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Original research
Decision-making and regret in patients with germline CDH1 variants undergoing prophylactic total gastrectomy
  1. Lauren A Gamble1,
  2. Robert R C Grant1,
  3. Sarah G Samaranayake1,
  4. Grace-Ann Fasaye2,
  5. Christopher Koh3,
  6. Louis Korman3,
  7. Bilal Asif3,
  8. Theo Heller3,
  9. Jonathan M Hernandez1,
  10. Andrew M Blakely1,
  11. Jeremy L Davis1
  1. 1National Cancer Institute, Surgical Oncology Program, National Institutes of Health, Bethesda, Maryland, USA
  2. 2National Cancer Institute, Genetics Branch, National Institutes of Health, Bethesda, Maryland, USA
  3. 3National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
  1. Correspondence to Dr Jeremy L Davis, National Cancer Institute, Surgical Oncology Program, National Institutes of Health, Bethesda, Maryland, USA; jeremy.davis{at}nih.gov

Abstract

Introduction Prophylactic total gastrectomy (PTG) can eliminate gastric cancer risk and is recommended in carriers of a germline CDH1 pathogenic variant. PTG has established risks and potential life-long morbidity. Decision-making regarding PTG is complex and not well-understood.

Methods Individuals with germline CDH1 pathogenic or likely pathogenic variants who underwent surveillance endoscopy and recommended for PTG were evaluated. Factors associated with decision to pursue PTG (PTGpos) or not (PTGneg) were queried. A decision-regret survey was administered to patients who elected PTG.

Results Decision-making was assessed in 120 patients. PTGpos patients (63%, 76/120) were younger than PTGneg (median 45 vs 58 years) and more often had a strong family history of gastric cancer (80.3% vs 34.1%). PTGpos patients reported decision-making based on family history more often and decided soon after diagnosis (8 vs 27 months) compared with PTGneg. Negative endoscopic surveillance results were more common among PTGneg patients. Age >60 years, male sex and longer time to decision were associated with deferring PTG. Strong family history, a family member who died of gastric cancer and carcinoma on endoscopic biopsies were associated with decision to pursue PTG. In the PTGpos group, 30 patients (43%) reported regret which was associated with occurrence of a postoperative complication and no carcinoma detected on final pathology.

Conclusion The decision to undergo PTG is influenced by family cancer history and surveillance endoscopy results. Regret is associated with surgical complications and pathological absence of cancer. Individual cancer-risk assessment is necessary to improve pre-operative counselling and inform the decision-making process.

Trial registration number NCT03030404.

  • surgical oncology
  • surgical procedures, operative
  • clinical decision-making
  • digestive system neoplasms
  • genetic predisposition to disease

Data availability statement

No data are available. Not applicable.

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Footnotes

  • Twitter @sarahgsam, @JeremyLDavisMD

  • Contributors LAG: study design, data collection, data analysis, draft manuscript preparation; RG: data analysis, draft manuscript preparation; SS: study design, data collection, data analysis; G-AF: study design, data collection, data analysis; CK: study design, data collection, data analysis; LK: study design, data collection, data analysis; BA: study design, data collection, data analysis; TH: study design, data collection, data analysis; JMH: study design, data collection, data analysis; AB: study design, data collection, data analysis; JLD: study oversight, study design, data collection, data analysis, draft manuscript preparation. All authors approved the final manuscript. GUarantor: JLD.

  • Funding This study was supported in part by the Intramural Research Programme, National Cancer Institute, National Institutes of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.