC progression. These observations suggest that the tRF-24-V29K9UV3IU/GPR78 axis serves as a potential therapeutic target in GC.

Epidemiological Trends and Future Perspectives of Gastric Cancer in Eastern Asia

BACKGROUND

The global epidemiological situation of gastric cancer has changed considerably over time, and it is essential to understand the epidemiological trends and future perspectives of gastric cancer.

SUMMARY

Although gastric cancer was common in the United States less than a century previously, it is no longer common in this country. Currently, over 60% of gastric cancers are found in Eastern Asia. In some Eastern Asian countries such as Japan and Korea, population-based gastric cancer screening has been conducted using upper gastrointestinal endoscopy or radiography to lower gastric cancer mortality. Due to earlier detection of gastric cancer, the survival of patients with gastric cancer is more favorable in these countries than in other Western countries. Even in Eastern Asia, a remarkable decrease in the age-standardized incidence and mortality of gastric cancer has been observed. This downward trend is mainly due to the reduced Helicobacter pylori infection, and this trend is considered to continue. Nevertheless, both the absolute number of incident cases and deaths of gastric cancer are still increasing at present due to the aging population. For the time being, the management of gastric cancer in elderly population is a critical issue in Eastern Asia. The absolute numbers of gastric cancer cases and deaths are believed to peak in the near future, following the decreasing age-standardized incidence and mortality. Key Messages: After a long period, gastric cancer may become a rare cancer even in Eastern Asia, and new efficient approaches for its prevention, screening, and treatment are warranted.

Is Additional Gastrectomy Required for Elderly Patients after Endoscopic Submucosal Dissection with Endoscopic Curability C-2 for Early Gastric Cancer?

BACKGROUND

With the ongoing growth of the aged population, the number of elderly patients suffering from gastric cancer has increased in Japan. Since the frequency of lymph node metastasis (LNM) in patients after endoscopic submucosal dissection (ESD) with endoscopic curability (eCura) C-2 for early gastric cancer (EGC) is relative low, the following question can be raised: "Is additional gastrectomy required for elderly patients with such criteria for ESD?"

SUMMARY

For therapeutic decision-making after ESD with eCura C-2, the risk of all-cause mortality and impaired quality of life (QoL) should thus be evaluated. Risk stratification of LNM and gastric cancer-specific mortality was established by the eCura system; however, it remains unclear how much these categories and treatment selection affect all-cause mortality. The contribution of prognostic tools for predicting all-cause mortality was noted to vary across the studies of patients with EGC; thus, further studies that investigate comprehensive geriatric assessment (CGA) may be required. Regarding the QoL, studies on elderly patients remain to be lacking. Furthermore, one of the issues with CGA and QoL tools is that they are time consuming. Key Messages: Combined evaluation of risk stratification of gastric cancer-specific mortality by the eCura system and risk of nongastric cancer-related mortality and impaired QoL may be the current optimal method to decide treatment strategy after ESD with eCura C-2 for EGC among elderly patients. A large-scale prospective study that investigates CGA domains is required to identify predictors of all-cause mortality and impaired QoL, and a more easily usable tool should be developed.

Management following endoscopic resection in elderly patients with early-stage upper gastrointestinal neoplasia

With the ongoing increase in the aging population in Japan, the number of elderly patients among the total population with upper gastrointestinal (GI) neoplasia has also been increasing. As elderly patients present unique age-related variations in their physical condition, the therapeutic approach for upper GI neoplasia should be differentiated between elderly and nonelderly patients. According to the existing guidelines, additional treatment is the standard therapy in patients who undergo endoscopic resection (ER) with a possible risk of lymph node metastasis (LNM) for upper GI neoplasia. However, due to the relatively low rate of LNM, applying additional treatment in all elderly patients may be excessive. Although additional treatment has the advantage of reducing cancer-specific mortality, its disadvantages include deteriorated quality of life, complications, and mortality in surgery. In patients with early gastric cancer, we propose treatment decisions be made using a risk-scoring system for LNM and upon considering the physical condition of the patient after ER with curability C-2. In those with superficial esophageal squamous cell carcinoma with a possible risk of LNM after ER, selective chemoradiotherapy may be a less-invasive treatment option, although the present standard treatment is esophagectomy. When considering the treatment decision, achieving a "cure" of the tumor has been regarded as critical. However, as the main cause of mortality in elderly patients with ER for upper GI neoplasia is noncancer-related death, both achieving a "cure" and also a good level of "care" is important in the management of elderly patients.

A Recent Argument for the Use of Endoscopic Submucosal Dissection for Early Gastric Cancers

Endoscopic submucosal dissection (ESD) has become the standard treatment method for early gastric cancers (EGCs) due to the negligible risk for lymph node metastasis (LNM) in Eastern Asian countries. According to the guidelines, the curability of EGC after endoscopic resection was classified into three groups: curative resection, expanded curative resection, and noncurative resection. In Eastern Asian countries, a structured follow-up schedule is needed for patients undergoing curative resection and expanded curative resection. Conversely, in Western countries, additional surgery may be recommended for some patients undergoing expanded curative resection (ulcerated, undifferentiated, or slight submucosal invasion) due to the potential risk for LNM, even though specimens of ESD and surgery may not be handled with the same methodology as that used in Japan, which may lead to this slightly higher risk. In noncurative resection, additional surgery is the standard method after ESD because of the risk for LNM. However, in elderly patients and/or those with severe underlying diseases, the advantages and disadvantages of additional surgery should be considered when selecting a post-ESD treatment strategy for patients undergoing noncurative resection. Risk-scoring systems for LNM may facilitate clinical decisions for these patients. However, it should be noted that when recurrence was detected in patients who were followed up with no additional treatment after ESD with noncurative resection, most of them had a poor prognosis. To select an appropriate treatment method, especially in elderly patients undergoing ESD with noncurative resection, a new tool for evaluating the condition of patients should be established.

Minimally invasive approaches for early gastric cancer in East Asia: current status and future perspective

East Asia is well known as a region with higher incidences of gastric cancer compared with the rest of the world. This region has also experienced a rise in the detection of early gastric cancer (EGC) for the past three decades. The success of nationwide screening programs conducted in Japan or South Korea, increasing public awareness of gastric cancer, improved diagnostic ability of gastroenterologists and the aging population of modern societies may all contribute to the increase in EGC detection rates. Along with the increasing diagnosis of EGC, several key advances in the minimally invasive approach to EGC treatment have been made. Endoscopic resection is an ideal procedure for lesions without lymph node involvement, and its indications have expanded based on the results of prospective studies. Laparoscopic surgery with lymph node dissection has been becoming a standard treatment for EGC patients. Additionally, robot-assisted surgery is penetrating the field of gastric cancer surgery as surgeons pursue a more accurate minimally invasive approach with reduced morbidity rates. However, prolonged operation time and high cost remain problems to be solved for robot-assisted surgery. In this context, function-preserving surgery has become ever more important and should be considered as a method to enhance patients' quality of life after a gastrectomy for EGC. Pylorus-preserving gastrectomy or proximal gastrectomy is more frequently employed in East Asia and strategies that employ sentinel node (SN) navigation to personalize function-preserving surgery in clinical practice are emerging as several prospective studies investigate its efficacy.