Improved survival of gastric cancer with tumour Epstein-Barr virus positivity: an international pooled analysis

Abstract

Background and objective: About 9% of gastric carcinomas have Epstein-Barr virus (EBV) in the tumour cells, but it is unclear whether viral presence influences clinical progression. We therefore examined a large multicentre case series for the association of tumour EBV status with survival after gastric cancer diagnosis, accounting for surgical stage and other prognostic factors.

Methods: We combined individual-level data on 4599 gastric cancer patients diagnosed between 1976 and 2010 from 13 studies in Asia (n=8), Europe (n=3), and Latin America (n=2). EBV positivity of tumours was assessed by in situ hybridisation. Mortality HRs for EBV positivity were estimated by Cox regression models stratified by study, adjusted for distributions of sex (71% male), age (mean 58 years), stage (52% tumour-node-metastasis stages III or IV), tumour histology (49% poorly differentiated, 57% Lauren intestinal-type), anatomic subsite (70% non-cardia) and year of diagnosis. Variations by study and continent were assessed using study-specific HRs for EBV positivity.

Results: During median 3.0 years follow-up, 49% of patients died. Stage was strongly predictive of mortality, with unadjusted HRs (vs stage I) of 3.1 for stage II, 8.1 for stage III and 13.2 for stage IV. Tumour EBV positivity was 8.2% overall and inversely associated with stage (adjusted OR: 0.79 per unit change). Adjusted for stage and other confounders, EBV positivity was associated with lower mortality (HR, 0.72; 95% CI 0.61 to 0.86), with low heterogeneity among the study populations (p=0.2). The association did not significantly vary across patient or tumour characteristics. There was no significant variation among the three continent-specific HRs (p=0.4).

Conclusions: Our findings suggest that tumour EBV positivity is an additional prognostic indicator in gastric cancer. Further studies are warranted to identify the mechanisms underlying this protective association.

Figure 1

ORs and 95% CIs for the associations of selected clinical and demographic characteristics with gastric tumour Epstein–Barr virus positivity.

Figure 2

Kaplan–Meier estimated survival after gastric cancer diagnosis by tumour Epstein–Barr virus (EBV) status.

Figure 3

HRs and 95% CIs for associations of tumour Epstein–Barr virus (EBV) status and other selected characteristics with overall mortality after gastric cancer diagnosis.

Figure 4

Forest plot of HRs for the association of gastric cancer mortality with tumour Epstein–Barr virus (EBV) positivity for the study populations, by continent. Study-specific HRs are shown as squares, with the size of the symbol inversely proportional to the study specific variance. Summary random-effects HRs are shown as diamonds, with the middle corresponding to the point estimate and the width representing the 95% CIs.