Smoking, H pylori Risk Factors for Synchronous Gastric Cancers After ESD

Patients who undergo ESD for early gastric cancer should be closely monitored before the procedure, as some patients may already have synchronous gastric cancer.

In patients who underwent endoscopic submucosal dissection (ESD) for early gastric cancers (EGCs), risk for synchronous gastric cancers (SGCs) was associated with smoking, according to study results published in the Journal of Gastroenterology.

Data for this analysis were sourced from the Tohoku Gastrointestinal Study, which is an ongoing prospective cohort study conducted at 22 sites in Japan. The aim of this analysis was to evaluate lifestyle risk factors for SGCs, defined as multiple gastric cancers within 1 year of ESD. Concomitant and missed EGCs were defined as cancers detected after or during the procedure, respectively, and Helicobacter pylori eradication was based on pepsinogen (PG) levels.

The patients (N=850) had a median age of 70 (IQR, 65-76) years where 75.1% were men who had a BMI of 23.7 (IQR, 21.5-25.7) kg/m2, 71.1% were current or former smokers, and 48.8% were positive for H pylori.

The patients who had SGCs (16.0%) were more likely to be men, to smoke, and have lower PG I and II levels than patients who only had a single EGC event (all P £.032).

[I]t is important to identify high-risk patients for the prevalence of SGCs as well as careful endoscopic observation.

Among the patients with SGCs, 93 had concomitant EGCs, 30 had missed EGCs, and 13 had both missed and concomitant EGCs. The patients who had missed EGCs had higher rates (P <.001) of tumor invasion into the submucosa at less than 500 µm (9.5% vs 4.1%) and at least 500 µm (2.4% vs 0.0%) compared with those who had a single EGC event, respectively.

Predictors for SGCs included smoking history (odds ratio [OR], 1.93; 95% CI, 1.01-3.69; P =.048) and severe atrophic gastritis (OR, 1.92; 95% CI, 1.23-2.98; P =.004).

To better evaluate the relationship with smoking, more detailed characteristics were assessed in adjusted analyses. The significant predictors were current (adjusted OR [aOR], 2.33; 95% CI, 1.14-4.78; P =.021), but not former (aOR, 1.76; 95% CI, 0.90-3.43; P =.098) smoking status compared with never smokers and a history of at least 40 pack-years of smoking (aOR, 2.26; 95% CI, 1.12-4.57; P =.023) compared with 0 pack-years.

Similarly, in a more detailed analyses of severe atrophic gastritis, the association remined significant among patients without H pylori eradication (aOR, 2.10; 95% CI, 1.32-3.34; P =.002), but not among those with successful eradication (aOR, 0.75; 95% CI, 0.14-3.98; P =.737) compared with nonsevere atrophic gastritis.

In a combinatorial analysis, risk for GSCs associated with both smoking history and severe atrophic gastritis (aOR, 4.14; 95% CI, 1.58-10.85; P =.004), but not with either alone.

Study limitations include the small sample size and the fact that lifestyle factors may have included recall bias.

“Patients who undergo ESD for EGCs sometimes have SGCs; however, some of them are missed before ESD and detected after ESD at a stage that cannot be curatively treated in endoscopic resection,” the study authors wrote. “To resolve this issue, it is important to identify high-risk patients for the prevalence of SGCs as well as careful endoscopic observation.”

This article originally appeared on Gastroenterology Advisor


Hatta W, Koike T, Asonuma S, et al. Smoking history and severe atrophic gastritis assessed by pepsinogen are risk factors for the prevalence of synchronous gastric cancers in patients with gastric endoscopic submucosal dissection: a multicenter prospective cohort study. J Gastroenterol. Published online February 14, 2023. doi:10.1007/s00535-023-01967-y