Follow-up of gastric cancer: a review

Although there is broad agreement in the staging, classification, and surgery for gastric cancer, there is no consensus regarding follow-up after gastrectomy. Follow-up varies from investigations on clinical suspicion of relapse to intensive investigations to detect recurrences early, assuming that this improves survival and quality of life. Advanced gastric cancers recur mainly by locoregional recurrence or distant metastasis. Local recurrences detected at endoscopy or on computed tomography (CT) are invariably incurable. For early gastric cancers, endoscopy can detect new primaries, but the incidence of these tumors is low, and many thousands of procedures are required to detect each operable case. CT is much better at detecting liver metastasis and, although these are usually multiple and unresectable, there are several reports of good survival following liver resection for isolated metastasis. Tumor markers have been used with some success to detect subclinical recurrences and could be used to target more invasive or expensive procedures. In chemotherapy, many newer agents are promising significantly improved survival, but again, the evidence for greater benefit when administered prior to the patient becoming symptomatic is lacking. Overall, it appears that follow-up policy is as much decided by the wealth and facilities of the institution as by any significant evidence base. Although the early detection of recurrent cancer is an emotive issue for both patients and surgeons, considering the amount of time and money invested in follow-up, and the lack of evidence of efficacy, a randomized controlled trial of intensive follow-up is required.