Policy responses and statements
- Name of organisation:
- UK National Screening
Committee
- Name of policy document:
- Stomach Cancer Screening Services in Wales.
'Screening for Stomach Cancer - A report for the National Screening
Committee'
- Deadline for response:
- 14 March 2010
Background: This report reviews screening
for stomach (gastric) cancer in the United Kingdom (UK) population
against the UK National Screening Committee Criteria for appraising
the viability, effectiveness and appropriateness of a screening programme.1
Stomach cancer is a disease with the recognised risk factors of Helicobacter
pylori (H. Pylori) infection, genetic, environmental and nutritional
factors. In 1994 H. pylori was classified as a group I carcinogen for
stomach cancer by the International Agency for Research on Cancer.
COMMENTS ON
UK NATIONAL SCREENING COMMITTEE
STOMACH CANCER SCREENING SERVICES IN WALES. 'SCREENING
FOR STOMACH CANCER - A REPORT FOR THE NATIONAL SCREENING COMMITTEE'
The Royal College of Physicians of Edinburgh is pleased to respond to the
UK National Screening Committee on Stomach Cancer Screening Services in
Wales. 'Screening for Stomach Cancer - A report for the National Screening
Committee'.
The authors have effectively answered the questions they pose as to the feasibility
of a National Screening Programme in Wales by concluding that this would not
be an effective exercise and we are therefore unclear as to why this document
has gone out to consultation. In particular, we would agree with their statement
that the incidence of this cancer in the UK is low and probably not significantly
different throughout the United Kingdom. National screening strategies have
only been applied previously in countries with a high incidence of stomach
cancer. We would comment upon the specific points as follows (numbers refer
to sections within the document):
1. The incidence and 5 year
survival rate throughout the United Kingdom are unlikely to be
significantly different.
2. In respect of the natural
history, we would comment that while the incidence of gastric cancer
is indeed declining overall in the UK, there is an increase in the incidence
of diffuse gastric
cancer, more than offset by the decreasing incidence of intestinal type gastric
cancer.
Perhaps
the most telling paragraph in the whole report (page 4) relates to the estimates
of progression, thus from 100 HP positive patients, only one or two will eventually
develop gastric cancer. Equally, while the progression of pre-malignant stages
may take decades, the important point is that early stage gastric cancer (EGC) progression
to advanced stage takes almost 4 years. Therefore the optimal time for any screening
intervention should attempt to detect EGC. Strategies to eradicate helicobacter,
screening for intestinal metaplasia and probably even dysplasia would be
ineffective as well as uneconomic.
We agree
that screening based on symptoms is not practical although we would also note
that there may be considerable merit in the implementation of opportunistic screening
of this condition by undertaking endoscopy in the symptomatic population.
3. Thus at the present state
of our knowledge and availability of potential screening tools, the
most effective strategy would seem to be attempts directed at modifying risk
factors (e.g. increasing dietary manipulation, salt restriction
and smoking cessation ).
5. This is a good description
of the available screening methods and their drawbacks. A specific
comment would be that combination testing with gastrin-17, pepsinogen and HP
status might not be as effective as quoted, since neither the disease prevalence
in the study population nor whether this was a prospective
study are stated. We would agree that barium studies are not a realistic option.
In respect of endoscopy, it is particularly true
that the technique, when used to detect EGC, is heavily operator dependent
and it is likely that
the overall endoscopic expertise in the UK at present is insufficiently good
to detect a high proportion of EGC. It is hoped that the implementation of
a National endoscopy training
programme supervised by JAG will remedy this in due course.
7. Again this is a particularly
relevant section since it has been consistently established in two
high risk areas for populations for gastric cancer that the uptake of endoscopic screening
is really very low, of the order of 20%.
10. We would comment that the paper does
not adequately acknowledge the existence and availability,
even in the UK, of advanced endoscopic techniques for endoscopic mucosal resection
of even quite substantial early gastric tumours. This expertise is properly confined
to large tertiary centres but does need considerable further development and investment
as an effective strategy for managing these patients. The five year survival rate
for EGC greatly exceeds that for tumours staged at level 3 and above.
13. Reservations over the impact and effectiveness
of screening in Japan are well founded. Likewise we would also agree
that there is insufficient evidence to justify a screening programme
in the UK.
14. We suspect that, if a screening programme
did become feasible in due course and was to involve
endoscopy, this test as the screening option would be acceptable based on the experience
from the National Bowel Screening Programme. Basically, major costs and resource
implications of any screening programme are not feasible at present.
As a final comment we would mention that there is already a nationwide screening
programme for colorectal cancer. Thus, patients in this cohort are already
having their FOBs measured and half of these will have a positive faecal occult
blood test but a negative colonoscopy. It would be worth considering screening
for upper GI cancer in this population but this would again have resource implications.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[8 March 2010]
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