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Temple Researchers Find Patients with Aggressive Type of Gastric Cancer Don't Necessarily Fare Worse

Alliric Willis, MDSignet ring gastric cancer has long been thought by Western oncologists and surgeons to be extremely aggressive and dangerous, with a worse prognosis than other forms of gastric cancer. Now, a new study by Temple University researchers finds that this may not be true, and their findings may help change current thinking about how to treat the disease.

Using a large federal database of U.S. cancer patients called SEER (Surveillance, Epidemiology and End Results), surgical oncologist Alliric Willis, MD, Assistant Professor of Surgery at Temple University School of Medicine, and his co-workers reviewed records of more than 10,000 cases of gastric cancer diagnosed between 2004 and 2007. They found that, compared to the more common gastric adenocarcinoma, patients with signet ring cancer didn't fare any worse. The researchers reported their findings recently in the Journal of Clinical Oncology.

"The dogma in the West has been that signet ring gastric cancer in many cases is considered practically a death sentence," said Dr. Willis. "Our study shows that this isn't the case. While it is a markedly more aggressive disease in some patients and they tend to be diagnosed at a later stage with worse disease in general than those with gastric adenocarcinoma, their prognosis isn't much different."

These findings are similar to recent studies in Asia, Dr. Willis noted, where gastric cancer is much more common, as is surgery for patients with signet cell cancer.

In the study, the researchers reviewed 10,246 cases of patients with gastric cancer, including 2,666 of signet ring gastric cancer and 7,580 of gastric adenocarcinoma. They found that signet ring cancer was more likely to be found at later stages of disease (46 percent versus 33 percent) and have spread to the body's lymph nodes (60 percent versus 52 percent). The median survival (defined as the amount of time half of those with the disease are expected to still be alive) was very similar between the two groups: patients with signet ring gastric cancer lived 14.0 months after diagnosis compared to 13.0 months for those with gastric adenocarcinoma.

"We found that stage for stage – meaning patients with signet cell cancer and gastric adenocarcinoma, at the same stage of disease – should continue to be treated both with standard surgery and post-operative chemotherapy and expect the same outcome. That's very important for the surgeon to know," said Dr. Willis.

While overall survival from gastric cancer is poor, and has not improved over the last two decades, gastric cancer incidence has been declining in the U.S., Dr. Willis noted. According to the American Society of Clinical Oncology's patient website,, an estimated 21,320 adults in the United States will be diagnosed this year with stomach cancer, with approximately 10,540 deaths. About 26 percent of those with gastric cancer are expected to live at least five years after diagnosis. Most people with stomach cancer are diagnosed after the cancer has already spread to other parts of the body.

The Asian Factor: Different Cancer or Different Patients?

In Asia, gastric cancer remains an extremely common disease and is screened for in the general population, similar to colorectal cancer in the U.S., Dr. Willis noted. Asians with signet cell cancer tend to have surgery more frequently than their Western counterparts, and early detection has resulted in better outcomes for some patients, despite the disease often being found at later stages.

Because studies in Asia questioned the notion that signet cell gastric cancer had a worse prognosis than gastric adenocarcinoma, Dr. Willis wondered if gastric cancer was different in Asia, or if patients were different. "The U.S. has a much more diverse population than in Asia," he said. "That raises the issue about this cancer – is it as aggressive and has as bad an outcome as we as surgeons and oncologists have been taught; or is it, in fact, not as different as the Asian literature suggests, especially in light of our improved surgical techniques, radiation therapy and chemotherapy options? This question has never been asked in this way in this country."

The researchers found that Asians in the U.S. have a higher incidence of signet cell gastric cancer and gastric adenocarcinoma, but have better survival than other non-Asian groups. The cancer may be environmental in nature in Asia, and the thought was, when Asians move to the U.S., the way gastric cancer behaves and outcomes in the disease would reflect the U.S. population. In fact, they don't. Asian patients still have a different presentation and improved outcomes. There may be a biological component involved.

"These results tell us that, particularly after surgery, we should be aggressive in offering the same treatments to patients with signet cell cancer as we would to patients with adenocarcinoma," Dr. Willis said. "We can expect the same outcomes, and we should be willing to offer the same aggressive adjuvant therapies. We shouldn't be thinking that these patients are going to die just because they are diagnosed with this disease."

Other researchers who contributed to this work include Sharven Taghavi and Senthil N. Jayarajan, Temple University School of Medicine, and Adam Davey, Temple University College of Health Professions and Social Work.

The research was supported by grants from the National Institutes of Health and the U.S. Department of Agriculture.

Date Published: Wednesday, October 31, 2012

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