Japanese Journal of Clinical Oncology 31:469-470 (2001)
© 2001 Foundation for Promotion of Cancer Research
Letters to the Editor |
East is East and West was West: Closing the Gap in the Delivery of Gastric Cancer Surgery
To the Editor:With the recent publication of the Clinical Outcomes Guidance (COG) document for the management of upper gastrointestinal malignancy in England and Wales (1), there finally appears to be an appreciation in the United Kingdom that the management of these cancers should be performed in regional cancer centres, on dedicated units, by teams comprised of multi-disciplinary personnel, with the ultimate goal of delivering clinical excellence. The establishment of such dedicated units and interaction with world-renowned centres may at last offer hope of delivering a standard of care to gastric cancer patients in the UK that has become standard in Japan.
I have recently had the opportunity of visiting the Gastric Surgery Division at the National Cancer Center Hospital in Tokyo, the first since the publication of the COG guidance document. Since January 1999, the NCCH has been housed in a stunning, highly functional, 19-storey building. The running of the gastric division, with its team approach, is still instantly recognizable as that described by Iain Martin as the first exchange visitor in 1995 (2); however, the number of cancers treated has increased significantly since then. Time, staff and theatre space always appear sufficient to meet the demands of the volume of work available, with prompt starts and no pressure from general emergency admissions.
Gastric cancer within the UK has, for many years, been considered as a disease capable of being managed by the ‘average’ British surgeon (3). It is clear from the report of Welbourn (3) and from the MRC D1 versus D2 trial (4) that this is far from the case. Reports from Western Units specializing in gastric cancer surgery have demonstrated that extended (D2) lymphadenectomy can be performed with low morbidity and mortality and with survival figures which stage for stage tend towards those achieved in Japan (5–7). The level of meticulous dissection necessary to perform ‘bloodless’ gastrectomy with full D2 lymphadenectomy, omental bursectomy and the ability to manage the complications which inevitably arise following gastrectomy, even in Japan, can only be achieved by concentrating services into specialist centres. Only by the establishment of such units will British surgeons be able to gain sufficient exposure to the disease to allow morbidity and mortality to be minimized. Once established, with audited, standardized, high-quality surgery and overall results, we may then ensure the quality control of future trials is high enough to generate results which will alter surgical practice. This will take time, investment and a change in the nation’s perception of the delivery of cancer services (3).
The mortality following D1 lymphadenectomy in the MRC study (4) was 6.5%, which exceeds that of specialist units routinely performing D2 lymphadenectomy on Western patients (5–7) and differs greatly from the 0.5% seen at the NCCH. D2 lymphadenectomy was assessed in the UK (4) and The Netherlands (8) by surgeons learning the technique, submitting small numbers of patients each (average one patient undergoing D2 dissection per surgeon per year). There was also significant contamination (i.e. dissection greater than that which should have been performed), 6 and 7% for D1 and D2 dissection, respectively; and non-compliance (i.e. absence of nodes from stations which should have been dissected), 36 and 51% for D1 and D2 dissection, respectively, within the Dutch trial, which was also a significant problem in the MRC trial. When combined with the fact that D2 dissection in these studies included pancreatico-splenectomy, it is difficult to relate these studies to that which is practised in specialized gastric units in the West today.
Within Japan the standard of surgery is such that large randomized trials can be performed by collaborating cancer units and results obtained which may be translated into changes in practice. Once such units are established as the standard for cancer care in the UK then translation of such results to our practice is a more realistic proposition. In addition, more meaningful comparative studies may be performed to establish where the true differences lie between Western and Japanese practice such that we may identify any factors which may further reduce mortality for British patients undergoing gastrectomy for cancer. Whilst at the NCCH I saw the conclusion of one such multi-centre trial: the Japanese Clinical Oncology Group (JCOG) Study 9501, a comparative study of standard radical (D2) lymphadenectomy with extended radical (previously called D4) gastrectomy, with the multi-centre entry of 523 patients with very tight entry criteria over a 5-year period. I await the results with great interest.
Patients’ knowledge and understanding of their disease and the quality of endoscopy performed both within and outwith the NCCH are also features which I found remarkable throughout my visit. The former I am sure reflects the prevalence of the disease which in turn increases the willingness of the Japanese patient to undergo endoscopy. Many will present fasted to an upper GI clinic outside the hospital with a short history of minor symptoms expecting an endoscopy during that visit, which will usually be performed. Once the patient has presented for endoscopy, the quality of this procedure is exceptional. The techniques used, which routinely involve dye spray, are well described, but consequently small lesions are frequently identified. Only ~20% of early gastric cancers are identified by the mass screening programme, the remainder being detected in patients presenting for endoscopy outside the screening programme. This again is testament to the general quality of endoscopy and outlines two major issues that need to be addressed within the UK if we are to increase the proportion of patients presenting with early gastric cancer and consequently improve survival. As a consequence of the prevalence and indolent nature of the symptoms of early upper GI cancer, the threshold for endoscopy must be lowered and general public awareness improved. As cancer at the oesophago-gastric junction is rapidly increasing in incidence within the UK, the time is ripe for this to be implemented. In addition, the quality of the delivery of endoscopic services must be closely regulated, time allowed for detailed examination with more widespread use of dye spray and photographic documentation of both positive and negative endoscopies, by means of a standard set of views, available for review and audit (9).
The technique of endoscopic mucosal resection (EMR) was fascinating to watch in the hands of world experts. Within the NCCH, dedicated endoscopists manage 30% of all gastric cancers referred to the hospital. There is much interest in this technique within the UK; however it is of very limited use as so few lesions are suitable. In order to make this technique more readily available, we first need to increase the number of early cancers detected. The technique should then only be available, closely audited, in a limited number of centres to allow exposure to sufficient numbers to allow expertise to develop.
Having outlined the necessity to improve services within the UK, the gap is clearly closing between best practice in the UK and Japan. However, it is essential that the gap between standard practice and best practice within the UK and that in Japan is closed if all are to benefit. I was delighted to see that many aspects of the working week within the gastric division at NCCH were almost identical with those in the dedicated upper GI unit in which I work within the UK. The multi-disciplinary meeting (MDM) described by Martin in 1996 (2) is now routine, as addressed by the 1995 Calman–Hine report within the UK (10). One essential component in the new guidance document is the need for the discussion of all cases in the MDM whether they are considered suitable candidates for surgery or not. This is already addressed at the NCCH, where all cases for EMR are discussed in open forum prior to the procedure being performed; this does not happen within most centres within the UK and unilateral decisions in patient management should be actively discouraged.
I was further reassured that progress was being made by virtue of the fact that the bursectomy and D2 lymphadenectomy (with pancreas and splenic preservation in the majority of cases) taught to me in two major cities in the north of England (Leeds and Newcastle) over the last 5 years are essentially the same as those performed in the NCCH. The differences were subtle, the dissection often extended and tailored to the individual case, but exposure to useful techniques has been gained which I will incorporate into my practice upon my return. The more widespread use of intra-operative cytology and carbon particle lymphangiography to aid intra-operative decision making are useful techniques that could easily be introduced within UK practice.
This enlightening visit to the National Cancer Center Hospital was made possible by the surgical staff at the NCCH, the Foundation for the Promotion of Cancer Research and the British Council of Japan, for their combined Fellowship established in 1995 (9). To all those involved I am eternally grateful.
Shaun R. Preston
Specialist Registrar, Northern Oesophago-gastric Cancer Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
E-mail: shaun.preston@ukgateway.net
REFERENCES
1 Guidance on the commissioning of cancer services. Improving outcomes in upper gastro-intestinal cancers. www.doh.gov.uk/cancer/pdfs/intestinalmain.pdf. 2001.
2 Martin IG. An Englishman abroad – thoughts on the Japanese management of gastric cancer. Jpn J Clin Oncol 1996;26:283–4.
3 Welbourn CRB. Japanese challenge to gastric cancer surgeons: add ‘meticulous accuracy’ to Halstead’s ‘gentleness, haemostasis and minimal trauma’. Jpn J Clin Oncol 1997;27:369.[Medline]
4 Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V, et al., for the Surgical Cooperative Group. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer 1999;79:1522–30.[Web of Science][Medline]
5 Sue-Ling HM, Johnston D, Martin IG, Dixon MF, Lansdown MRJ, McMahon MJ, et al. Gastric cancer: a curable disease in Britain. Br Med J 1993;307:591–6.
6 Smith JW, Shiu MH, Lesley L, Brennan MF. Morbidity of radical lymphadenectomy in the curative resection of gastric carcinoma. Arch Surg 1991;126:1469–73.
7 Roder JD, Bottcher K, Siewert JR, Busch R, Hermanek P, Meyer HJ. Prognostic factors in gastric carcinoma: results of the German Gastric Carcinoma Study 1992. Cancer 1993;72:2089–97.[Web of Science][Medline]
8 Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJH, for the Dutch Gastric Cancer Group. Extended lymph node dissection for gastric cancer. N Engl J Med 1999;340:908–14.
9 Sano T. Managing gastric cancer in Britain: a Japanese experience. Br Med J 1997;314:382–3.
10 Calman K, Hine D. Policy Framework for Commissioning Cancer Services. London: UK Department of Health 1995.
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