Evidences from medical literature

E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)

Every medical literature review to date has failed to show high-level evidence about any followup schedule to be applied for curatively resected gastric cancer patients. All data are retrospective and observational, thus preventing any definitive conclusion.

We have selected seven studies and one systematic review concerning follow-up after surgery for gastric cancer (Table 19.1).

All these studies focused on the possible survival benefit of early detection of recurrence by intensive postoperative surveillance.

Four studies indicated that an intense postoperative follow-up protocol was successful in identifying asymptomatic recurrences earlier than symptomatic recurrences with an improvement in post-recurrence survival [11]. Nevertheless, they could not achieve any evident advantage in overall survival [8, 10, 12]. Overall survival was reported only by two of these studies but estimated survival did not show any statistically significant difference between patients who underwent an intensive follow-up schedule.

With this purpose a study from Memorial Sloan-Kettering Cancer Center [13] showed that follow-up did not detect asymptomatic recurrences earlier than symptomatic recurrences in patients with gastric cancer who underwent a curative gastrectomy. In this report patients with asymptomatic recurrences showed better postrecurrence and disease-specific survival than those with symptomatic recurrences; in their conclusions the authors suggest that symptomatic and asymptomatic recurrence patterns are possibly different in their biological behavior and are associated with different survival outcomes. Similarly, in a paper by Kim et al. [14] median overall survival and post-recurrence survival were worse for patients with a symptomatic recurrence than for those with an asymptomatic recurrence. Moreover, in this study, multivariate analysis revealed that the presence of a symptomatic recurrence and the disease-free interval were independent prognostic indicators for postrecurrence survival. Furthermore, asymptomatic patients had a major benefit from re-resection and post-recurrence chemotherapy and at multivariate survival analysis the presence of symptoms was the only independent factor of poor survival suggesting a more biologically aggressive disease in symptomatic patients. Bilici et al. [15], in a study on 173 patients with recurrent gastric cancer, found that symptomatic recurrence is an important prognostic factor for post-recurrence survival and that presence of symptoms may be considered a marker of biologic tumor aggressiveness, which is an important determinant of survival at the time of recurrence diagnosis during follow-up for gastric cancer.

Table 19.1. Evidences from medical literature

Gastric cancer. Principles and practice (2015) T 19.1

A recent systematic review by Cardoso et al. reviewed five studies enrolling a total of 810 patients and assessing outcomes of follow-up after gastrectomy for gastric cancer [16].

This review did not find any evidence suggesting that postoperative surveillance has any survival benefit; it has been also stressed that no such study has ever addressed quality-of-life issues. Major limitations in current literature were the study design and a lead-time bias in which the observed prolonged survival is due to earlier detection of recurrence, rather than to an effect on disease outcome.

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