Implications of serum pepsinogen I in early endoscopic diagnosis of gastric cancer and dysplasia

Background and Aims: The risk of gastric cancer (GCA) is increased in atrop hic gastritis. A low serum pepsinogen group I (SPGI) level is a good serolo gic indicator of atrophic gastritis of the gastric corpus and fundus, and c an be used for diagnosis of subjects with atrophic gastritis and of increas ed risk for GCA. The present study was undertaken to investigate whether SP GI assay and a diagnostic gastroscopy could enable the diagnosis of GCA at an early stage. Material and Methods: The study was carried out as part of the Alpha-Tocopherol, Beta-Carotene Cancer prevention study (ATBC study) in Finland, in which 22,436 male smokers aged 50-69 years were screened by SP GI. Low SPGI levels (< 25 mu g/l) were found in 2196 (9.8%) men. Upper GI e ndoscopy (gastroscopy) was performed in 1344 men (61%) and 78% of these had moderate or severe atrophic corpus gastritis in endoscopic biopsies. A con trol series of 136 men from the ATBC study cohort with abdominal symptoms, but with SPGI greater than or equal to 50 mu g/l were similarly endoscopied , and 2.2% of these had corpus atrophy. Results: Neoplastic alterations wer e found in 63 (4.7%; 95% CI: 3.6%-5.8%) of the 1344 endoscopied men with lo w SPGI levels. Of these, 42 were definite dysplasias of low grade, 7 dyspla sias of high grade, 11 invasive carcinomas, of which 7 were 'early' cancers , and 3 carcinoid tumors. In the control series, 1 man (0.7%) of the 136 me n had a definite low-grade dysplasia. Thus, 18 (1.3%; 95% CI 0.7%-2.0%) cas es with 'severe' neoplastic lesions (4 advanced cancers, 7 early cancers an d 7 dysplasias of high grade) were found in the low SPGI group, but there w ere none in the control group. All four patients with advanced cancer died from the malignancy within 5 years (mean survival time 2.5 years), whereas surgical treatment in all those with early cancer or high-grade dysplasia w as curative. One of the seven patients with early cancer and two of the sev en with high-grade dysplasia died within 5 years, but none died from the ga stric cancer. Thus, curative treatment was given to 14 of 18 men in whom a malignant lesion was found in gastroscopy. This is about 15% of all gastric cancer cases (92 cases) which were diagnosed within 5 years after SPGI scr eening in the 22,436 men. Among the gastric cancer cases of the main ATBC s tudy, the 5-year survival rate was 33% (85% of the non-survivors died from gastric cancer). Conclusions: We conclude that assay of SPGI followed by en doscopy is an approach which can enable the early diagnosis of gastric canc er at a curable stage.