10.1245/ASO.2003.12.009
Annals of Surgical Oncology 10:898-902 (2003)
© 2003 Society of Surgical Oncology
Follow-Up Surveillance for Recurrence After Curative Gastric Cancer Surgery Lacks Survival Benefit
Yasuhiro Kodera, MD,
Seiji Ito, MD,
Yoshitaka Yamamura, MD,
Yoshinari Mochizuki, MD,
Michitaka Fujiwara, MD,
Kenji Hibi, MD,
Katsuki Ito, MD,
Seiji Akiyama, MD and
Akimasa Nakao, MD
From the Department of Surgery II (YK, MF, KH, KI, SA, AN), Nagoya University School of Medicine, Aichi, Japan; and the Department of Gastroenterological Surgery (SI, YY, YM), Aichi Cancer Center, Aichi, Japan.
Correspondence: Address correspondence and reprint requests to: Yasuhiro Kodera, MD, Department of Surgery II, Nagoya University School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan; Fax: 81-52-744-2255; E-mail: ykodera{at}med.nagoya-u.ac.jp
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ABSTRACT
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Background: Although routine follow-up to detect asymptomatic recurrence after surgery for gastric cancer is recommended, the effect of such reassessment on survival has not been evaluated.
Methods: Clinical records of patients developing recurrent disease after potentially curative resection between 1985 and 1996 were retrieved. Among these patients, 197 were in our follow-up program. We analyzed survival in these patients according to the presence or absence of cancer-related symptoms when recurrent disease was diagnosed.
Results: Of all patients with recurrent disease, 50% were diagnosed within 1 year and 75% within 2 years of surgery. Asymptomatic recurrence, detected in 88 patients (45%), frequently represented distant metastasis. Although early detection significantly improved survival after detection of recurrent disease, disease-free survival for this subset was shorter. Thus, no significant difference in overall survival was observed.
Conclusions: Early detection of asymptomatic gastric cancer recurrence did not improve overall survival of patients with recurrence after curative resection. Until development of more effective treatment for this disease, close follow-up may offer no survival benefit.
Key Words: Cancer recurrence • Follow-up • Gastrectomy • Curative resection • Gastric carcinoma
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INTRODUCTION
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Gastric carcinoma still accounts for 10% of all invasive cancers worldwide and is the second leading neoplastic cause of death.1 Recurrences are often observed even among patients treated by potentially curative resection. Surgeons therefore customarily reassess patients for asymptomatic recurrence at regular intervals after resection.2 A model follow-up program has been reported,3 including schedules for performing various diagnostic procedures. However, an analysis of 67 recurrences after potentially curative resection suggested that such follow-up conferred no survival benefit.2 Given the poor survival of patients with recurrent gastric cancer, the prognostic effect of early detection seems doubtful. This study is a similar analysis performed with more patients, who were treated at a specialized center in Japan with a large caseload.
We assumed that routine follow-up would increase the detection of symptom-free recurrences. If such "early" detection is beneficial in terms of survival, patients with asymptomatic recurrence generally should live longer than those with cancer-related symptoms at the time of detection. Patients who developed recurrence after potentially curative resection were therefore grouped according to the presence or absence of symptoms when recurrence was detected. Survival data between the two groups were compared to determine whether routine follow-up enhances survival after curative resection of gastric carcinoma.
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METHODS
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Patients
A prospectively compiled database was subsequently searched for patients with gastric carcinoma who had recurrent disease after undergoing a potentially curative (R0) resection between 1985 and 1996 at Aichi Cancer Center Hospital. Results of cytological examination of peritoneal washings were disregarded, because washings were not routinely obtained before 1994. Of all patients undergoing curative resection, 305 were confirmed to have recurrent disease as of January 2002. Of these, 94 patients were either lost to follow-up or treated at other hospitals after the recurrence. The remaining 211 patients had been followed up according to the program described below and are currently receiving treatment or were treated until death at Aichi Cancer Center. Of these, 14 patients had synchronous metastases to the peritoneum or liver and underwent resection of these lesions along with the primary tumor; these patients were excluded from analysis. The data from the 197 other patients who had no evidence of distant metastases before or at the initial surgery were analyzed. In most analyses, patients were divided into groups with and without cancer-related symptoms at the time recurrent disease was diagnosed. Survival data were compared between these two groups. Resected specimens had been examined and classified by pathologists after the initial surgery in terms of pathologically determined tumor and node (pT and pN) categories, and patients had been assigned to appropriate clinical stages according to the International Union Against Cancer classification system.4
Follow-Up Program
Follow-up evaluation consisted of interim history, physical examination, hematological and blood chemistry panels, and blood tests for carcinoembryonic antigen and carbohydrate antigen 19-9. These assessments were repeated every 3 months for the first postoperative year and every 6 months thereafter for at least 5 years. Either abdominal ultrasonography or computed tomography was performed every 6 months, as was chest radiography. Endoscopy was performed annually to screen for cancer in the gastric remnant, beginning 1 to 1.5 years after surgery. In addition to this regular follow-up, patients were free to consult their surgeons or local physicians whenever they had clinical symptoms that suggested recurrent disease. Bone scintigraphy, barium enema radiography, and computed tomography of the chest or brain were performed only when metastasis to these sites was suspected. After detection of recurrent disease, appropriate therapy was given at the discretion of the treating surgeons.
Items extracted from the database included when recurrence first was diagnosed, whether cancer-related symptoms were present or absent when recurrence was diagnosed, and the sites of first relapse. Recurrences were categorized as local (gastric bed or regional lymph nodes), regional (peritoneal carcinomatosis or para-aortic or hepatic hilar lymph nodes), or distant (liver, bone, or other hematogenous metastases).
Statistical Analysis
Survival from the date of operation was estimated by the Kaplan-Meier product-limit method. The Breslow-Gehan-Wilcoxon test was used to evaluate differences in survival between the two groups. The Kaplan-Meier method was also used to assess disease-free survival. The 
2 test was used to evaluate differences in background factors.
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RESULTS
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Eighty-eight patients (45%) were asymptomatic when recurrence was detected, whereas 109 patients either consulted a physician because of symptoms suggesting recurrence or had such symptoms at the time they came to the hospital for a regular follow-up. Patient demographics at the time of initial surgery and patterns of recurrence are listed in Table 1. No differences in clinicopathologic variables were evident between patients who had cancer-related symptoms when recurrent disease was diagnosed and those without symptoms. Treatments given before and after detection of recurrent disease are listed in Table 2. Although a subgroup of patients who underwent adjuvant chemotherapy came to the outpatient clinic more often than those who did not, asymptomatic recurrences were not more frequent in this group. Detection of recurrent disease at an asymptomatic stage enabled a greater proportion of patients to be treated with chemotherapy (P = .076), possibly because performance status was better at the time of detection. Resection of metastatic lesions was performed in 15 patients (7.6%), which was marginally more frequent among those with asymptomatic recurrences (P = .08). Regional recurrence (n = 110), and peritoneal carcinomatosis in particular (n = 105; 53%), was the most common pattern of failure, whereas local recurrence was infrequent (n = 24). Liver metastasis was detected in 45 patients (23%), representing a relatively common pattern of treatment failure among patients with distant metastasis. Asymptomatic recurrences were detected more often in the form of distant metastases, whereas regional recurrences were diagnosed mostly after patients complained of cancer-related symptoms.
Received for publication December 17, 2002.
Accepted for publication May 14, 2003.
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ABSTRACT
INTRODUCTION
