Helicobacter pylori is one of the most common infections worldwide, with up to 30% to 40% of the United States population estimated to be infected.1 Infection with H. pylori is associated with gastritis, peptic ulcer disease (PUD), and gastric cancer. Gastric cancer represents the third most common cause of cancer death in the world; therefore, the role of H. pylori in its pathogenesis is critical to understand.2
Some retrospective reviews have shown between a 3- and 6-fold increase in the risk for gastric cancer in patients infected with H. pylori.1 If patients are infected with H. pylori, they may or may not have symptoms such as abdominal pain, heartburn, nausea, or dyspepsia. Because H. pylori is so common, especially in developing countries, clinicians may be faced with a difficult decision as to whether they should empirically treat patients that could be infected with H. pylori, since treatment may prevent the development of gastric cancer.
Recently, Ford and colleagues performed a systematic review and meta-analysis of randomized controlled trials that examined the role of treatment in asymptomatic patients that were infected with H. pylori.2 This review was able to identify six randomized trials that included 3,203 controls and 3,294 patients receiving treatment for H. pylori.
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Seventy-six patients (2.4%) in the control group developed gastric cancers compared with 51 patients (1.6%) in the treatment group (relative risk, 0.66; 95% CI, 0.46-0.95). Although there was a statistically significant reduction in gastric cancer, the meta-analysis did not show a difference in mortality between the two patient groups.
This study raises several interesting questions. If there truly is a significant difference in the rates of gastric cancers when treating asymptomatic patients, is it useful to implement an extensive screening program and formal guidelines?
Several societies and medical organizations have recommendations for H. pylori screening, but they vary significantly. Unified screening guidelines may be difficult to develop based on the prevalence and varying medical economics from country to country.
Aside from the obvious alarm symptoms, more subtle risk factors that make a patient “high risk” for gastric cancer will most likely need to be clarified from past studies and in studies that will be performed in the future, especially in those patients without symptoms.
However, when it comes to which treatment option to choose, each country or region may have different resistance patterns, so the best treatment regimen may be difficult to identify. Treating asymptomatic patients may also lead to adverse events, which could affect both compliance and the development of new resistance patterns.
Overall, additional cost-effectiveness studies are needed to determine the value of screening for H. pylori in the context of preventing gastric cancer.
- Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102(8):1808-1825.
- Ford AC, Forman D, Hunt RH, Yuan Y, Moayyedi P. Helicobacter pylori eradication therapy to prevent gastric cancer in healthy asymptomatic infected individuals: systematic review and meta-analysis of randomised controlled trials. BMJ. 2014;348:g3174.