The Full Scope: Standardization of the Use of Endoscopy for Earlier Diagnosis of Stomach Cancer in the USA

BACKGROUND: The USA is a low-incidence country for gastric cancer and screening is not performed. The use of diagnostic endoscopy (EGD) is not well standardized. As a result, patients most commonly have advanced-stage disease at diagnosis. PATIENTS AND METHODS: All patients with gastric cancer treated at a single center over the past 10 years were identified, and demographics, presenting symptoms, diagnostic evaluations, stage at diagnosis, and outcomes were analyzed. RESULTS: A total of 249 patients with gastroesophageal junction (GEJ) or gastric or GEJ adenocarcinoma were identified. The presence of gastrointestinal (GI)-related symptoms at diagnosis was associated with more advanced disease (p < 0.001), but 73% of stage I patients were symptomatic. The median self-reported duration of symptoms prior to first EGD was 2 months (range 0-35 months), but nearly 50% of patients with stage IV were diagnosed by cross-sectional imaging before performance of EGD. In addition, 182 patients (73%) were participating in colon cancer screening. The median overall survival (OS) of the entire cohort was 23.0 months (95% CI 14.4-31.6) and was not reached for stage I patients, 47 months (95% CI 24.3-69.7) for stage II, 23.0 months (95% CI 19.9-26.3) for stage III, and 11.0 months (95% CI 6.6-15.4) for stage IV (p < 0.001). Non-EGD method of original diagnosis was an independent predictor of poorer survival, regardless of stage (HR 1.46, 95% CI 1.03-2.09; p = 0.036). CONCLUSIONS: Diagnostic EGD is underutilized in symptomatic patients, particularly those with dyspepsia, while most patients were participating in colon cancer screening. Novel protocols to standardize the use of diagnostic EGD should be investigated in the USA.