Upper gastrointestinal tumors

 

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Mass screening and early detection of gastric cancer

An increasing burden of cancer is shown in the health statistics of the aging population of developed countries. More attention is now given to primary and secondary prevention of cancer worldwide. Secondary prevention is based on early detection of cancer and pre-malignant precursors at a completely curable stage in individuals who are asymptomatic or without suggestive symptoms. “Mass screening” is offered in various countries by the health authorities to all individuals within the age classes at risk of cancer, and is generally provided free of charge. Opportunistic or individual screening occurs when early detection is proposed to either symptomatic or asymptomatic patients who consult their doctor or attend a private health center.

Organized screening protocols can be evaluated through cost/benefit analyses, which do not include the individual opportunistic screenings. Questions arise about the respective impact (concurrent or complementary) of cancer prevention on population health during organized and individual screening interventions. Stomach cancer is still the first cause of cancer mortality in Japan, and since 1962 a national screening policy based on photofluorography has been in operation. This filter test is offered annually to individuals from the age of 40 years, and is performed in special radio-equipped trucks located in the municipalities. Individuals who test positive are offered gastroscopy. Each year more than 6 millions people go through this screening protocol.

Suzuki et al. [1] conducted a retrospective study on 1226 cases of early gastric cancer (EGC, confirmed by the pathologist after treatment), which were addressed to the National Cancer Center in Tokyo in 2001 - 2003. The first question was on the presence or absence of digestive symptoms: epigastric pain, nausea, vomiting. Symptoms were present in 512 (41.8 %), and 714 (58.2 %) were asymptomatic. The second question concerned diagnosis. In the symptomatic group, gastroscopy was the detection test for 91.6 %. In most cases this occurred in outpatient clinics (91.4 %), seldom in health check-up centers (7.6 %), and rarely (1 %) through mass screening. In the group of asymptomatic individuals, gastroscopy was more often used as the detection test than photofluorography (67.8 % and 32.2 %, respectively). Detection occurred in outpatient clinics in 44.8 %, in health check-up centers in 42.9 %, and through mass screening in only 12.3 %.

The results of this series are in line with national data collected in Japan. Statistics on cancer in Japan estimated that only 20 % of the eligible population accepted the governmental screening. Only 6 % of all cases of gastric cancer are detected by the government screening program, whereas 4.6 % are detected in health check-up centers, and all other cases are detected in private clinics for outpatients [2] [3]. In 2004, the Insurance Services of the Public Health system [4] confirmed the general use of gastroscopy in Japan. Each year, 7.8 million gastroscopies are carried out. Gastroscopy is performed annually in 9 % of Japanese individuals aged over 20 years. It is concluded that organized screening plays a marginal role in the early detection of gastric cancer in Japan. However, since the beginning of the national screening policy in this country, the global proportion of cases of stomach cancer diagnosed at the early superficial stage increased from 15 % to 50 %. As a consequence, the survival rate from stomach cancer is now about 45 % in Japan (at least twice the figure occurring in other countries of the world).

The temporal correlation between the screening policy and the improved survival from stomach cancer shows a good demonstration of possible misunderstanding in the evaluation of the benefit of an intervention. The organized screening policy is not failing and should be maintained in Japan; actually its benefit is linked to the massive diffusion of information about early detection of stomach cancer among medical professionals and the Japanese population. A similar analysis could be conducted on the actual benefit of an organized screening policy for colorectal cancer based on the fecal occult blood test.

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R. Lambert, MD

Screening Group IARC

150 cours Albert Thomas
Lyon 69372
cedex 8
France

Fax: +33-4-72738518

Email: lambert@iarc.fr