"An Evaluation and Continuation of a Gastric Cancer Screening Effort in Chinese Immigrants in New York City"

Amina Chaudhry MD†, Alex Cho MD†, Lisa Minsky-Primus MD†, Stuart Marcus MD†, David Diehl MD†, Guillermo Perez-Perez PhD†, Alan Tso MD‡, Francesca Gany MD, MS†, † NYU Medical Center/Bellevue Hospital Center; ‡ Charles B. Wang Community Health Center

Introduction: Gastric cancer has a well-defined high-risk population. In China, the annual incidence among men is approximately 55/100,000, which is five times higher than it is among white men in the United States. Gastric cancer is associated with detectable precursor lesions and at least one risk factor has been identified. H. pylori infection is associated with increased prevalence of atrophic gastritis, intestinal metaplasia (IM), and gastric cancer.
Objectives: This study, Repeat Endoscopy in Patients from East Asia Trial (REPEAT), examined the potential import and feasibility of a large-scale population-based study on gastric cancer prevention in Chinese immigrant populations. It built on a recent community center-based research trial that screened over 120 Chinese immigrants (primarily non-English speaking and uninsured) for gastric cancer at Bellevue Hospital in New York City between 1998 and 2000. Researchers for this study gathered epidemiologic and clinical information about each participant, performed endoscopy (EGD) with biopsy, and made recommendations for therapy, further work-up, and follow-up based on the findings. However, there had been no follow-up evaluation of the intervention. For gastric cancer screening to have an impact on mortality, it would need not only to reach patients at high risk, it would also need to convince them to return for follow-up EGD. Retrospective data suggest that, in order to be effective, EGD may be necessary as often as every two years. The study was designed to gather logistical, cultural, and pathophysiologic data that will help in the design of a larger, longer gastric cancer screening trial.
Results: 79 of the 126 immigrants were successfully contacted. Of the 79, 30 agreed to repeat EGD; 39 declined; and 10 were undecided. Ultimately, 24 individuals completed a repeat EGD. Of the 55 who declined, 41 completed a refusal instrument. The most common reasons given for refusing repeat EGD were absence of symptoms (19), recent EGD (12), and lack of time (12). Of the 24 who had a repeat EGD, 20 had been positive for Helicobacter pylori (Hp). Thirteen had undergone triple therapy, and upon repeat EGD, 12 achieved eradication. Eight of the 12 showed improvement in histologic findings, and none showed progression. In contrast, of the seven patients who did not receive Hp therapy, six were still positive for Hp infection and two showed progression of histology.
Conclusion: Even though EGD with biopsy is recommended as an early intervention in dyspeptic patients at higher risk for gastric cancer, few would accept repeat EGD. Patients are more likely to adhere to recommendations following an initial screening test if they have a regular physician or regular source of health care. Patients without symptoms were much less likely to agree to repeat endoscopy. Improving access to primary care for underserved Asian immigrant populations is thus an important step toward achieving increased rates of treatment of Hp infection, which is thought to be a risk factor for gastric cancer.
Abstracts Submitted:
(1) Determinants of follow-up and likelihood of participation in a gastric cancer screening intervention. Chinese American Medical Society Annual Scientific Meeting, New York, NY, October 2003.
(2) The Repeat Endoscopy in Patients from East Asia Trial (REPEAT). Cancer Health Disparities Summit. Washington, DC. July 2003. Center to Reduce Cancer Health Disparities, National Cancer Institute.
(3) Predictors of follow-up after a one-time gastric cancer screening intervention. NYU Department of Medicine Research Day. New York, NY. May 2003.