DOI: https://doi.org/10.21203/rs.3.rs-2192622/v1
Blood type is related to the occurrence and development of gastric cancer. The aim of this study is to explore the value of combined detection of ABO blood group and tumor markers in the diagnosis of gastric cancer.
A total of 3650 gastric cancer patients treated in our center from January 2015 to December 2019, and 5822 controls were recruited, and divided into training set and validation set according to 7:3. The clinicopathological characteristics were recorded. Receiver operating characteristic curve (ROC curve) was used to evaluate the diagnostic value of tumor markers and their combined blood type for gastric cancer. The results were validated using another group of people (validation group).
In both the training set and the validation set, the levels of tumor markers in gastric cancer patients were higher than those in the healthy control group (P < 0.05). The distribution of blood group in gastric cancer group was: A > B > O > AB, while that in healthy control group was: B > O > A > AB. Type B blood (AUC = 0.850,95%CI 0.837–0.863, P = 0.0006) and type AB blood (AUC = 0.837,95%CI 0.812–0.860, P = 0.0439) could improve the diagnostic value of CEA in gastric cancer.
The detection of blood group combined with tumor markers can improve the sensitivity and specificity for the diagnosis of gastric cancer, which has a high reference value for the diagnosis of gastric cancer patients, and is worthy of further clinical study.
Gastric cancer (GC) is an important cancer worldwide. According to the latest data of the International Agency for Research on Cancer (IARC), it ranks the 5th in incidence and the 4th in mortality globally[1]. GC is the most common gastrointestinal tumor in China, of which the rate of early detection is low. Compared with 2015, GC ranked third in the number of new cases and mortality of common malignant tumors in 2020[2], posing a serious threat to human health. Early GC can be treated by surgery, and the 5-year survival rate is more than 90%, while advanced GC can be treated by surgery, and the 5-year survival rate is less than 30%[3]. The gold standard for screening early GC is gastroscopy, but its detection rate is less than 10%, it is invasive, it requires a lot of human resources, and its acceptance is low. It is not suitable for large-scale population screening and follow-up of GC.
Tumor markers have the advantages of non-invasive, easy specimen acquisition and low cost, which are suitable for dynamic monitoring. However, the positive rate of tumor markers in advanced GC is only 20%-30%, and the positive rate in early GC is less than 10%[4]. Although the sensitivity of combined serum tumor markers in the diagnosis of GC has been improved, it is still low [5]. Since Aird et al. [6] first proposed that blood type A was associated with the occurrence of GC in 1953, a large number of studies on blood type and the incidence, clinicopathological characteristics and prognosis of GC have been carried out. However, the relationship between ABO blood group and GC cannot be concluded with certainty due to conflicting findings at different studies[7, 8]. If the combined detection of blood group and tumor markers can improve the diagnostic efficiency of GC, the diagnostic timing, diagnostic cost and diagnostic accuracy of GC can be improved. Therefore, the purpose of the present study was to investigate the value of ABO blood group combined with serum tumor markers, including CEA, CA199, CA125, AFP and CA724, for the diagnosis of GC and provide additional reference indicators for the early diagnosis and treatment of the disease.
A total of 3650 GC patients from January 2015 to December 2019 in the Xijing Hospital of Digestive Diseases were selected as the GC group, and 5822 healthy people from January 2015 to March 2022 in the physical examination center were selected as the control group. All patients in the GC group underwent radical gastrectomy and were confirmed to be GC by surgical pathology, excluding those with previous malignant tumor history and incomplete data. This study was approved by the Ethics Committee of Xijing Hospital.
Baseline data included age, sex, ABO blood group, TNM stage, degree of differentiation, tumor location, lymph node metastasis, distant metastasis, and pathological typing. TNM staging was performed using American Joint Committee on Cancer (AJCC) Version 8. Tumor marker levels were measured 7 days before surgery. The serum tumor markers were determined after centrifugation of 3ml venous blood samples. Electrochemiluminescence (ECL) was used, and the instrument was the ECL analyzer and the matching kit provided by Roche Diagnostics (Germany). The reference values of CEA, CA199, CA125, AFP and CA724 were 5.0ng/ml, 27.0U/ml, 35 U/ml, 7.0ng/ml and 6.9U/ml, respectively.
All the research objects were divided into training set and validation set according to 7:3. SPSS26.0 software was used for data analysis. Measurement data were expressed as mean ± standard deviation or median and quartile. χ2 test was used for comparison of rates, and Mann-Whitney U test was used for comparison between groups. The area under the ROC curve (AUC) was used to evaluate the diagnostic efficacy of the index. The sensitivity, specificity, positive predictive value and negative predictive value were used to evaluate the efficacy. A P value of 0.05 was used as the threshold for statistical significance.
Comparison of general clinical features
The study population was divided into training set and validation set according to 7:3. There were 4091 healthy controls and 2552 GC patients in the training set, 1731 healthy controls and 1098 GC patients in the validation set. There was no significant difference in the basic clinical characteristics between the training set and the validation set (P > 0.05, Table 1).
Table 1. The clinicopathological characteristics of the study population, number (%)
|
Characteristics
|
Training set （N=6643） |
Validation set （ N=2829） |
t/χ2 |
P |
|
Healthy controls |
4091 |
1731 |
|
|
|
Age, y Mean±standard deviation Gender Male Female ABO blood group A B O AB Patients with GC Age, y Mean±standard deviation Gender Male Female ABO blood group A B O AB TNM stage I II III IV Differentiation Well differentiation Well and middle differentiation Middle differentiation Middle and low differentiation Low differentiation Tumor site Pylorus Gastric body Antrum Whole stomach Lymphatic metastasis N0 N1-3 Remote metastasis M0 M1 Pathological stage Early stage Advanced stage |
50±10
2134（52.2） 1957（47.8）
1178（28.8） 1259（30.8） 1224（29.9） 430（10.5） 2552
58±11
1896（74.3） 656（25.7）
818（32.1） 769（30.1） 714（28.0） 251（9.8）
716（28.1） 510（20.0） 1202（47.1） 124（4.9）
62（2.4） 57（2.2） 509（19.9） 316（12.4） 1608（63.0）
282（11.1） 838（32.8） 1283（50.3） 149（5.8）
1568（61.4） 984（38.6）
1883（73.8） 669（26.2）
601（23.6） 1951（76.4） |
50±10
935（54.0） 796（46.0）
519（30.0） 525（30.3） 519（30.0） 168（9.7） 1098
58±11
823（75.0） 275（25.0）
358（32.6） 320（29.1） 302（27.5） 118（10.7）
335（30.5） 203（18.5） 515（46.9） 45（4.1）
43（3.9） 20（1.8） 222（20.2） 127（11.6） 686（62.5）
125（11.4） 349（31.8） 547（49.8） 77（7.0）
645（58.7） 453（41.3）
818（74.5） 280（25.5）
277（25.2） 821（74.8） |
1.673
1.437
0.176
1.017
3.450
7.001
2.079
2.343
0.203
1.183
|
0.813
0.196
0.697
0.915
0.675
0.797
0.327
0.136
0.556
0.126
0.652
0.277
|
Tumor marker levels and blood group distribution
In both the training and validation sets, the level of tumor markers in the GC group was significantly higher than that in the healthy control group, and the difference was statistically significant (P < 0.05), as shown in Table 2. The distribution of blood group in GC group was: A > B > O > AB, while that in healthy control group was: B > O > A > AB. There were statistically significant differences in ABO distribution constituent ratios in the whole population (χ2=10.920, P =0.012, Table 3) and the training set (χ2=8.495, P =0.037, Table 3).
Table 2. Differences in tumor marker levels between GC group and healthy controls, median (IQR)
|
|
Patients with GC |
Healthy subjects |
Z |
P |
|
CEA（ng/ml） Training set Validation set |
3.875（2.250,105.000）* 4.280（2.378,106.250） |
1.620（1.080,2.330） 1.600（1.030,2.360） |
-40.048 -27.908 |
.000 .000 |
|
CA199（U/ml） Training set Validation set |
6.290（1.733,20.075） 6.305（1.850,15.650） |
9.050（6.120,13.590） 8.620（5.890,12.890） |
-13.194 -7.871 |
.000 .000 |
|
CA125（U/ml） Training set Validation set AFP（ng/ml） Training set Validation set |
5.505（1.560,8.868） 5.790（1.578,8.750）
3.720（2.590,27.095） 3.730（2.520,17.550） |
10.180（7.680,13.590） 10.140（7.630,13.660）
2.880（2.100,3.910） 2.830（2.050,3.800） |
-35.102 -22.221
-23.428 -15.612 |
.000 .000
.000 .000 |
|
CA72-4（U/ml） Training set Validation set |
4.580（2.022,47.600） 4.620（2.000,44.615） |
1.610（0.980,2.960） 1.680（1.020,3.040） |
-32.623 -20.392 |
.000 .000 |
Note: *Values are expressed as medians and interquartile ranges.
Table 3. Distribution of ABO blood groups
|
|
Patients with GC |
Healthy subjects |
χ2 |
P |
|
A Training set Validation set B Training set Validation set O Training set Validation set |
818（32.1） 358（32.6）
769（30.1） 320（29.1）
714（28.0） 302（27.5） |
1178（28.8） 519（30.0）
1259（30.8） 525（30.3）
1224（29.9） 519（30.0） |
8.495 3.949 |
0.037 0.267 |
|
AB Training set Validation set |
251（9.8） 118（10.7） |
430（10.5） 168（9.7） |
|
|
Diagnostic value of single tumor marker and combined detection for GC
The AUC of the five tumor markers ranged from 0.594-0.797, with a sensitivity of 32.22%-66.99%, which was at a low level (Table 4, Figure 1). The combined detection of tumor markers can improve its sensitivity and specificity. Compared with the combined detection of 5 tumor markers, the combination of type B and AB blood with 5 tumor markers can improve the diagnostic value of GC. The B blood group (AUC=0.936, 95%CI 0.927-0.945, P < 0.0001) combined with swelling mark detection was higher than that of swelling mark detection alone, and the difference was statistically significant. There was no significant difference in the AUC of AB blood (AUC=0.928, 95%CI 0.909-0.943, P =0.0566), but the P value was at the critical value of the test level (Table 5).
Table 4. Diagnostic value of single tumor marker in patients with GC
|
TM |
AUC |
95%CI |
TPR（%） |
TNR（%） |
Youden index |
|
CEA |
0.797 |
0.789-0.806 |
66.99 |
82.05 |
0.4904 |
|
CA199 |
0.594 |
0.584-0.604 |
34.05 |
91.64 |
0.2569 |
|
CA125 AFP CA724 |
0.753 0.672 0.734 |
0.744-0.762 0.662-0.681 0.725-0.743 |
44.68 32.22 42.79 |
99.07 99.71 99.02 |
0.4376 0.3193 0.4182 |
Note: TM: tumor maker, CI: confidence interval, TPR: true positive rate, TNR: true negative rate
Table 5. Combined diagnosis compared with stratified combined diagnosis
|
TM |
AUC |
95%CI |
TPR (%) |
TNR (%) |
Youden index |
Z |
P |
|
|
TM A+TM |
0.917 0.908 |
0.912-0.923 0.897-0.919 |
78.82 80.53 |
97.39 95.99 |
0.7621 0.7652 |
116.750 60.185 |
＜0.0001 ＜0.0001 |
|
|
B+TM O+TM AB+TM |
0.936 0.911 0.928 |
0.927-0.945 0.900-0.921 0.909-0.943 |
80.17 79.92 78.32 |
95.85 96.90 98.33 |
0.7602 0.7682 0.7665 |
81.086 57.473 42.531 |
＜0.0001 ＜0.0001 ＜0.0001 |
|
Diagnostic value of blood group combined with single serum tumor marker for GC
Stratified ABO blood group, in the training set, it was found that compared with the unstratified group, the stratified type A blood group could improve the diagnostic value of CA199, CA125, AFP and CA724 for GC, but the difference was not statistically significant (Table 6, Figure 2a). Blood type B could improve the diagnostic value of CEA (AUC=0.847, 95%CI 0.831-0.863, P=0.0081) in GC, and the difference was statistically significant (Table 6, Figure 2b). Blood type O could improve the diagnostic value of CA199 and CA724 for GC, and CA199 (AUC=0.611, 95%CI 0.589-0.633, P=0.0469) had statistical significance, while CA724 had no statistical difference (Table 6, Figure 2c). AB blood group can improve the diagnostic value of CEA, CA199, CA125 and AFP in GC, but no statistical difference was found (Table 6, Figure 2d). The same method was used to explore the diagnostic value of ABO blood group combined with tumor markers for GC in the validation set. It was found that compared with unstratified blood group, type A blood group could improve the diagnostic value of CA724 for GC, but the difference was not statistically significant (Table 7, Figure 3a). Consistent with the results of the training set, type B blood could improve the diagnostic value of CEA (AUC=0.857, 95%CI 0.832-0.880, P < 0.0001) for GC, and the difference was statistically significant (Table 7, Figure 3b). Type O blood can improve the diagnostic value of AFP in GC, but the difference was not statistically significant (Table 7, Figure 3c). AB blood group can improve the diagnostic value of CEA, CA199 and AFP in GC, but no statistical difference was found (Table 7, Figure 3d). In addition, the overall study population was stratified according to ABO blood group, it was found that in addition to type B blood (AUC=0.850,95%CI 0.837-0.863, P =0.0006) and type AB blood (AUC=0.837,95%CI 0.812-0.860, P =0.0439) could also improve the diagnostic value of CEA for GC, as shown in Figure 4.
Table 6. Diagnostic Value of ABO blood group combined with tumor markers for GC (training set)
|
TM |
AUC |
95%CI |
TPR (%) |
TNR (%) |
Youden index |
Z |
P |
|||
|
A |
|
|
|
|
|
|
|
|||
|
CEA |
0.740 |
0.720-0.759 |
48.29 |
98.22 |
0.4651 |
18.433 |
＜0.0001 |
|||
|
CA199 CA125 AFP CA724 |
0.601 0.762 0.677 0.742 |
0.579-0.622 0.743-0.780 0.656-0.698 0.722-0.761 |
35.09 45.23 31.54 42.42 |
90.32 99.24 99.99 99.15 |
0.2541 0.4470 0.3754 0.4157 |
7.083 21.343 14.276 19.966 |
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|||
|
B |
|
|
|
|
|
|
|
|||
|
CEA |
0.847 |
0.831-0.863 |
77.63 |
76.73 |
0.5436 |
36.781 |
＜0.0001 |
|||
|
CA199 |
0.571 |
0.549-0.593 |
31.21 |
92.53 |
0.2374 |
4.787 |
＜0.0001 |
|||
|
CA125 AFP CA724 O CEA CA199 CA125 AFP CA724 AB CEA CA199 CA125 AFP CA724 |
0.747 0.664 0.728
0.777 0.611 0.749 0.667 0.748
0.830 0.616 0.779 0.682 0.725 |
0.728-0.766 0.643-0.685 0.708-0.747
0.757-0.795 0.589-0.633 0.730-0.769 0.646-0.688 0.728-0.767
0.799-0.857 0.578-0.653 0.746-0.810 0.645-0.716 0.690-0.758 |
47.98 30.82 43.56
59.38 40.06 44.68 34.03 46.36
79.68 32.67 71.71 36.25 55.38 |
98.73 99.76 99.99
87.83 92.08 97.63 99.59 97.88
73.72 95.81 77.21 98.84 85.81 |
0.4671 0.3058 0.4356
0.4721 0.3213 0.4231 0.3363 0.4423
0.5340 0.2848 0.4892 0.3509 0.4119 |
19.100 12.76 17.802
21.969 7.283 18.572 12.695 19.361
18.195 4.562 12.824 8.000 9.978 |
＜0.0001 ＜0.0001 ＜0.0001
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|||
Table 7. Diagnostic Value of ABO blood group combined with tumor markers for GC (validation set)
|
TM |
AUC |
95%CI |
TPR (%) |
TNR (%) |
Youden index |
Z |
P |
|
|
A |
|
|
|
|
|
|
|
|
|
CEA |
0.782 |
0.753-0.809 |
52.79 |
99.61 |
0.5241 |
15.568 |
＜0.0001 |
|
|
CA199 CA125 AFP CA724 |
0.576 0.741 0.658 0.735 |
0.542-0.609 0.711-0.770 0.626-0.689 0.705-0.764 |
50.28 47.77 33.80 45.81 |
73.32 94.61 99.81 98.84 |
0.2350 0.4237 0.3361 0.4465 |
3.476 12.431 8.063 12.698 |
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|
|
B |
|
|
|
|
|
|
|
|
|
CEA |
0.857 |
0.832-0.880 |
90.31 |
67.05 |
0.5736 |
26.005 |
＜0.0001 |
|
|
CA199 CA125 AFP CA724 |
0.587 0.771 0.664 0.749 |
0.553-0.621 0.741-0.799 0.631-0.696 0.718-0.778 |
38.75 46.56 31.25 41.56 |
85.90 99.81 97.52 99.05 |
0.2465 0.4637 0.2877 0.4067 |
3.911 14.067 8.186 13.219 |
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|
|
O |
|
|
|
|
|
|
|
|
|
CEA |
0.781 |
0.751-0.808 |
69.21 |
77.84 |
0.4705 |
14.858 |
＜0.0001 |
|
|
CA199 CA125 AFP CA724 |
0.592 0.750 0.695 0.696 |
0.558-0.626 0.719-0.779 0.662-0.726 0.663-0.727 |
35.76 57.62 39.40 43.05 |
86.90 83.82 94.99 98.84 |
0.2266 0.4143 0.3439 0.4189 |
4.031 12.414 9.754 8.938 |
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|
|
AB |
|
|
|
|
|
|
|
|
|
CEA |
0.852 |
0.805-0.891 |
74.58 |
85.12 |
0.5970 |
13.831 |
＜0.0001 |
|
|
CA199 CA125 AFP CA724 |
0.612 0.696 0.695 0.711 |
0.553-0.669 0.639-0.748 0.638-0.748 0.655-0.763 |
46.61 44.92 33.90 46.61 |
86.90 97.62 99.99 94.05 |
0.3351 0.4253 0.3390 0.4066 |
2.955 5.391 5.926 6.274 |
＜0.0001 ＜0.0001 ＜0.0001 ＜0.0001 |
|
Tumor marker is a kind of substance synthesized and released by tumor itself. In the process of tumor occurrence and development, it is also accompanied by the modified expression of blood group antigen in tumor cells. So far, a large number of studies have explored the value of tumor markers on the incidence of gastric cancer [9, 10], clinicopathological features and prognosis[11–13]. However, there is no study on the diagnostic value of ABO blood group combined with tumor markers for gastric cancer. This study found that type B blood and AB blood can improve the diagnostic value of CEA in patients with GC. Combined detection of tumor markers can improve the sensitivity and specificity of GC diagnosis. Blood type B and AB can improve the diagnostic value of combined detection of tumor markers for gastric cancer. Furthermore, joint five kinds of tumor markers detection of blood type B blood AUC value was higher than 5 kinds of tumor markers detection, and statistically difference. However, AB blood there was no statistically significant difference, but the p value in the inspection level threshold.
The sensitivity of single tumor markers in detecting gastric cancer is insufficient. Studies have explored the diagnostic value of CEA, CA724, CA199 and CA125 for gastric cancer, and the results suggest that the sensitivity of these tumor markers in diagnosing gastric cancer is between 20% and 40%, and the sensitivity of combining these four tumor markers is only 60.9%[14]. In this study, the sensitivity of the five tumor markers in the diagnosis of gastric cancer ranged from 32–67%, and the sensitivity of the combined detection increased to 91.7%. It is somewhat different from previous reports, which may be because this study only included gastric cancer patients and healthy people, and did not include population with gastric precancerous lesions, leading to increased sensitivity.
It is well known that the occurrence and development of gastric cancer are related to genetic factors, environmental factors and Helicobacter pylori infection. Blood group is one of the most stable genetic factors, among which ABO blood group is by far the most important blood group system[15]. This study found that B type blood combined with tumor markers can improve the diagnostic value of gastric cancer. At present, there is no study on the combined detection of blood group and tumor markers for the diagnosis of gastric cancer, but some studies[16, 17] have explored the correlation between ABO blood group and clinicopathological characteristics of gastric cancer, and proposed that the proportion of elevated CEA in blood group B and AB was higher than that in other blood groups, which could indirectly explain the results of this study. In addition, Qiu et al.[18] found that in patients with gastric adenocarcinoma, the proportion of increased CEA in blood group A was significantly higher than that in other blood groups (P = 0.003), and the proportion of increased CEA and CA199 in blood group AB was significantly lower than that in other blood groups (P < 0.001, P = 0.005) for untreated gastric cancer patients. In this study, the combination of blood group A and tumor markers did not improve the diagnostic value of gastric cancer. AB blood type can improve the diagnostic value of CEA and CA199 for gastric cancer, but the difference is not statistically significant.
The main strength of our study is that the sample size is large and the subjects are divided into training set and validation set by 7:3 for double validation. In addition, our current study has several limitations. Firstly, due to the limitation of conditions, ABO blood group and tumor marker level information of patients with GC precancerous diseases could not be obtained, and patients with GC precancerous diseases were not included, so the objectivity of the results was slightly weak. Secondly, this study is a retrospective study, and prospective studies are needed to further verify the diagnostic value of ABO blood group combined with tumor markers for GC.
In summary, our results suggested that ABO blood group combined with tumor markers as screening indicators for GC can improve the diagnostic value of GC patients. Among them, type B and AB blood combined with tumor markers have the most significant value in the diagnosis of GC.
Ethics approval and consent to participate
This retrospective study was reviewed by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University and approval was obtained. All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University. Due to the retrospective nature of the study, the informed consent was waived by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University.
Consent for publication
Not applicable.
Availability of data and materials
The datasets generated and analyzed during the current study are available from the corresponding authors on reasonable request.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding
This work was supported by grants from the National Natural Science Foundation of China (No. 82170560 to YQS).
Authors' contributions
YQS, YHL, SSC, WNS, XDQ and SBL contributed to the design of the study, interpretation of the data, and critical revision of the manuscript. YHL contributed to the analysis and interpretation of the data and drafted the manuscript. All authors approved the final version of the manuscript for submission.
Acknowledgments
We would like to thank the individuals who have contributed to the current study in various capacities.