Presentation and Outcomes of Gastric Cancer at a University Teaching Hospital in Nepal

Gastric cancer is the fifth commonest cancer (after cancer of the lung, breast, colorectal, prostate) which accounts 6.8% of all cancer worldwide, and third commonest cause of cancer related mortality (after cancer of the lung and liver) which accounts 8.8% of cancer mortality (Ferlay et al., 2013). Incidence of gastric cancer varies according to geographic locations in different parts of world. According to GLOBOCAN 2012, more than 70% of cases (677,000 cases) occur in developing countries and half the world total occurs in Eastern Asia (mainly in China). Studies done in Nepal showed gastric cancer as the 3rd most common cancer in males preceded by lung cancer and oral cancers where as it is the 2nd most common cause of cancer related mortality in males. In females, it is the 6th most common cancer and is the 5th most common cause of cancer related mortality (Pradhananga et al., 2009). Currently, the only potentially curative treatment for


Introduction
Gastric cancer is the fifth commonest cancer (after cancer of the lung, breast, colorectal, prostate) which accounts 6.8% of all cancer worldwide, and third commonest cause of cancer related mortality (after cancer

Materials and Methods
This was a retrospective study conducted over a period of five years (January 2009 to December 2013) at the Department of Surgery, Tribhuvan University Teaching Hospital (TUTH) Kathmandu, Nepal.TUTH was established in 1983 and is a 700 beded tertiary care and teaching hospital and serves as a referral center for tertiary specialist care in the country.Average number of patients attending the outpatient department and admissions are 23858 and 5486 patients in surgical gastroenterology units of the Department of Surgery, respectively; with average number of patients operated 2310 patients annually.All patients with histologically proven adenocarcinoma of the stomach, admitted for surgery, were included in this study and patients with incomplete data were excluded.
The patient's details were collected from patients' records kept in the medical record department, the surgical wards, operating theater and pathology department.Patient's data regarding demographics, ethnicity, geographical distribution, presenting symptoms, location, AJCC (TNM) staging (Edge et al., 2010), management, survival, perioperative morbidity and mortality, and follow-up were analyzed.
Follow-up period was up to five years or death.Survival analysis was carried out with survival defined as the time between the date of commencement of treatment and the date of last follow-up or death.The recurrence of disease was confirmed by physical findings, radiological studies, endoscopic examination with biopsy and surgery.
All data were analyzed by SPSS for windows version 17 and simple descriptive methods were used.

Results
One hundred forty (75.3%) out of the total 186 patients with histologically proven gastric adenocarcinoma, were admitted for surgery.Operative procedures were deferred in remaining 46 patients (24.7%) because of metastatic disease or patient denied surgery.Mean age of presentation was 59.6±12.4 years with 125 (89.3%) patients were above 40 years (Table 1).Of the 140 patients 93 were males and 47 females, with the male to female ratio of 2:1.Male to female ratio was 1:1.5 in less than 40 years of age.Seventy eight (55.7%)patients were in age group of 50-70 years.Seventy seven (55%) patients belonged to the Indo-Aryan decent where as 63 (45%) patients belonged to Tibeto-Burman decent.Out of 63 patients, 40 patients belonged to Gurung, Sherpa, Lama (Janajatis-Hill).According to 2011 census of Nepal, Indo-Aryan group comprises of 79% and Tibeto-Burman 18% of population.When we consider this fact, a significant portion of the patients with carcinoma stomach belonged to the Tibeto-Burman group, moreover belonged to Gurung, Sherpa, Lama (Janajatis-Hill).
One hundred thirty five (96%) patients had advanced gastric cancer whereas 5 (4%) patients had early gastric cancer which was diagnosed post-operatively.Thirty four patients (24%) were of stage IIIB followed by 31 patients (22%) of stage IIIA and 11 patients (8%) of stage IIIC.Twenty patients (14%) were with metastatic disease and the remaining patients (32%) were of either stage I or II (Table 1).Surgery with curative intent (D1, D1+ or D2) was undertaken in 84 (60%) patients, out of which subtotal gastrectomy was done for 73 (87%) patients and total gastrectomy was done for 11 (13%) patients; with average number of lymph node retrieval was 16.6±8.2(Range 5-47 lymph nodes).Palliative surgery was done in 32 (23%) of which palliative subtotal gastrectomy was done for 14 (44%) patients, Gastrojejunostomy for 13 (41%), Feeding jejunostomy for 3 (9%) and Ileocolic anastomosis was done for two patients with obstruction of transverse colon (Table 2).No intervention was done in 21 (15%) patients.Three patients had presented with gastric cancer perforation and were operated in the emergency.Patient was referred for post-operative chemotherapy for all patients with T3/T4 tumors and/or node positive tumors.

Discussion
Gastric cancer is the commonest gastrointestinal malignancy and one of the most common causes of cancer related death in Nepal.The incidence of gastric cancer is known to increase with age with the peak incidence occurring at 60-80 years (Nagini et al., 2012).In our study also, more than half of the patients (55.7%) were in age group of 50-70 years with the mean age of 59.6 years and male to female ratio of 2:1.Similar finding was observed in other study which showed 80.5% patients of more than 45 years and male to female ratio was 1.97:1 (Khan et al., 2012).
Fifty percent of patients belonged to Brahmin and Chhetris (Hill) followed by Janajatis (Hill) 35% and Newars 11%, both of whom belonged to the Janajatis and amongst them it was more frequently observed in the Gurung and Sherpa community (Ghosh et al., 2010;Ghimire et al., 2014).In our study, sixty three (45%) patients with gastric cancer belonged to Tibeto-Burman decent though they comprise only 18% of the Nepal population, moreover belonged to Gurung, Sherpa, Lama (Janajatis-Hill).Since these patients belong to the hilly region and practice of traditional medicine, limits their accessibility to health care facilities (Raut et al., 2011).As their beliefs on witchcraft and reliance on traditional faith healer for treatment is quite strong among all the ethnic communities, visit to a health facility becomes inevitable only when problem gets worse or unbearable (Subba et al., 2004).
Surgery remains the mainstay of curative treatment of resectable gastric cancer and complete resection of a gastric tumor with resection of adjacent lymph node is the only chance for a cure (Alatise et al., 2007;Bakari et al., 2010).In our study, surgery with curative intent was performed in 84 (60%) patients with average number of lymph node retrieval was 16.6±8.2(Range 5-47 lymph nodes), and palliative surgery was done in 32 (23%).For localized resectable gastric cancer, D1 or modified D2 lymph node dissection with a goal of examining at least 15 lymph nodes is done (Schwarz et al., 2007;Songun et al., 2010).Patients who underwent D2 lymph node dissections, there was a trend toward improved survival for patients with T3/T4 gastric cancer as confirmed by recent meta-analysis (Seevaratnam et al., 2012).
Majority of patients (24%) were of stage IIIB followed by stage IIIA.Data were obtained from National Cancer Data Base (NCDB) reports of 50,169 gastric carcinoma cases diagnosed during the years 1985-1996 and treated with gastrectomy revealed similar findings (Hundahl et al., 2000).The prognosis of gastric cancer has remained poor in most developing countries where most patients are already in an advanced stage of the disease at the time of diagnosis (Edwards et al., 2004;Verdecchia et al., 2004;Tsugane et al., 2007).
Five years survival up to recent follow up was only 8.3%.This is an ongoing study, exact results of 5 years survival is still awaited.Five-year survival rate of all patients with gastric cancer in United States is 29%, where as Japan has 5 years survival rate of 60% (Kamangar at al., 2006).This difference is because of mass screening programs using photofluorography differences in tumor biology and location with more intestinal subtypes and distal locations, and stage migration due to higher lymph node yield in Japanese series (Bunt at al., 1995;Hamashima et al., 2008).
Early diagnosis of gastric cancer confers five year survival of 90% and is the only way to improve survival rate (Antonioli et al., 1994;Berrino et al., 1999;Kikuchi et al., 2004).Early diagnosis is difficult since symptoms appear late.In a study by Look et al, epigastric pain (63.3%) and gastrointestinal hemorrhage (27.3%) were the important symptoms, whereas according to Haugstvedt et al, weight loss was common symptom (Haugstvedt et al., 1991;Look et al., 2003).In our study, presenting symptom was pain abdomen (87%), anorexia (81%), and weight loss (77%).
Poor survival can be explained in gastric cancer patients, when symptoms occur, the cancer has usually spread and only a few patients are only suitable for curative surgery.Therefore, mass screening can only pick up asymptomatic early gastric cancer.In our series, effective risk population for gastric cancer e.g.Janajatis (Hill) is to be screened selectively (Ghimire et al., 2014).
In conclusion, gastric carcinoma is a male predominant malignancy usually of old age and commonly observed in the Tibeto-Burman group of peoples in distal third of stomach in Nepal.It is usually diagnosed at an advanced  stage and has poor prognosis.Thus, early detection is the key to improve the survival of gastric cancer patient.