The Investigation and Treatment of Helicobacter pylori for the Prevention of Gastric Cancer: A Narrative Review and Assessment of Management Approaches.

BACKGROUND

The rate of gastric cancer has reduced globally in all ages in recent years, but some data have started to emerge of a slowing in the decrease or even an increase in those aged >50 years, particularly in wealthier countries. Helicobacter pylori infection is associated with 89% of gastric cancer diagnoses worldwide, and its eradication is associated with a risk reduction. This review aims to assess the various approaches to diagnosing this carcinogenic pathogen.

SUMMARY: A test-and-treat approach (noninvasive H. pylori testing for symptomatic patients) towards young people has been advocated among European populations to date, and has been validated for improving symptoms of dyspepsia, and shown cost savings compared to symptomatic dyspepsia treatment alone. Randomised data on the reduction of gastric cancer since the introduction of this approach are lacking, but some retrospective studies show a clear cancer benefit to eradication. Several pilot studies in high-incidence countries have demonstrated cost-effective and real-world reductions in gastric cancer rates with population-based H. pylori screenings (screen-and-treat approach). Many of these countries have adopted national gastric cancer prevention strategies that incorporate H. pylori screening. Abundant modelling data in these countries show economic benefits to nearly all types of screening programmes; however, data in European populations, who have documented lower risks of both infection and progression to gastric cancer, are lacking. Modelled data suggest it may be feasible, but currently no guidelines recommend this approach. Currently, prospective European studies are underway to assess the practicality and cost-effectiveness of various methods of screening. We discuss the use of both endoscopy (test-scope-and-treat) and biomarkers as possible adjuncts to potential population-based screening to ensure maximum gastric cancer reduction from any such proposed approach.

KEY MESSAGES: Prospective data from H. pylori high-incidence countries in Asia have shown a clear reduction in gastric cancer diagnoses after the introduction of population screening. Cost-effectiveness of population-wide screening is well documented in these countries and forms part of many national gastric cancer screening programmes. Modelled data from H. pylori low-incidence countries show population-based screening may be cost-effective, but real-world feasibility data are lacking.