The difference in gastric cancer between Japan, USA and Europe: What are the facts? What are the suggestions?

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Abstract

In Japan the survival rate for gastric cancer has steadily improved over the last 30 years whilst that in the West has remained static and inferior. In this review three hypotheses are examined to explain the difference. There is little evidence to suggest genetic differences, which might result in a less aggressive cancer in Japan. Recently there has been a rise in the proportion of cancers of the gastro–oesophageal junction in the West and this has not been seen in Japan. The comparison of survival data from these two regions is problematic with different staging systems and a stage migration effect. The established surgical treatment of gastric cancer in Japan is radical gastrectomy and regional lymphadenectomy and this has been proposed as a superior treatment to the standard gastrectomy common in the West. The results for survival benefit however, have not been reproduced in randomized clinical trials. The heterogeneity of adjuvant and neoadjuvant treatment regimens in Japan and the West has led to difficulties in the interpretation of their effects. There is considerable scope for future collaboration between clinicians in the West and Japan.

Introduction

The incidence of gastric cancer is decreasing worldwide. It is however, only in Japan that the decreasing mortality of the disease seems to exceed the decreasing incidence. This indicates an overall increase in cure rate in Japan whereas that in Western countries such as the US and Europe is depressingly stable. This is despite the increase in the availability of sophisticated technology in both regions over recent years for diagnosis and staging. The latest treatment results for gastric cancer analysed by stage between Japan and the US are compared in Table 1, which is taken from a recent review [1]. In this, the organisation and collection of data varies considerably, therefore direct comparison between results is difficult. There is however a startling disparity evident throughout the stages. The possible causes for this great disparity are probably multifactorial and are the purpose of this review. Also discussed are the possible reasons that the results have failed to be emulated in the West despite recent study of the Japanese techniques, and the proposed collaboration in the future, which may help to rectify this problem of poor outcome for physicians in the West.

The differences in the end results for the treatment of gastric cancer may be due to either one of three main reasons:

  • 1.

    different biological behaviour of tumours or differing patient characteristics;

  • 2.

    different classification of stage of disease; or

  • 3.

    different treatments.

These are effectively theories of different disease, different classification or different treatment and it is not at all clear which of these predominates [2].

Section snippets

Biological differences

It has been suggested by physicians in the West, that the superior survival results for patients with gastric cancer treated in Japan, as opposed to the West is due to differences in the biological behaviour of tumours in the two regions. There is some evidence to support this: the differences in epidemiology and age of patients, the differing proportions of proximal and distal tumours, the predominance of the intestinal type in Japan compared to the diffuse type in the West and differences in

Differences in staging systems

The staging of gastric cancer has always been different in Japan and the West. While the Japanese classification was designed principally to aid surgeons in the extent of lymphadenectomy, the Western TNM system was designed for pathological description.

The first edition of the General Rules for Gastric Cancer Study was published by the Japanese Research Society for Gastric Cancer (JRSGC) in 1963. Initially produced for surgeons this classification, which has had several revisions so far, now

Diagnosis

In Japan the proportion of cases of early gastric cancer has steadily increased in recent years and has reached 50% in major hospitals. The recurrence of disease in these cases is low (1.4%) [38] with recurrence in the form of either haematogenous or peritoneal dissemination after radical surgery. In contrast in the West, diagnosis at this early stage is a relatively rare phenomenon, and experience is limited outside major centres, compared to that with Japan. In one study in the US, 165 cases

Future collaboration of Japanese and Western management

This report attempts to address the reasons for the differences in survival between patients with gastric cancer treated in Japan to those treated in the US or Europe. It also puts the case for a greater collaboration, which may bring about a change in the prognosis of the disease in the West, and through new research improve the treatment throughout.

As far as the different disease hypotheses are concerned, there is very little evidence that these are important factors. However epidemiological

Reviewers

Toshifusa Nakajima, M.D. Department of Surgery, Cancer Institute Hospital, 1-37-1 Kamiikebukuro, Toshima-ku, Tokyo 170-0012, Japan.

John W.L. Fielding, M.D. Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK.

Martin S. Karpeh, M.D., F.A.C.S. Associate Attending Surgeon, Gastric & Mixed Tumor Service, Department of Surgery, Memorial Sloan-Kettering Cancer center, 1275, York Avenue, New York, NY 10021, USA.

Peter McCulloch, M.D. Department of Surgery, University of

Acknowledgements

Supported by the Foundation for Promotion of Cancer Research of the Second Term Comprehensive 10 year Strategy for Cancer Control by the Ministry of Health and Welfare, Japan and the British Council, Tokyo.

Peter A Davis, MA. MChir. FRCS. Senior Surgical Registrar, Imperial College School of Medicine, St Marys’ Hospital, London UK. He graduated from the University of Cambridge in 1988 and completed surgical training in upper gastrointestinal surgery at the Chelsea and Westminster, Hammersmith and St Marys’ Hospitals in London. He was the Cholmeley research fellow at the Royal College of Surgeons of England, and a visiting clinical fellow at the National Cancer Center Hospital, Tokyo.

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    • Cited by (0)

    Peter A Davis, MA. MChir. FRCS. Senior Surgical Registrar, Imperial College School of Medicine, St Marys’ Hospital, London UK. He graduated from the University of Cambridge in 1988 and completed surgical training in upper gastrointestinal surgery at the Chelsea and Westminster, Hammersmith and St Marys’ Hospitals in London. He was the Cholmeley research fellow at the Royal College of Surgeons of England, and a visiting clinical fellow at the National Cancer Center Hospital, Tokyo.

    Takeshi Sano, MD. PhD. Head, Gastric Surgery Division, National Cancer Center Hospital, Tokyo, Japan. He graduated from the University of Tokyo in 1980 and completed surgical training at the University Hospital, Tokyo. He was a visiting research fellow at the Insitut Curie in Paris. He is a visiting professor at several universities and has visited many countries to demonstrate radical gastrectomy. He is executive editor of the Japanese Journal of Clinical Oncology, managing editor of Gastric Cancer and an executive committee member of the Japan Clinical Oncology Group.

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