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Editor,—We read with interest the study by Suvakovic et al (Gut1997;41:308–13) reporting that 63% of the patients with early gastric cancer had a previous history of upper gastrointestinal symptoms. These authors concluded that guidelines for the appropriateness of gastroscopy in patients with dyspepsia need to reflect the importance of not starting treatment prior to gastroscopy. General practitioners need to be made more aware of the potential for antisecretory drugs to mask early gastric cancer, which will then have a major detrimental impact on patient management. We have also studied whether patients with gastric cancer had serious and persistent dyspeptic symptoms necessitating consultation with their general practitioner (Laheij et al, unpublished observations). The results of our study, however, differ from Suvakovic et al’s.
We identified 46 patients with diagnostically verified early and late stage gastric cancer, using the Continuous Morbidity Register. This database is used to study the epidemiological aspects of diseases in primary care. The primary care population of approximately 12 000 patients has been followed since 1971. The recorded data have passed stringent quality controls and are consistent over the years of registration.1 Controls were selected and matched for sex, social class, practice, observation period, and age.
The mean observation period between the date of registration and the first diagnosis of gastric malignancy was 12 years. In this period, 18 (39%) patients had dyspeptic symptoms necessitating consultation with the general practitioner compared with 20 of the controls (odds ratio 0.8, 95% confidence interval 0.3 to 2.0). Patients with gastric cancer had no more visits to their general practitioner for gastrointestinal symptoms than controls. Therefore, consultation rates for dyspeptic symptoms cannot be considered a warning for gastric cancer.
Every patient with gastric cancer develops gastrointestinal symptoms and there will always be a delay in diagnosis.2Martin et al found a median delay of 17 weeks from the onset of symptoms to a definitive histological diagnosis in patients with gastric cancer. Use of an open access endoscopy service reduced this delay. There was no correlation between the delay in diagnosis and tumour stage or the success of potentially curative resection. The prognosis for gastric cancer is poor. To detect early gastric cancer, patients should be examined before the onset of dyspeptic symptoms. Fortunately, gastric cancer is rare in the Western world and epidemiological studies have shown that the incidence of and mortality from gastric cancer have decreased considerably. Screening people for gastric cancer before the onset of symptoms is therefore not feasible. Early detection of gastric cancer is not yet possible, and focusing attention on patients with a history of serious gastrointestinal symptoms may be of little value.
Editor,—The points raised by Laheij and colleagues are relevant to the debate regarding the late diagnosis of gastric cancer in Western Europe. Their figure of 39% consulting their general practitioner over a mean time period of 12 years is not far away from our figure of 30% investigated for symptoms in the 13 years leading up to diagnosis. We are not suggesting that all of these patients had gastric cancer at the initial time of presentation, but many almost certainly did (most of those investigated in the last four years—a “miss” rate of 1 in 6). There are two important points to note. Firstly, general practitioners may not think of the correct diagnosis because of previous (reassuring) investigations with the result that the diagnosis is delayed by years not months. Secondly, and related to the first point, general practitioners will prescribe powerful acid suppression for patients with a previous ulcer history which will result in resolution of symptoms and a further delay in diagnosis. This raises the question when do general practitioners re-refer a patient for gastroscopy when previous investigations showed no pathology or benign disease? It is also important to remember that early gastric cancer has “benign” symptoms and so it is effectively too late when the patient has lost weight or become anaemic.
We disagree that gastric cancer cannot be diagnosed earlier and progress will only be made if we alter current practice to include investigating patients “at risk” before starting antisecretory therapy and lowering the threshold for re-investigating patients who may have a history of dyspepsia. Screening is not feasible and we are not proposing such a policy. However within current practice we feel that there is room for improvement in the diagnosis of this disease which is not uncommon, representing the fourth commonest cancer in men in the UK.
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