Endoscopic screening for gastric stump cancer--would it be beneficial? A hypothetical cohort study

The incidence of gastric cancer is increased in the gastric stump. It has, therefore, been recommended that subjects who have undergone partial gastrectomy be screened by regular endoscopy. However, several factors make it very difficult to test, in a clinical trial, the efficacy of such screening. To solve this problem, known clinical observations on partial gastrectomy patients were applied to a hypothetical cohort of 100,000 German or American partial gastrectomy patients. In this way the possible benefits of regular endoscopic screening in such a population were predicted. Markov type of decision analysis was used on the hypothetical cohorts to see if yearly endoscopy significantly improved outcomes as compared with no endoscopic screening. Under the very liberal, but arbitrary, assumption that endoscopic screening could prevent death from gastric stump cancer in 80% of those diagnosed as having gastric stump cancer, 8.5% and 5.4% of German male and female gastrectomy patients, respectively, and 2.2% and 1.3% of American male and female gastrectomy patients, respectively, would benefit from screening. Lives of German men and women would be prolonged 10 and 13 yr, respectively, [11 and 15 yr for American men and women]. Life expectancy of the total male and female cohort would increase by 9 and 8 mo, respectively, [U.S.A: 2 and 2 mo]. Per 100 endoscopies invested, 6.4 and 4.3 [U.S.A.: 1.8 and 1.2] male and female life years would be gained. However, a sensitivity analysis shows the outcomes of the calculations to depend most on the rate of a 5-yr survival gained by endoscopy and surgery: as the postoperative 5-yr survival of gastric stump cancer patients falls below 80%, the benefit achieved by endoscopic screening becomes even less apparent. In American subjects who have undergone partial gastrectomy, the benefit of endoscopic screening would probably be too low to justify screening. Only in populations with high frequencies of gastric cancer may endoscopic screening be beneficial.