Irrational thinking fear gastric cancer

First International Consensus Conference on the Mini-Bypass /

One Anastomosis Bypass

Paris 2012 October 18-19

Email [email protected]

Fear of Gastric Cancer

• Surgeons who repport Fear of Gastric Cancer after MGB

• Show evidence of limited knowledge of

• Gastric Cancer, General Surgery and Bariatric Surgery

Irrational Thinking in Surgeons that Fear Gastric Cancer after the Mini-

Gastric BypassAn Analysis of Knowledge of the use of the Billroth II and Gastric Caner in Surgeons that Express

Fear of Gastric Cancer after MGB

Survey Results

• As part of a Pre-Conference survey for the MGB/OAB Consensus Conference we asked Expert Surgeons a variety of questions related gastrointestinal surgery, bariatric surgery and gastric and esophageal cancer

74. I Fear that MGB patients can have an increased risk of gastric cancer from

bile reflux

• As part of our survey asking over 120 questions of 118 surgeons from 23 countries and 6 continents we asked the question above and 23% Agreed with this Fear of Gastric Cancer following the Billroth II used in the Mini-Gastric Bypass

Surgeons Who Fear Gastric Cancer after Billroth II

• We investigated these surgeons knowledge and opinions on a variety of topics related to gastrointestinal surgery, gastric cancer, esophageal cancer and bariatric surgery to determine if these surgeons had a logically consistent thinking on this topic

Primary Hypothesis

• Our primary hypothesis was that surgeons who had an expressed fear of gastric cancer following the Billroth II used in the Mini-Gastric Bypass

• Have limited knowledge of Billroth II and Gastric Cancer

• Show conflicting and paradoxical and illogical opinions

• Have trouble making a logical case for their belief

Are You Knowledgable About Gastric Cancer

• Our first issue was whether the fear of gastric cancer was based uon knowledge of the subject or on incomplete information, ignorance or misinformation misremembered from past experiences and education


• We asked:

• Do you agree or disagree with the following statement:

• 85. I have recently reviewed the literature on gastric cancer and am very knowledgeable about the risk of gastric cancer


• 85. I have recently reviewed the literature on gastric cancer and am very knowledgeable about the risk of gastric cancer

• Only 24% of surgeons felt they were "very knowledgeable" about the risk of gastric cancer

Are You Knowledgable About Gastric CancerAnswer NO

• So before we go any further with this study we can conlude that surgeons that fear gastric cancer after Billroth II used in Mini-Gastric Bypass appear to have limited knowledge about the risk of gastric cancer by their own admission!


• Surgeons that Fear Gstric Cancer• Have By Their Own Admission • Limited Knowledge about the risk of

gastric cancer• This is very common in Humans and

in Human Decision Making• We fear what we do not understand


• We can determine the scientific understanding of these surgeons by asking about their understanding of assocaition and causation

• so we asked: "76. I understand the difference between "Association" and "Causation" "

• Surprisingly 15% disagreed

Knowledge of Association and Causation

• We gave and example of association as opposed to causation

• 77. In a study from the Netherlands of 58,279 patients 162 stomach cancers were detected.

• A higher risk for stomach cancer was found for men with the lowest level of education

• (RR lowest/highest level = 2.0, p = 0.02)• i.e. Lower education = higher risk of stomach

cancer• Do you think less education "CAUSES"

stomach cancer?• Again surprisingly 15% said the less education

causes gastric cancer!


• Fear of Gastric Cancer Driven by Lack of Understanding

• We can go further and investigate these surgeons knowledge about the details of the gastrointestinal surgery, bariatric surgery and gastric and esophageal cancers

• We asked the following questions

Fear of Billroth II

• While it can be assumed that these surgeons are aware that there are some articles in the medical literature that show and increased risk of gastric cancer after Billroth II there are many published studies showing no such increase

• We wanted to know if these surgeons were aware of these studies s we asked:

Agree or Disagree

• “75. There are many large scale studies that show no increased risk of gastric cancer after Billroth II:

• i.e.: 30 yr f/u, over 500 pts

• "Risk of gastric cancer is * Not * increased after partial gastrectomy."

• Bassily R, Dept Gastroent., Victoria, Australia.J Gastroent Hepatol. 2000 15(7):762;”

"Some Studies Show NO Gastric Cancer Increase after Billroth II" (True)

• We even included a reference to one such study in the body of the question:

• i.e.: 30 yr f/u, over 500 pts"Risk of gastric cancer is * Not * increased after partial gastrectomy."

• Bassily R, Dept Gastroent., Victoria, Australia.J Gastroent Hepatol. 2000 15(7):762;”


• Inspite of providing them with a reference still

• 60% of these surgeons disagreed with the demonstrable fact that there are many such studies


• How can we explain the 60% of surgeons who erroneous reported that they disagreed with the statement "Some studied show no increase in gastric cancer after BillrothII"

• One possibility is ignorance• But there was a Reference Provided!

Billroth II Further Investigations

• Rather than stop here we probed the surgeons opinons and knowledge about the Billroth II

• We asked:

78. There are some studies showing a slight increased risk of gastric cancer 20-30 years after

Billroth II. But these patients had the Billroth II overwhelmingly for Ulcer Disease and Ulcer and Gastric Cancer have

a common etiology; H. Pylori.

• Again Somewhat surprisingly• 100% of surgeons that fear gastric

cancer after Billroth II, • Agreed with this statement,

correctly so.

79. Unoperated Gastric Ulcer patients have double the risk for Gastric Cancer

• We then asked about their knowledge of the association between ulcer disease and gastric cancer and included a reference:

• Am J Gastroenterol. 2007 Long-term risk of gastric cancer by subsite in operated and unoperated patients hospitalized for peptic ulcer. Bahmanyar S, et al, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

79. Unoperated Gastric Ulcer patients have double the risk for Gastric Cancer:

• Again surprisingly

• While 61.5% correctly agreed

• 38.5% Disagreed with this statement

Fear

• To try and get the surgeon's impression of the magnitude of the risk of gastric cancer

• Because the issue here is fear

• So we compared the risk to the risk of eating a hot dog

• 80. Which is more deadly a Hot Dog or a Billroth II?

• Processed meats (bacon, sausage, hot dogs, sandwich meat, packaged ham, pepperoni, salami, etc.)

• have been shown to be associatesd with gastric cancer.• An increase intake of 100 g of processed meat per day• Increases the risk of Gastric Cancer by 3.5 times

• = Natl Cancer Inst. 2006 Mar 1;98(5):345-54. Meat intake and risk of stomach and esophageal adenocarcinoma within the European Prospective Investigation Into Cancer and Nutrition (EPIC).

• = J Natl Cancer Inst. 2006 2;98(15):1078 "Processed meat consumption and stomach cancer risk: a meta-analysis" The Karolinska Institutet

• (Hint: A Hot Dog weight 3.7 oz = 100 g = INCREASED RISK 3.5!)

80. Which is more deadly a Hot Dog or a Billroth II?

• A daily serving of processed meat (bacon, sausage, hot dogs, sandwich meat, packaged ham, pepperoni, salami, etc.)

• Was chosen by 92.3%• What this does is show that 92% of

these sugeons judge that the dietary intake of common foods are more dangerous than the Billroth II

Fear

• How fearful can the Billroth II be if

• Eating a hot dog is more dangerous

• 92% of these surgeons judged the cancer risk of processed meats as more dangerous than Billroth II

The Causes of Gastric Cancer

• These surgeons expressed fear that the Billroth II led to or "Causes" Gastric Cancer

• So this question is designed to assess the surgeon's knowledge of the Major causes of gastric cancer

• Smoking, Helicobacter pylori, Diet: high salt intake, processed meats, salted, pickled, or smoked foods & low intake of green leafy vegetables and fruit

The high rates of Gastric Cancer are from Environmental Causes.

• 81. Gastric Cancer is Most Common Cancer in Korea & Japan Rates in Japan 69/100,000 men & 29/100,000 women.

• Moving from Japan/ Korea to USA Drops Risk to Low USA Rates.

• The high rates of Gastric Cancer are from Environmental Causes.

• (Smoking, Helicobacter pylori, Diet: high salt intake, processed meats, salted, pickled, or smoked foods & low intake of green leafy vegetables and fruit)

• World J Gastroenterol 2006 Jan 21;12(3):354 "Epidemiology of gastric cancer"

The high rates of Gastric Cancer are from Environmental Causes.

• 100% of these surgeons agreed

• Gastric Cancer is caused by these Environmental Factors:

• Smoking, Helicobacter pylori, Diet: high salt intake, processed meats, salted, pickled, or smoked foods & low intake of green leafy vegetables and fruit

Do Surgeons Who Fear Gastric Cancer after Billroth II Know What They are

Talking About?

• What is the rate of Gastric Cancer after MGB And in the Population

• 50% 1 out of 10,000 after 20 years in the General Population and

• 40% 1 out of 10,000 after 20 years after MGB


Talking About?

• What is the rate of Gastric Cancer after MGB And in the Population

• 27.3% 1 out 1000 in the General Population and

• 30.0% 1 out 1000 after MGB


Talking About?

• In other words:

• Surgeons that fear gastric cancer predicted the

• Risk of gastric cancer after MGB was

• EQUAL to the risk of Gastric Cancer in the General Population!


Talking About?

• In other words:

• Surgeons who fear that the risk of gastric cancer is higher after MGB than the risk in the general population predicted that the

• Risk of gastric cancer after MGB was

• EQUAL to the risk of Gastric Cancer in the General Population!

H. Pylori and Gastric Cancer

• The next 2 questions were designed to assess the surgeon's knowledge of the relation between H. Pylori and Gastric Cancer

86. The association between H pylori infection and the development of gastric cancer is well

establishedIn 1994, the International Agency for

Research on Cancer classified H pylori as aType I (definite) carcinogen in human beings.

• 100% of these surgeons agreed

87. H. Pylori Treatment Normalizes Risk of Gastric Cancer in Ulcer Patients. Early treatment of H. Pylori in Gastric Ulcer patients => Risk of Gastric Cancer decreased to NORMAL! Decrease risk from 1.60 to

1.05 ( = general population);"Early Helicobacter pylori eradication decreases risk of gastric cancer in patients

with peptic ulcer disease." Wu CY,et al. Div of Gastro., Taichung, Taiwan

• 100% Agreed

H. Pylori and Gastric Cancer

• So according to the surgeons' answers on these questions

• They all agreed that H. Pylori is primary cause of Gastric Cancer and

• That Treament of H.Pylori can normalize the risk of gstric cancer

• Yet the still reportedly fear gastric cacner after the MGB

Gastric Cancer Prevention

• 90% of Surgeons Agreed that:

• "88. Gastric cancer can be prevented by treating H. Pylori, eating a diet of fresh fruit and vegetables and avoiding smoking, alcohol and nitrates in preserved foods"

Billroth II in Oncologic Surgery

• The Billroth II is used routinely in general surgery

• Since distal gastrectomy and Billroth II Gastrojejunostomy is a routine procedure in gastrc cancer patients we thought it would be interesting to see what these surgeons thought about this fact.

98. Oncologic Surgeons Use the Billroth II

• Oncologic Surgeons have reported over 800 articles recently of

• Distal Gastrectomy and Billroth II for Distal Gastric Cancer,

• Including more than 20 in the first 3 month 2012. (True)

• 43% DISAGREED

• 99. Most Gastroenterologists DO NOT recommend follow up screening endoscopy in Billroth II patients because of the low risk of gastric cancer

• 60% Disagreed

• 100. There were approximately 40 deaths from stomach cancer per 1,000,000 population in USA 2009.

• = Median age at death for cancer of the stomach 73 years

• = 2/3 stomach cancer patients are > 65• Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF,

Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.

• 24% Disagreed

• 102. According to the National Inpatient Sample from USA, over 16,000 Billroth II operations were performed in 2007 in the USA. (True)

• The Nationwide Inpatient Sample (NIS) is a unique and powerful database of hospital inpatient stays. Researchers and policymakers use the NIS to identify, track, and analyze national trends in health care utilization, access, charges, quality, and outcomes.

• 10% Disagreed

• 103. Korea has the Highest Risk of Gastric Cancer in the World.

• In April 2012 two different papers by Oncologic Surgeons from Korea (379 cases) and China (70 cases) reported on 2 series of Laparosocpic Antrectomy & Billroth II for distal Gastric Cancer.

• In the first 3 months of 2012 there 20 other similar papers. (True)

• Antrectomy & Billroth II by these surgeons was a *reasonable and acceptable* surgical choice.

• 14% Disagreed

Question Basic General Surgery

• 104. A Billroth II gastro-jejunostomy is a common and accepted reconstruction after antretomy;

• A BII * IS NOT * an acceptable reconstruction following total gastrectomy because of bile reflux into the esophagus.

• 81.5% Agreed; But 18.5% DISAGREED

• 105. Billroth II with anastomosis at the junction of the body and the antrum of the stomach in the Mini-Gastric Bypass / One Anastomosis Gastric Bypass is a *reasonable and acceptable* surgical choice.

• The OLD Mason Loop Gastric Bypass placed the Billroth II high on the stomach adjacent to the esophagus, NOT *reasonable or acceptable* and could be predicted to fail.

• 83.3% Agreed

Surgeons Who Reported Fear of Gastric Cancer

After Mini-Gastric BypassPerformed Significantly Worse

on 12 out of 20 GI Surgery Questions

In no question did Surgeons withFear of Gastric Cancer Outperform SurgeonsWho Did Not Report


Tesst Performance & Patient Outcomes

• If, as other studies have shown

• There is an association between test performance and patient outcomes

• This study raises concerns about the knowledge levels and potentially patient outcomes in surgeons who have Fear of Gastric Cancer


• Surgeons who repport Fear of Gastric Cancer after MGB

• Show evidence of limited knowledge of

• Gastric Cancer, General Surgery and Bariatric Surgery

The Mini-Gastric Bypass is an Excellent Operation with Results Reported on Thousands

of Patients Over the Past 10-15 years

• Survey Shows:• Short, Simple, Effective, Durable,• 30 min Operation with 1 day Hospital Stay• Lower Leak rate than Sleeve or RNY• Better / Best Weight Loss• Leaks easily identified and easily

managed• Easily Reversible, Revisable• MGB Marginal Ulcer / Gastritis = RNY

Irrational thinking fear gastric cancer

Education

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