To Improve Gastric Cancer Care, East and West Have to Learn from Each Other --Dr. Giovanni De Manzoni Talks to Chinese Oncology Media

To Improve Gastric Cancer Care, East and West Have to Learn from Each Other

--Dr. De Manzoni Talks to Chinese Oncology Media  

 

Dr. Giovanni de Manzoni, President of International Gastric Cancer Association(IGCA) at EHA2015

Oncology Frontier(肿瘤瞭望): Can east and west learn from each other in gastric cancer research?

Dr. de Manzoni： This question is very important. When the IGCC organizers asked me what I wanted to speak about in my Presidential lecture， I wanted to speak about the difference between the East and West. Nowadays, we are facing different realities. 

In my opinion，China is more similar to the Western countries at present compared to Korea and Japan. In Korea and Japan， their surgeons are dealing with very small areas of cancer using endoscopic resection and organ-preserving surgery using minimally invasive laparoscopic approaches. 

In the West， we are facing more advanced cancer and more aggressive cancer. So we learnt from the Japanese oncologists how to perform lymphadenectomy. In Japan and Korea， they are using the less-invasive D1+ surgery， while in my country we still need aggressive lymphadenectomy. We have learned in the last few years that this lymphadenectomy might be very useful in the treatment of diffuse gastric cancer. This is a type of gastric cancer that is common in the West and a challenge for us in the future. 

How do we treat diffuse gastric cancer? For the last fifteen years， we have treated this group of patients with D2 dissection， always. But unless it was perfect surgery， we could not improve survival because the number of diffuse signet ring carcinomas increase day-by-day， year-by-year and today our survival rates are the same as they were in 1995. So we have to research further or approach differently the treatment of diffuse， and particularly signet ring， gastric carcinoma. This type of cancer is not sensitive to chemotherapy. Usually we use neoadjuvant chemotherapy but it is not good for this cancer type. We need to determine which type of chemotherapy and which type of surgery to apply to these cancers. This is the challenge for Western countries. 

China probably stands in between the Western nations and the other Eastern nations. My understanding is that the types of cancer seen in China are similar to Korea， so when the Chinese develop early endoscopic screening procedures， they will arrive at the same position as Korea and Japan with that bigger difference between incidence and mortality. 

Oncology Frontier: (肿瘤瞭望):  What issues exist in evidence-based medicine gastric surgical research? What are the possible solutions?

Dr. de Manzoni： The possible solution for the future is to understand and learn from each other better – East and West. The Western surgeons need to understand and learn the more aggressive surgery. I believe that in the Asian countries， the GE and upper third gastric cancers will increase in the future because the diet and lifestyle changes occurring in the younger generations are similar to the Western norm. 

So potentially in the future， the East will be learning from our example in treating upper third/GE junction gastric cancers. Today， more than 50% of gastric cancers are in the upper third. In Korea， this is 8%; in Japan， 10%. In China， there are upper third cancers， but they are mainly squamous cell tumors. So， in the future， I think the Asian surgeons and oncologists will have to learn from their Western colleagues how to treat upper third and GE junction cancers. I hope we are able to provide adequate weaponry to our eastern colleagues. 

Oncology Frontier(肿瘤瞭望): : You have compared Western nations with China, Japan and Korea, what about India? 

Dr. de Manzoni：India is a mystery to me. 

They have some very good surgeons and very good researchers. The incidence is quite high but not as high as Korea， Japan or China. I would say that India is currently in the same situation as the Eastern European countries (Russia， Ukraine， Moldavia， Georgia)， which are twenty or thirty years behind the other European nations. They are dealing with very advanced disease and have less opportunity to give chemotherapy and so on. India would be much the same， apart from a couple of universities and hospitals in Mumbai and Chennai， generally speaking， the treatment of gastric cancer is poor. Of course， class distinctions， patient economics and the functionality of national health systems globally， with or without insurance， will affect treatment of these cancers at the individual level. 

Oncology Frontier(肿瘤瞭望): :  Regarding the concern of lymphadenectomy in gastroesophageal junction tumors， could you give us some suggestions on lymph node dissections and whether to remove the spleen and pancreas or not?

Dr. de Manzoni：The treatment of gastroesophageal junction tumors with lymphadenectomy remains a challenging field. There has been a lot of discussion not about how to treat the gastric cancer invading the GE junction， but how to treat the esophageal cancer. 

Many of us believe that if the infiltration of these cells is more than 2 or 3 cm we have to enter the thorax and also remove the mediastinal nodes， in many cases without touching the spleen and pancreas. We have never removed the spleen or pancreas in upper third gastric cancers. Japanese researchers have arrived at the same conclusion with a randomized clinical trial that they presented today. 

Splenectomy is not useful for gastric cancer patients including patients affected in the GE junction. Lymphadenectomy is important， but not splenectomy. Lymphadenectomy depends on how much of the esophagus is involved. If the esophageal involvement is just 2 cm then I think the lymphadenectomy could be abdominal only and lower mediastinal. If involvement is more than 2 cm， then you have to go into the thorax to have a good clean resection margin and also a lymphadenectomy of the thorax. That is the current thinking of specialists in esophageal cancer. The gastric cancer specialists say it is enough to treat from the abdomen only.

References: 1. IGCC 访谈，东西方对胃癌的不同看法：我们应该互相学习什么？ http://mp.weixin.qq.com/s?__biz=MzA4MDM4MzExMA==&mid=208045398&idx=4&sn=2624ec983b204bc670cb421a8b1713ee#rd 肿瘤瞭望  June 11， 2015 WeChat Video