00:00:00: - Hello everyone, welcome to this episode of the UUG Talks.

00:00:04: It's Pradeep Munda here,

00:00:05: and I'm your host for the UUG Talks today.

00:00:08: Now, gastric cancer is potentially preventable.

00:00:12: And I have covered this aspect

00:00:16: with my very first podcast for UUG Talks

00:00:19: with Professor Marcis Lea nearly 18 months ago.

00:00:23: We did discuss various things and basics.

00:00:25: I felt go back to Pylori and things.

00:00:27: And I would urge the listeners to listen to that episode.

00:00:32: And this goes in conjunction with this episode.

00:00:35: And one of the things in relation to this

00:00:37: that I often notice routinely in my clinical practice

00:00:41: is huge variability in the quality of upper genoscopy

00:00:46: in terms of reporting gastric pre-malangal lesions.

00:00:51: And I find that these are often missed.

00:00:54: And if sometimes they're reported,

00:00:57: they're reported very inadequately

00:00:59: in terms of the extent of the pre-malangal lesions

00:01:03: and everything else that comes with it.

00:01:05: And this has huge implications

00:01:08: in terms of patient management.

00:01:10: And often the offer of surveillance

00:01:14: or no surveillance for such patients ends up being potluck.

00:01:18: So to say, depending on how the endoscopist describes

00:01:21: the findings or the clinician's interpretation

00:01:25: of the endoscopist's report.

00:01:27: And I suspect the reason for this is lack of awareness.

00:01:30: And previous guidelines had addressed this issue

00:01:33: but may not have been crystal clear

00:01:37: or crisp in guiding us clinicians.

00:01:39: And on that note, the European Society of Gastrointestinal

00:01:43: Endoscopy have now updated their latest guidelines

00:01:47: on this topic called the MAPS Three Guidelines.

00:01:51: And whilst we can't cover the entirety of the guidelines,

00:01:55: today's discussion is about the most important aspects of this.

00:01:59: And to discuss this today,

00:02:01: we have none other than the lead author

00:02:03: for this guidelines, Dr. Mario Dinis-Riveru.

00:02:07: Professor Dinis-Riveru is a full professor

00:02:10: at the Faculty of Medicine at the University of Porto,

00:02:14: Consultant Gastrointestinal at Porto Comprehensive Cancer Center

00:02:18: where he's the head of the department

00:02:20: and vice director of research center.

00:02:24: - Welcome to UIG Talks, Mario. - Thank you.

00:02:27: So, Mario, I've been looking at the MAPS Three Guidelines

00:02:32: in preparation for this.

00:02:33: It's extensive compared to the previous ESG guidelines

00:02:37: and very amazingly succinct.

00:02:39: And I have to give all kudos to your team

00:02:42: and you and your team to put this together.

00:02:45: And it's 40 pages long.

00:02:47: Can I ask you to begin with,

00:02:49: what is the scope of these guidelines

00:02:50: and how this was developed

00:02:52: and what all aspects have it covered in these guidelines?

00:02:55: Well, first of all, thank you again for inviting me

00:02:58: and I hope that we can have a discussion around,

00:03:00: we believe, a nice guideline

00:03:03: and a very comprehensive guideline.

00:03:04: That was the main aim always of the team

00:03:07: that embarked on this adventure.

00:03:11: So, as you said, this is the third edition for this guideline.

00:03:15: And when we started in 2011, 2010,

00:03:19: when we kicked off the first guideline,

00:03:22: we joined forces with the European Helicobacter

00:03:25: and Microway of the study group.

00:03:27: Well, it's obvious because the Helicobacter

00:03:29: is the main risk factor for gastric cancer

00:03:31: and also the European Society of Pathology

00:03:33: because finally it's all about merging the concepts

00:03:37: between endoscope and pathology

00:03:39: on managing these patients.

00:03:41: But we will have the chance to go to that topic.

00:03:45: So, every five years, approximately the guidelines,

00:03:48: they have to be updated and meanwhile,

00:03:50: of course, they are exposed to the community

00:03:52: and lots of discussions occur in conferences.

00:03:55: And we felt along the line with the recent systematic review

00:04:00: that even though the guidelines have been uptaken,

00:04:03: there was somehow, sometimes some discrepancy

00:04:06: in the way they were read.

00:04:08: This is on one side, so it's probably not anymore,

00:04:11: a lot of heterogeneity, but on the other side,

00:04:14: a lot of discrepancy in the way the different guidelines

00:04:17: from different parts of the globe, they were understood.

00:04:21: Also, there were some areas that have not been covered

00:04:24: and there were some criticism

00:04:26: because of course you can manage a patient

00:04:28: when it comes finally to your outpatient clinics,

00:04:31: but what about enrolling the patient

00:04:33: at the very first moment to endoscopy

00:04:36: or how to deal with special situations.

00:04:39: And finally, she decided also for other guidelines

00:04:45: that we would be more, even more comprehensive

00:04:47: in terms of organ.

00:04:48: So, yes, she did that for merits

00:04:51: and we did this in terms of how to manage finally

00:04:55: if we find out the superficial reason

00:04:57: that would be respectable.

00:04:59: And that's why at the end became quite a long guideline.

00:05:04: In the top of that, we also aim to have the consequences

00:05:09: in terms of greener endoscopy.

00:05:12: But we did not, of course, cover everything.

00:05:16: So, the readers of the guideline

00:05:18: may miss also some technical and training concepts,

00:05:21: but this can be found elsewhere.

00:05:24: - So, you covered screening here,

00:05:27: surveillance, identification of pre-meding lesions,

00:05:32: management of such lesions,

00:05:34: and treatment of alcovacter pylori and all that.

00:05:37: I guess for the benefit of audience, Mario,

00:05:41: they probably focus less on treatment of displace here

00:05:46: and we will cover some of it,

00:05:48: but I think predominantly we'll cover screening surveillance,

00:05:50: which is more important to our colleagues

00:05:53: 'cause management of displace here as such

00:05:55: is dealt in by specialists.

00:05:57: And although we'll touch, we'll cover less on that,

00:06:00: hopefully, let's see.

00:06:01: Now, let's start off, Mario,

00:06:04: with screening for gastric cancer and pre-medicine lesions.

00:06:08: And in the guidelines, you mentioned

00:06:12: three different domains of screening.

00:06:15: Can you expand on that

00:06:18: and briefly explain what this means

00:06:20: and how it's best done?

00:06:22: - Of course, there is always some differences in taxonomy

00:06:25: if you speak with different groups,

00:06:27: but at least within the guideline we aim

00:06:31: that's a discussing population-based screening

00:06:35: when we refer to an entire population solely defined

00:06:40: as the setting end or the age,

00:06:43: like we can discuss for others, the screenings,

00:06:47: or target screening.

00:06:49: That would mean that you further define a subsetting again,

00:06:54: like for instance, if we would be defining screening

00:06:57: for barrens or for other diseases

00:07:01: like pancreatic cancer, et cetera.

00:07:03: And then lastly, a screening/opportunistic diagnosis

00:07:08: that we suggested that in every gastroscopy should be done,

00:07:12: that is probably a chance

00:07:14: when the citizen come to the health system

00:07:17: for the first time and it's probably a lost moment

00:07:20: if you don't care about looking carefully to the stomach

00:07:23: and detect what you should be detecting.

00:07:25: Of course, if the first two,

00:07:27: meaning the population and the target,

00:07:29: would be more, let's say, more or less to be defined

00:07:32: by policy makers and when and how to implement

00:07:36: and maybe we can discuss further this.

00:07:38: The last is for everyday clinicians to decide

00:07:42: and that should be applying what we suggest in the guidelines.

00:07:46: - Okay, let's briefly dwell into population-based screening

00:07:50: and you do make some statements about this

00:07:52: in the guidelines.

00:07:53: Can you briefly tell us how this is done,

00:07:58: where this should be done

00:07:59: and when it should be done, how frequently?

00:08:02: - Yeah, well, some of the answers are not, let's say, there yet.

00:08:06: So, for instance, there is some evidence to suggest

00:08:11: that in Eastern countries,

00:08:14: that of course we are discussing mostly for Europe,

00:08:16: even though this guideline has been taken

00:08:18: by others in different parts of the globe.

00:08:21: But of course, if the country as a whole

00:08:23: has a very high incidence for gastric cancer,

00:08:27: probably justifies to implement even a standalone screening

00:08:30: procedure for gastric.

00:08:33: That all means that that individual would be recommended

00:08:36: to make an endoscopy or any other matter for screening,

00:08:39: such as seronpicepepsinogen or other measures,

00:08:43: such as primary prevention,

00:08:45: such as screening and treating forage pylori.

00:08:48: If we move to Europe, we may not have such areas

00:08:53: with a very high incidence

00:08:55: and we discuss mostly intermediate and low areas.

00:08:59: So, the suggestion that we make is that if,

00:09:02: for that specific area, it's finally shown

00:09:06: that it's cost effective to have screening

00:09:09: for gastric cancer, then it should be implemented.

00:09:12: So, of course, it's a circular suggestion,

00:09:14: but we open the door to the projects that are ongoing,

00:09:18: like Togas, it's a European consortium

00:09:21: that will address these topics.

00:09:23: And we may find out different answers in different parts,

00:09:26: depending on facilities.

00:09:29: And finally, the cost, of course,

00:09:30: I will not go into detail on cost effective studies,

00:09:33: but our suggestion is that if in a specific area,

00:09:37: it's finally shown that it's cost effective to go

00:09:41: for screening, we should go.

00:09:42: The suggestion is also made in a previous position statement

00:09:47: and also based even for the states

00:09:51: in some cost effectiveness there,

00:09:53: that it may be cost effective

00:09:55: to synergistically approach the population

00:09:58: together with the correct cancer screening.

00:10:01: How, well, we could go for fit based

00:10:04: plus seeking for H. pylori,

00:10:06: I guess that Mars is already alluded to that in this talk,

00:10:10: or if the patient finally comes to prognoscopy,

00:10:13: either from primary colonoscopy towards screening

00:10:17: or fit based programs, we could add up the upper GI.

00:10:20: This was shown to be cost effective almost one decade ago

00:10:24: and also recently, when we addressed

00:10:26: by our group also the role of AI

00:10:29: in intermediate regions in Europe,

00:10:31: such as Portugal, Romania, some parts of Spain

00:10:35: and Italy, et cetera.

00:10:36: So these were the suggestions.

00:10:39: In Europe, I think we could differentiate

00:10:41: between intermediate regions and risk areas

00:10:45: for the first synergistic approach

00:10:48: could be cost effective.

00:10:50: - So to summarize, Mario, within Europe,

00:10:52: there's no high risk regions.

00:10:54: - Yeah, we can define Europe in different ways.

00:10:56: So there may be some specific regions

00:11:01: that I don't know by heart in different countries,

00:11:03: where it may be just a file,

00:11:04: but in general, there are no high risk areas.

00:11:06: - Okay, so the intermediate risk regions,

00:11:10: you can consider the screening

00:11:12: as long as cost effective is what you said.

00:11:14: And most European countries are low risk

00:11:18: except for is that Portugal and Eastern European countries

00:11:22: and screening is not advised based on the guidelines.

00:11:26: Is that correct?

00:11:27: - Yeah, that is our suggestion.

00:11:30: And also, for instance, if we discuss the low regions

00:11:34: that are more frequently in Europe,

00:11:36: one topic that is also important to mention here

00:11:39: is that we didn't include this in our definitions.

00:11:41: When you speak about screening,

00:11:42: public should be organized,

00:11:44: meaning that it can address all the population

00:11:47: like we were discussing before,

00:11:49: or eventually, even if for low risk countries,

00:11:53: to be organized means that probably

00:11:55: either first degree relatives or some ethnicities

00:11:59: or some immigrants should be probably proposed to screening.

00:12:03: For instance, the result of a cost effective study

00:12:06: is also in the USA.

00:12:08: And there is a sub task in targets

00:12:11: that will address these kind of questions.

00:12:13: Because even if it is not cost effective

00:12:16: for the entire population,

00:12:17: there is a nice manuscript published by the Dutch group

00:12:20: alluding to the ethical aspects

00:12:22: of not going for a general population

00:12:26: and going only for some segments.

00:12:28: That on one side, of course,

00:12:29: you increase paradoxically equity

00:12:32: by proposing to those that are probably lost.

00:12:35: But you can also bring some prejudice to those that are,

00:12:38: let's say, the target of a specific screening such as these

00:12:42: because they can be, let's say, identified as such a group

00:12:47: with a high risk, et cetera.

00:12:49: So you can consider screening for high risk population

00:12:52: within a low risk region, kind of technically speaking.

00:12:57: Exactly.

00:12:58: Okay, now, once a patient develops a pre-malignant changes

00:13:03: within the stomach, does geography or ethnicity

00:13:09: play a role in progression towards cancer?

00:13:11: Or any other factor that plays a role?

00:13:13: That's a very, very important question.

00:13:15: And I think this is a very practical question.

00:13:17: practical one and that this was one of the reasons that motivated the systematic review

00:13:23: that we were able to publish in God last year, that where we systematically review the guidelines

00:13:31: and all of them tend to say that when we detect such changes, first of all, we will not surveil

00:13:41: everyone and we will have to select those that merit surveillance. Then there are some

00:13:46: differences in the schedule of that surveillance that we can come back. But in principle, the

00:13:52: answer is no. It doesn't matter if you are Portuguese or Dutch or Norwegian or German.

00:14:00: Once you have that phenotype at risk, then you should be surveilled. And it's the same

00:14:05: of having a denomination in the colon for our merits. So this is an important message that

00:14:11: sometimes eventually we may think that the same reasons that led us to implement a screening

00:14:19: procedure would affect then the decisions towards surveilling or not. And this is a

00:14:25: different, let's say, moment in the pathway of managing an individual.

00:14:29: Mario, some of the audience may, I'm sure everyone knows, we describe pre-malignant changes in

00:14:35: the stomach. For the benefit of audience, can you describe what they are?

00:14:39: Yeah, within this scope, mostly, we are discussing trophic changes in the stomach and the presence

00:14:46: of in testament to pleasure. Of course, it's a marker of a trophy, but it's a step. So

00:14:52: the paleo-carea cascade, the perfect cascade, suggests that from a normal mucosa, there

00:14:59: is a progression from gastritis, then trophic changes, then in testament to pleasure and

00:15:05: final dysplasia. What we understood is that this is not, let's say, this does not occur

00:15:11: in 100% of the patients, of course. And from step to step, there are some, let's say, markers

00:15:18: of further increase in the risk. For instance, if the trophic changes and testament to pleasure

00:15:23: are more frequent in the stomach, meaning they are seen in several parts of the stomach,

00:15:30: those are the individuals that merit surveillance rather than the others. We will come back for

00:15:34: sure for this to discuss about this. One thing that struck me, probably a bit

00:15:38: of practice changing, or at least have not come across this in any of the previous guidelines,

00:15:44: you make two statements on the relatives of patients with gastric cancer. You just alluded

00:15:50: to just now that ethnicity in things may not matter, but family history does matter in

00:15:56: terms of value-added risk. You mentioned two things. You mentioned about the helicobacterpylori

00:16:01: screening and you mentioned about endoscopy screening for such individuals. Can you explain

00:16:08: what recommendation the Guideline Committee made and how strong is the evidence for making

00:16:16: such recommendation?

00:16:18: So just to stress, and this is nice to have this chat, so what I've said is that for determining

00:16:25: if the patient has to be surveilled or not, in principle, ethnicity does not matter. But

00:16:30: for instance, when defining an organized screening program in a low risk country, it may matter.

00:16:37: Coming to the first degree, relatives of family, of patients with gastric cancer, well, first

00:16:44: of all, it's an easy marker. So all the commissions should have the family history of their patients.

00:16:51: Secondly, patients, they know that marker and eventually they can be empowered to seek

00:16:58: health care and health resources. The evidence is not that strong, but it's not that strong

00:17:03: and also for the colon, where we anticipate the screening based on an increased risk for

00:17:10: colorectal cancer of a certain magnitude. So for gastric cancer and also for premillian

00:17:15: conditions, what we observed is that family, first degree relatives of patients with gastric

00:17:22: cancer, and it doesn't matter too much if it's from the intestinal type or diffuse type,

00:17:27: they do have an increased risk for gastric cancer and for premillian changes. So based

00:17:33: on this, and also consistently with other, I'd say, panels, we suggested that we should

00:17:41: go for an anticipation of, or eventually only for this, the primary prevention moment, where

00:17:48: we seek for H. pylori and we eradicate, if we speak with patients, this is what we say,

00:17:54: that is, what can I do to avoid what my brother had or my father? And of course, we are discussing

00:18:02: outside genetic syndromes. And then there is a second moment of secondary prevention.

00:18:08: And for that, the suggestion that we've made is not with a strong evidence because we don't

00:18:13: have trials, we don't have many studies suggesting that we should do what we suggest, but on

00:18:18: the other side, it's the best we can suggest to someone that has a relative that is to

00:18:23: anticipate somehow an endoscopic screening procedure for detecting exactly what I said.

00:18:30: We hope also, by suggesting this, that eventually either it's consolidated by the community,

00:18:36: by further studies, or it's contradicted and then we need to adapt the recommendation.

00:18:41: But this is kind of consistent, also for practice in most countries and also in some of the guidelines

00:18:47: that use, this is probably the most consistent marker, even for instance, in Europe for the

00:18:53: Spanish guideline that somehow does not suggest there's as commonly the surveillance for some

00:19:00: of these patients, the family risk is there, and also for the surveillance of the treatments.

00:19:06: Yeah, I think you recommend two things. You recommend Helicobacter pylori testing for

00:19:12: first-aid relatives between the ages of 20 and 30, and OGD at the age of 45 or 10 years

00:19:19: before the age of diagnosis of the affected relative. I think this is something I think

00:19:23: people should be aware because this is not something we have traditionally done in clinical

00:19:28: practice and it came as a completely new knowledge to me, which I have not been offering, although

00:19:35: it was in the back of my mind. Of course, there are many health problems that we need to deal with,

00:19:41: and of course, there will be priorities. But if you think along the an ageing population in

00:19:46: Europe, also with some immigrants with an eye in between countries, and also other risk factors

00:19:54: that prevail like smoking, obesity, assault intake, so all of those makes probably this

00:20:01: measurement of family history so easy that it may lead to a screening procedure and an early

00:20:09: diagnosis because again, there is also a notion that I think it's all important to disseminate

00:20:16: this, even though the incidence, so the number of new cases over those that are at risk has been

00:20:22: decreasing year after year in Europe, we face an increase in the number of cases because of what

00:20:28: I said before. So in Europe, what is expected is that the number of cases will increase during the

00:20:34: next decades, and if we don't do anything in terms of early diagnosis, these small prognoses will

00:20:41: continue to be absurd. What I see lately, the number of endoscopies that we do is significantly

00:20:48: gone up, and the number of patients, older patients we're subjecting endoscopy to has gone up,

00:20:56: and more and more we do this by refining pre-malignant lesions in the stomach in older patients.

00:21:02: Does the guideline can't you make any recommendation of either not doing some, is there any age cut

00:21:09: off or not offering surveillance for these patients? Again, of course, we need to take

00:21:13: care of all patients. On the other side, we first do no harm. So this is the other side

00:21:20: of the coin that we were discussing before. That is, is it reasonable for someone with 88 years old

00:21:29: asymptomatic patients to suggest to that patient screening procedure for any disease

00:21:37: in the luminal GI tract? No. So we set a bar at 80 years because life expectancy in Europe

00:21:46: is now increasing, or if for that specific individual, it doesn't make sense in terms

00:21:52: of life expectancy because of other comorbidities. I think this is bringing to the stomach what has

00:21:57: been said in the column and also in Barrett's recently, but at a certain stage it should not only

00:22:04: let's say we should stop. It's not giving up of that individual. It's allowing that individual not

00:22:10: to be submitted to procedures that probably will not affect finally their life expectancy.

00:22:16: Yeah. I guess that boils down to this career cascade that you mentioned, that you go to

00:22:21: stepwise and this takes often years to change. And even if it is an early gastro-cancer by the time

00:22:28: that kind of progresses and causes harm to the patient, it may take some time, right?

00:22:34: And it leads then to difficult decisions because then, okay, if finally you detect the lesion,

00:22:40: and then how to say to that patient that I will not treat you because, well,

00:22:45: probably finally exactly what you say, you will not suffer from this specific disease. So it's,

00:22:51: I think that the message is regardless of the screening program that you organized,

00:22:56: there will be an age limit. Or at the individual that is in front of you, don't start making

00:23:03: procedures that finally may lead to diseases that you were not, let's say, interested in managing

00:23:10: or the patient was not interested at all in knowing that, that phase of their life. This is

00:23:16: difficult, but I think it's an important recommendation. Of course, there is no evidence

00:23:20: about this. There is some scattered evidence of showing that then finally, for instance,

00:23:25: if even if you treat the cancer, but this is non-curity, you don't send the patient to surgery.

00:23:29: So it's very questionable.

00:23:32: Mario, we discussed earlier that what I see in clinical practice is huge variation in terms

00:23:38: of reporting of pre-malignant lesions. And that the main reason for this is lack of awareness

00:23:44: by the endoscopers. And certainly when I see our trainees, most of the education they get is from

00:23:52: peers, from their trainers, who are also not so much of recognizing these lesions and describing

00:23:58: these lesions. Is there any resource that we can refer to? I don't know, could be just videos and

00:24:05: things for our listeners to get some training in recognizing and describing these gastric

00:24:11: pre-malignant lesions. So this was probably the only thing in terms of, let's say, technical

00:24:17: perspectives that we brought to this guideline that were some hopefully considered nice pictures.

00:24:23: And in fact, the descriptors that we may use to describe the presence of a trophy, but mainly

00:24:31: testament to pleasure that is quite more reliable, even among observers that are considered to be

00:24:36: experts, are similar to that to those that we observed in various. So for most of the European

00:24:45: endoscopers, if they are used to describe bearers, they will be able easily to learn how to

00:24:51: assess the gastric mucosa. Regardless of this, there are some educational tools delivered by ESC,

00:24:58: of course, reserved for ESC individual members. And we will have a course coordinated by EU,

00:25:07: within a consortium that is called You Can Screen, that will have three editions during the next

00:25:12: two years, two in Portugal and one in Lithuania, where at least 30 participants, 30 train the

00:25:20: trainers, will be able to participate and learn more about this. So be aware of this and be ready

00:25:26: to register in those courses. I think for those, the guidelines are amazing. The way, you know,

00:25:33: the pictorial representation of the tables in the guidelines are really good. And if people

00:25:39: want to refer to those, I really suggest. And that's the best way to know. And it's very

00:25:45: simplified in the guidelines, so I have to say. So we've had some wonderful conversation for the

00:25:50: last 30 minutes. There's still a lot more to cover and we'll be discussing this. But as we've

00:25:56: gone past 30 minutes, we thought we should end this as the first part. There's still lots to

00:26:02: discuss in the second part, which will be discussed in a week on the 9th of July. So there

00:26:09: we continue our discussion on maps three, the recommendations on the use of artificial intelligence,

00:26:15: the management of early gastric cancers and identification of pre-malignant lesions.

00:26:21: And of course, what the acronym MAPS stands for, which has been a bit of mystery so far for me.

00:26:29: Be sure to tune in again next week. Goodbye.