Delays in diagnosing oesophagogastric cancer

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7105.426b (Published 16 August 1997) Cite this as: BMJ 1997;315:426

Attempts to reduce delays in diagnosis should be done in controlled trial

  1. Johannes G Schmidt, General practitionera
  1. a Family Practice and Institute for Clinical Epidemiology, Furrenmatte 4, CH-8840, Einsiedeln, Switzerland
  2. b City Hospital NHS Trust, Birmingham B18 7QH
  3. c Birmingham Heartlands Hospital, Birmingham B9 5SS
  4. d University Hospital NHS Trust, Birmingham B15 2TH
  5. e St James Medical Practice, King's Lynn, Norfolk
  6. f Jubilee Surgery, Titchfield, Hampshire
  7. g Department of Surgery, Christie Hospital NHS Trust, Manchester M20 4BX
  8. h Oesophagogastric Cancer Unit, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
  9. i Chinese University of Hong Kong, Hong Kong

    Editor—The finding that gastric cancer detected early has a long doubling time (several years) whereas that diagnosed in an advanced stage has a short doubling time (several months)1 is consistent with the well known length bias. A non-aggressive course is associated with a long subclinical period with a high chance of early detection, whereas aggressive growth with a rapid onset of severe clinical symptoms leaves little chance of recognition of disease in an early stage. This confounds the observation that “early” cancer has a better prognosis than “late stage” cancer. The low case fatality from gastric cancer in Japan is a logical consequence of such biases, given that over six million Japanese people (presumably a selection of healthy people) have stomach screening annually. The suggestion that “patients with new onset dyspepsia and with changes in long standing dyspepsia must be referred promptly [for gastroscopy]” 1 is therefore not evidence based.

    In practice, early detection of cancer means not only the possible advantage of better curability in some cases but also the possible disadvantage of overdiagnosis and overtreatment in many other cases. Necropsy studies show that 25% of women have cancerous breast tissue at the time of death, but in only 29% of these was it diagnosed during their lifetime.2 Screening or case finding has invariably resulted in a considerable increase in diagnosed breast cancer. The incidence of malignant melanoma, similarly, has doubled in places where early detection campaigns took place, with no subsequent change in mortality being observed. “It is possible that earlier diagnosis has uncovered a pre-existing nonmetastasising, nonfatal form of melanoma, and that this accounts for a substantial proportion of increases in incidence.” 3 Furthermore, necropsy studies indicate that prostate cancer is present in nearly half of older men, suggesting that many occult cancers detected through …

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