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| Japanese Journal of Clinical Oncology | Pages |
Letters: Management of Early Gastric Cancer in Japan
To the Editor:
I consider myself fortunate to have been the second English surgeon to participate in an exchange programme for surgeons and endoscopists set up by Professor K. Rogers between the United Kingdom and the NCCH in Tokyo, Japan. I also had the privilege of working with Dr. T. Sano of the Gastric Division of NCCH in the Northern General Hospital in Sheffield in 1995, when he visited the UK as part of the same exchange programme. After working with him in England I had a good idea of the differences in approach to the management of gastric cancer in England and in Japan, and my visit to NCCH allowed me to explore this topic in more depth.
My predecessor on this exchange programme, G. Martin (1), as well as Riley (2) has already described in some detail the Japanese approaches to colonoscopy and to the peri-operative management of gastric cancer. I have been equally impressed with the pre-operative staging and the surgical and endoscopic techniques I observed during my stay, but for the purposes of this report I would like to comment on the management of early gastric cancer at NCCH. Gastric cancer is rarely diagnosed at an early stage in the UK, and few British surgeons are familiar with the options for its management.
Early gastric cancer (EGC) is defined as gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis. As a result of the high level of awareness of gastric cancer in the Japanese population, many patients with gastric cancer present at an early stage. The proportion of Japanese gastric cancer patients presenting with EGC is still increasing, and is as high as 50% in some centers. In contrast, early gastric cancer is much less common in the UK. Sue-Ling et al. reported that 15% of a series of 493 patients with gastric cancer presented with EGC in a specialist centre in Leeds (3). For surgeons with a specialist interest in gastric cancer, the ability to diagnose gastric cancer at an early stage when chances of cure are highest is of fundamental importance. Having worked in upper GI endoscopy units in the UK, I am convinced that the main reason for the higher incidence of EGC in Japan is endoscopic technique. In the UK, endoscopy is not performed by specialists. Endoscopists are often trainees, either surgical or medical. In many hospitals endoscopy lists are performed by GPs without specialist training in gastroenterology or endoscopy. I think it is fair to say that many of these groups of endoscopists have little knowlege of early gastric cancer. Most examinations are rushed in comparison to Japanese endoscopy. In particular, the use of indigo-carmine spray to detect minor mucosal irregularities is unknown in the UK. I believe that by educating our endoscopists and introducing the use of indigo-carmine spray (4), it would be possible to increase the detection rate of EGC in the UK.
I was particularly interested in the use of endoscopic resection for early gastric cancer. This technique is not currently available in the UK, but as British patients with gastric cancer tend to be older and have more cardiorespiratory problems than Japanese patients, it is a technique which could be utilised in the UK with advantage in patients with early cancers. Patients considered suitable for endoscopic resection are those with small tumours, and with lowest risk of lymph node metastasis. This group comprises patients with histologically differentiated gastric cancers confined to the mucosa, less than 2 cm diameter, macroscopically elevated or macroscopically depressed and without ulceration (5). This detailed pre-operative tumour staging is usually available in NCCH following endoscopy and endoscopic ultrasound. At present this is not possible in the UK as apart from the lack of experienced endoscopists, facilities for endoscopic ultrasound are not widely available.
Many cases of early gastric cancer were presented at the weekly NCCH case conference as potential candidates for endoscopic resection. Some of these patients were already suffering from advanced cancer in other organs, and EGC was an incidental finding only. I did feel that for these patients intervention for their gastric cancers was not always appropriate as their life expectancy was sometimes very short. I was also interested to see one or two cases presented where patients had suffered gastric perforation during endoscopic resection. These patients had been treated by initial emergency laparotomy and either local resection of the perforation or oversewing, but at least one patient had subsequently required gastrectomy when histology showed that the endoscopic resection had not completely excised the tumour.
With experience in techniques of endoscopic resection, and in selection of patients suitable for this approach, the outcome for patients undergoing this technique will probably be excellent. It is important though to remember that at NCCH the outcome for patients having D2 gastrectomy for EGC also have an excellent prognosis, with a low mortality and morbidity rate. I believe that if we could adopt endoscopic section in the UK, with our much higher complication rates for gastric surgery, the benefit would be much greater. I therefore think it is essential that endoscopic techniques should be improved in the UK to facilitate diagnosis of gastric cancer at an early stage. We also need to learn to use EUS to assess depth of invasion of gastric cancers. I think in the long term British patients could benefit far more than Japanese patients from endoscopic cancer resection.
I would like to acknowledge the generous support of both the Foundation for Promotion of Cancer Research and the British Council for my visit to NCCH.
Ms Iona Reid
Lecturer/ Senior Registrar in Surgery
University of Sheffield
Sheffield, United Kingdom
References
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Copyright© Japanese Journal of Clinical Oncology, 1997.
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  M. E. Sayegh 'Those who can do; those who can teach' Management of Gastric Cancer in Japan Jpn. J. Clin. Oncol., August 1, 2004; 34(8): 489 - 490. [Full Text] [PDF]
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