WHO Urges H pylori Screening to Prevent Gastric Cancer

Janis C. Kelly

September 30, 2014

Evaluating the possibility of large population-based programs of Helicobacter pylori screening and treatment should be a global priority to reduce the burden of gastric cancer, according to a report from the International Agency for Research on Cancer (IARC), the specialized cancer agency of the World Health Organization.

Gastric cancer is the third leading cause of cancer deaths worldwide, and 80% of the 1 million new cases annually are caused by a treatable infection, according to the report.

However, public health programs to prevent gastric cancer are almost nonexistent, according to Christopher P. Wild, PhD, director of the IARC in Lyon, France, and the other members of the working group.

"Unless effective control measures are established, thousands of unnecessary deaths will continue to occur each year. Ignoring stomach cancer in the hope that it will soon disappear on its own is not a tenable health policy," Dr. Wild said in a statement.

Screening and treatment provide "the potential means of preventing deaths from this lethal cancer," he added.

The new recommendations are based on the work of an international panel of 19 gastric cancer experts and IARC staff assembled to review evidence and evaluate strategies for the prevention of stomach cancer based on H pylori eradication.

Their review looked at the status of regional gastric cancer prevention efforts, the effectiveness and potential risks (bacterial resistance) of population-based H pylori treatment, and the feasibility and cost-effectiveness of H pylori screening and treatment programs.

The gastric cancer programs of Chile, China, Japan, Korea (which has the highest gastric cancer rate in the world), and Taiwan were among those reviewed.

The report also addresses ongoing and planned studies of H pylori eradication.

"There is an acute need to commit more public health resources to gastric cancer control," according to a summary section of the IARC report. "This working group recommends that all countries consider including gastric cancer in their national cancer control programs and that they conduct detailed assessments of its current and future human and economic impacts and of the potential value of prevention strategies."

"H pylori treatment lowers gastric cancer incidence by 30% to 40%," the report explains, but the results might not be generalizable across all populations and do not account for possible adverse consequences, such as a possible increase in resistance to antibiotics needed to treat serious infections.

The IARC working group recommends a 7- to 10-day treatment regimen that includes 2 or 3 inexpensive generic antibiotics and a proton pump inhibitor, which can be 80% successful in eliminating H pylori. They group cautions that effectiveness "will vary according to the profile of antibiotic resistance in the target population."

There are clinical trials underway around the world.

In a high-risk Chinese population, 200,000 subjects, 25 to 64 years of age, randomized to anti–H pylori quadruple therapy or to low-dose omeprazole and bismuth citrate are being followed for 10 years.

In the United Kingdom, the H pylori Screening Study is being conducted to determine whether screening for and eradicating H pylori infection in 56,000 otherwise healthy subjects will reduce the incidence of gastric cancer over a 15-year follow-up period.

A multicenter study being conducted in Belarus, Latvia, and Russia (which have moderately high gastric cancer rates) is evaluating whether serum pepsinogen and H pylori testing can be used to identify high-risk subjects that need to be referred for treatment.

A multicenter Korean randomized controlled trial is being conducted to determine whether H pylori treatment can reduce the incidence of gastric cancer in subjects recruited from a national population-based screening program who are 40 to 60 years of age.

A Viewpoint on the IARC report was published in the September 24 issue of JAMA.

"Within the next 10 years, results from several ongoing randomized trials will likely resolve many uncertainties about H pylori screening and treatment. Nevertheless, practical questions about the implementation and outcomes of population-based gastric cancer prevention programs could best be answered by direct observation in the communities where they are applied," write a trio of IARC working group members: Rolando Herrero, MD, PhD, from the IARC in Lyon; Julie Parsonnet, MD, from Stanford University Medical Center in California; and Edwin Robert Greenberg, MD, from the Fred Hutchinson Cancer Research Center in Seattle

The team points out that stomach cancer is particularly common in low- and middle-income countries and among the most deprived populations, where there are few resources for public health prevention programs. Stomach cancer is usually diagnosed at advanced stages, and survival rates are therefore low in most geographic areas.

Some members of the IARC working group report financial relationships with industry, as detailed in the report.

JAMA. 2014;312:1197-1198. Abstract

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