Jim Kling

November 05, 2013

SAN DIEGO, California — A survey of Western patients with intestinal metaplasia of the stomach (IMS) shows they are at an 11-fold risk for gastric carcinoma (GCA) and that the median time to development of cancer was just 4 years. The results suggest that such patients should be candidates for esophagogastroduodenoscopy (EGD) surveillance at regular intervals.

"Gastric cancer develops through a process of changes in gastric mucosa that includes chronic inflammation, atrophy, metaplasia, and subsequently dysplasia. But the natural history of gastric metaplasia in the Western world is not well understood. That's why we decided to do this study," Wissam Bleibel, MD, attending physician at Owensboro Medical Center, Kentucky, told Medscape Medical News. Dr. Bleibel presented the study here at the American College of Gastroenterology (ACG) 2013 Annual Scientific Meeting and Postgraduate Course.

The researchers used a hospital database and electronic medical records to identify patients who underwent EGD and had a gastric biopsy showing IMS between 1993 and 2012. They compared patients with a control group of patients who had EGD with a normal gastric biopsy between 2002 and 2012.

Table. GCA risk vs IMS status

  IMS positive (n = 675) IMS negative (n = 1273) P
Subsequent GCA (n) 2.1% (14) 0.1% (1) <.0001
Time interval to GCA, years (standard deviation) 3.99 (3.5) 2.1 (0) .61
Follow-up time, years (standard deviation) 5.3 (4.1) 3.1 (2.0) <.0001

Patients with IMS tended to be older (61 vs 44 years) and had longer follow-up (5.3 vs 3.1 years). Helicobacter Pylori was found in 17.5% of patients with IMS at biopsy.

Univariate analysis identified both IMS (hazard ratio [HR], 15.7; 95% confidence interval [CI], 2.00 - 122.81; P < .009) and H pylori infection (HR, 3.4; 95% CI, 1.02 - 1.099; P < .05) as risk factors for GCA. However, in a multivariate analysis that included IMS, H pylori, age, sex, and race, only IMS remained significantly associated with GCA risk (HR, 11.23; 95% CI, 1.35 - 93.40; P < .025).

The time interval between IMS and GCA diagnoses was about 4 years.

The results suggest a need for guidelines for intestinal metaplasia of the stomach, according to coauthor Andrew Y. Wang, MD, associate professor of medicine and co-medical director of the endoscopy unit at the University of Virginia, Charlottesville. There are such guidelines for Barrett's esophagus, but "the risk of getting cancer is probably even higher in the stomach. But we have no screening or surveillance guidelines. Based on data that we and others have generated, it looks like the risk of going from intestinal metaplasia to cancer in the stomach probably is higher over a lifetime [than Barrett's esophagus progressing to esophageal cancer]," Dr. Yang told Medscape Medical News.

Moreover, improved endoscopy methods have led physicians to spot lesions that once remained hidden. "We're seeing things we didn't see 10 or 20 years ago. There's great anxiety about how to deal with this because for so long it was thought we could just ignore [metaplasia of the stomach]. But we don't ignore intestinal metaplasia in the esophagus, so there's a lot of interest in who to screen and who to survey," Dr. Wang said.

The study was impressive, according to Bradley Connor, MD, a clinical associate professor of medicine at Weill Cornell Medical College in New York City, who attended the presentation. "The continuum of inflammation, atrophy, metaplasia and cancer, this has been well-established," Dr. Connor told Medscape Medical News. "But there's been really a paucity of data to give a sense of how great that risk was. This was a very elegantly designed retrospective study that gave us a clearcut answer to that question."

The study also raises new questions, such as the effects of different types of stomach metaplasia on the risk for gastric cancer and whether therapeutic interventions could reduce the risk. "The question is, what is the appropriate surveillance interval before you find dysplasia, and what can you do about it," Dr. Connor added.

Dr. Bleibel, Dr. Wang, and Dr. Connor have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2013 Annual Scientific Meeting and Postgraduate Course: Abstract 3. Presented October 14, 2013.


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