Natural history of surgically treated gastric cancer

Abstract

Although over 100 years have passed since Theodore Billroth’s first successful resection of a gastric cancer in 1881, little has truly changed in the natural history of surgically treated gastric cancer. Gastric cancer, presenting in its symptomatic state, remains a highly lethal malignancy, leaving fewer than 15% of patients alive 5 years after surgical therapy [1–7]. Although a subset of patient with early gastric cancer may enjoy cure rates approaching 90% [3,4], the prognosis for the majority of patient with gastric cancer treated in Europe and North American remains grim. These distressing survival statistics, shown in Table 1, should not surprise us, since patients in Europe and North America present relatively late in the course of their disease with bulky or ulcerating tumors. In a recent American College of Surgeons survey of over 18,000 patients treated between 1982 and 1987 for gastric cancer, 66% of patients were found on presentation to have stage III or IV disease (that is, spread of gastric cancer to continuous organs, lymph nodes, or metastatic sites) [9]. In this setting, gastrectomies can be performed in only 50% of patients thought to be resectable (see Table 1, ‘Resection rate’), and wide resections for cure, where no tumor remains, can be achieved in only 30% of patients (see Table 1, ‘Curative resection rate’) [1,3]. Unlike other solid tumors of the gastrointestinal tract, which may grow to bulky dimensions and still leave a chance for cure (such as colon cancer), gastric cancer must be discovered in its earliest stages to leave a hope for patient salvage. What is it about gastric cancer in patients with macroscopic disease that leads to such poor survival statistics?